Advanced Trauma Life Support ATLS Student Course Manual 2018

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CHAPTER 7 Outline Objectives iNtroduction Anatomy and Physiology • Spinal Column • Spinal Cord Anatomy • Dermatomes • Myotomes • Neurogenic Shock versus Spinal Shock • Effects on Other Organ Systems Documentation of Spinal Cord Injuries • Level • Severity of Neurologic Deficit • Spinal Cord Syndromes • Morphology RadiogRAphic Evaluation • Cervical Spine • Thoracic and Lumbar Spine GeneRAl Management • Spinal Motion Restriction • Intravenous Fluids • Medications • Transfer Teamwork SummARy BibliogRAphy Specific Types of Spinal Injuries • Cervical Spine Fractures • Thoracic Spine Fractures • Thoracolumbar Junction Fractures (T11 through L1) • Lumbar Fractures • Penetrating Injuries • Blunt Carotid and Vertebral Artery Injuries OBJECTIVES After reading this chapter and comprehending the knowledge components of the ATLS provider course, you will be able to: 1. Describe the basic anatomy and physiology of the spine. 2. Describe the appropriate evaluation of a patient with suspected spinal injury and documentation of injury. 4. Describe the appropriate treatment of patients with spinal injuries during the first hours after injury. 5. Determine the appropriate disposition of patients with spine trauma. 3. Identify the common types of spinal injuries and the x-ray features that help identify them. n BACK TO TABLE OF CONTENTS 129
130 CHAPTER 7 n Spine and Spinal Cord Trauma Spine injury, with or without neurological deficits, must always be considered in patients with multiple injuries. Approximately 5% of patients with brain injury have an associated spinal injury, whereas 25% of patients with spinal injury have at least a mild brain injury. Approximately 55% of spinal injuries occur in the cervical region, 15% in the thoracic region, 15% at the thoracolumbar junction, and 15% in the lumbosacral area. Up to 10% of patients with a cervical spine fracture have a second, noncontiguous vertebral column fracture. In patients with potential spine injuries, excessive manipulation and inadequate restriction of spinal motion can cause additional neurological damage and worsen the patient’s outcome. At least 5% of patients with spine injury experience the onset of neurological symptoms or a worsening of preexisting symptoms after reaching the emergency department (ED). These complications are typically due to ischemia or progression of spinal cord edema, but they can also result from excessive movement of the spine. If the patient’s spine is protected, evaluation of the spine and exclusion of spinal injury can be safely deferred, especially in the presence of systemic instability, such as hypotension and respiratory inadequacy. Spinal protection does not require patients to spend hours on a long spine board; lying supine on a firm surface and utilizing spinal precautions when moving is sufficient. Excluding the presence of a spinal injury can be straightforward in patients without neurological deficit, pain or tenderness along the spine, evidence of intoxication, or additional painful injuries. In this case, the absence of pain or tenderness along the spine virtually excludes the presence of a significant spinal injury. The possibility of cervical spine injuries may be eliminated based on clinical tools, described later in this chapter. However, in other patients, such as those who are comatose or have a depressed level of consciousness, the process of evaluating for spine injury is more complicated. In this case, the clinician needs to obtain the appropriate radiographic imaging to exclude a spinal injury. If the images are inconclusive, restrict motion of the spine until further testing can be performed. Remember, the presence of a cervical collar and backboard can provide a false sense of security that movement of the spine is restricted. If the patient is not correctly secured to the board and the collar is not properly fitted, motion is still possible. Although the dangers of excessive spinal motion have been well documented, prolonged positioning of patients on a hard backboard and with a hard cervical collar (c-collar) can also be hazardous. In addition to causing severe discomfort in conscious patients, serious decubitus ulcers can form, and respiratory compromise can result from prolonged use. Therefore, long backboards should be used only during patient transportation, and every effort should be made to remove patients from spine boards as quickly as possible. Anatomy and Physiology The following review of the anatomy and physiology of the spine and spinal cord includes the spinal column, spinal cord anatomy, dermatomes, myotomes, the differences between neurogenic and spinal shock, and the effects of spine injury on other organ systems. Spinal Column The spinal column consists of 7 cervical, 12 thoracic, and 5 lumbar vertebrae, as well as the sacrum and coccyx (n FIGURE 7-1). The typical vertebra consists of an anteriorly placed vertebral body, which forms part of the main weight-bearing column. The vertebral bodies are separated by intervertebral disks that are held together anteriorly and posteriorly by the anterior and posterior longitudinal ligaments, respectively. Posterolaterally, two pedicles form the pillars on which the roof of the vertebral canal (i.e., the lamina) rests. The facet joints, interspinous ligaments, and paraspinal muscles all contribute to spine stability. The cervical spine, because of its mobility and exposure, is the most vulnerable part of the spine to injury. The cervical canal is wide from the foramen magnum to the lower part of C2. Most patients with injuries at this level who survive are neurologically intact on arrival to the hospital. However, approximately one-third of patients with upper cervical spine injuries (i.e., injury above C3) die at the scene from apnea caused by loss of central innervation of the phrenic nerves. Below the level of C3, the spinal canal diameter is much smaller relative to the spinal cord diameter, and vertebral column injuries are much more likely to cause spinal cord injuries. A child’s cervical spine is markedly different from that of an adult’s until approximately 8 years of age. These differences include more flexible joint capsules and interspinous ligaments, as well as flat facet joints and vertebral bodies that are wedged anteriorly and tend to slide forward with flexion. The differences decline steadily until approximately age 12, when the cervical spine is more similar to an adult’s. (See Chapter 10: Pediatric Trauma.) Thoracic spine mobility is much more restricted than cervical spine mobility, and the thoracic spine has additional support from the rib cage. Hence, the n BACK TO TABLE OF CONTENTS
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TENTH EDITION ATLS ® Advanced Trau
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Chair of Committee on Trauma: Ronal
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FOREWORD My first exposure to Advan
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viii PREFACE MyATLS Mobile Applicat
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x PREFACE Gary A. Vercruysse, MD, F
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xii PREFACE Jacqueline Bustraan, MS
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ACKNOWLEDGMENTS It is clear that ma
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xvii ACKNOWLEDGMENTS Bertil Bouillo
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xix ACKNOWLEDGMENTS Oscar Guillamon
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xxi ACKNOWLEDGMENTS Mahesh Misra, M
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xxiii ACKNOWLEDGMENTS James Vosswin
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xxv ACKNOWLEDGMENTS James A. Geilin
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xxvii ACKNOWLEDGMENTS Tone Slåke R
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xxx COURSE OVERVIEW m. Protection o
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xxxii COURSE OVERVIEW Atls and Trau
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xxxiv COURSE OVERVIEW a systematize
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xxxvi COURSE OVERVIEW 69. Switzerla
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xxxviii COURSE OVERVIEW United Stat
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xl COURSE OVERVIEW 67. Hendrickson
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xlii COURSE OVERVIEW 122. Palusci V
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BRIEF CONTENTS Foreword Preface Ack
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xlviii DETAILED CONTENTS Teamwork 5
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l DETAILED CONTENTS Introduction 21
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1 INITIAL ASSESSMENT AND MANAGEMENT
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4 CHAPTER 1 n Initial Assessment an
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10 CHAPTER 1 n Initial Assessment a
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2 AIRWAY AND VENTILATORY MANAGEMENT
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24 CHAPTER 2 n Airway and Ventilato
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3 SHOCK The first step in the initi
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44 CHAPTER 3 n Shock The first step
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46 CHAPTER 3 n Shock Recognition of
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48 CHAPTER 3 n Shock However, the a
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50 CHAPTER 3 n Shock Class II Hemor
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52 CHAPTER 3 n Shock hypothermia, a
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54 CHAPTER 3 n Shock replacement du
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56 CHAPTER 3 n Shock aggregation an
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58 CHAPTER 3 n Shock Presence of Pa
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60 CHAPTER 3 n Shock rate can be ac
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4 THORACIC TRAUMA Thoracic injury i
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64 CHAPTER 4 n Thoracic Trauma Thor
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66 CHAPTER 4 n Thoracic Trauma shoc
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68 CHAPTER 4 n Thoracic Trauma comp
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70 CHAPTER 4 n Thoracic Trauma Norm
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72 CHAPTER 4 n Thoracic Trauma Seco
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74 CHAPTER 4 n Thoracic Trauma A B
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76 CHAPTER 4 n Thoracic Trauma Spec
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Page 133 and 134: 80 CHAPTER 4 n Thoracic Trauma 18.
Page 135 and 136: ABDOMINAL AND 5 PELVIC TRAUMA When
Page 137 and 138: 84 CHAPTER 5 n Abdominal and Pelvic
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Page 155 and 156: 6 HEAD TRAUMA The primary goal of t
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Page 163 and 164: 110 CHAPTER 6 n Head Trauma table 6
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Page 184 and 185: ANATOMY AND PHYSIOLOGY 131 B A n FI
Page 186 and 187: RIGHT INTERNATIONAL STANDARDS FOR N
Page 188 and 189: DOCUMENTATION OF SPINAL CORD INJURI
Page 190 and 191: SPECIFIC TYPES OF SPINAL INJURIES 1
Page 192 and 193: RADIOGRAPHIC EVALUATION 139 Penetra
Page 194 and 195: GENERAL MANAGEMENT 141 When the low
Page 196 and 197: GENERAL MANAGEMENT 143 them to the
Page 198 and 199: BIBLIOGRAPHY 145 Bibliography 1. Bi
Page 201 and 202: 8 MUSCULOSKELETAL TRAUMA Injuries t
Page 203 and 204: 150 CHAPTER 8 n Musculoskeletal Tra
Page 221 and 222: 9 THERMAL INJURIES The most signifi
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180 CHAPTER 9 n Thermal Injuries Im
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182 CHAPTER 9 n Thermal Injuries lo
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184 CHAPTER 9 n Thermal Injuries 4.
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10 PEDIATRIC TRAUMA Injury remains
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188 CHAPTER 10 n Pediatric Trauma I
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190 CHAPTER 10 n Pediatric Trauma c
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192 CHAPTER 10 n Pediatric Trauma A
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194 CHAPTER 10 n Pediatric Trauma b
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196 CHAPTER 10 n Pediatric Trauma b
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198 CHAPTER 10 n Pediatric Trauma t
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200 CHAPTER 10 n Pediatric Trauma f
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202 CHAPTER 10 n Pediatric Trauma t
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204 CHAPTER 10 n Pediatric Trauma G
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206 CHAPTER 10 n Pediatric Trauma C
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208 CHAPTER 10 n Pediatric Trauma
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210 CHAPTER 10 n Pediatric Trauma 1
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212 CHAPTER 10 n Pediatric Trauma 6
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CHAPTER 11 Outline Objectives iNtro
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PRIMARY SURVEY WITH RESUSCITATION 2
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PRIMARY SURVEY WITH RESUSCITATION 2
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SPECIFIC INJURIES 221 table 11-6 ph
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BIBLIOGRAPHY 223 comprise only 12%
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12 TRAUMA IN PREGNANCY AND INTIMATE
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228 CHAPTER 12 n Trauma in Pregnanc
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240 CHAPTER 13 n Transfer to Defini
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Appendix A OCULAR TRAUMA OBJECTIVES
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259 APPENDIX A n Ocular Trauma In c
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261 APPENDIX A n Ocular Trauma to t
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Appendix B HYPOTHERMIA AND HEAT INJ
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267 APPENDIX B n Hypothermia and He
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Appendix C TRAUMA CARE IN MASS-CASU
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277 APPENDIX C n Trauma Care in Mas
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Appendix D DISASTER PREPAREDNESS AN
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291 APPENDIX D n Disaster Preparedn
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Pitfall Inadequate security Failed
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Appendix E ATLS AND TRAUMA TEAM RES
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305 APPENDIX E n ATLS and Trauma Te
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Appendix F TRIAGE SCENARIOS OBJECTI
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319 APPENDIX F n Triage Scenarios T
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333 APPENDIX F n Triage Scenarios 4
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Skill Station A AIRWAY Part 1: Basi
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339 APPENDIX G n Skills One-Person
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341 APPENDIX G n Skills STEP 5. Con
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343 APPENDIX G n Skills STEP 13. Co
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346 APPENDIX G n Skills STEP 1. D
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Skill Station C CIRCULATION LEARNIN
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351 APPENDIX G n Skills manual trac
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353 APPENDIX G n Skills STEP 3. Aft
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355 APPENDIX G n Skills STEP 2. If
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358 APPENDIX G n Skills A. Note fac
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360 APPENDIX G n Skills •• Flex
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362 APPENDIX G n Skills Utilization
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366 APPENDIX G n Skills n FIGURE G-
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368 APPENDIX G n Skills less than 1
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372 APPENDIX G n Skills G. Inspect
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374 APPENDIX G n Skills in the inju
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378 INDEX LTA for, 31-32, 32f Malla
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380 INDEX atlanto-occipital disloca
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382 INDEX Frostbite, 181-183, 182f
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384 INDEX Kussmaul’s sign, 69 Lac
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386 INDEX PEA. See Pulseless electr
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388 INDEX for musculoskeletal traum
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390 INDEX Tibial fractures, 163 Tou
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TRAUMA SCORES Correct triage is ess
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394 TRAUMA SCORES on Field Triage,
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396 INJURY PREVENTION Safety Admini
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398 INJURY PREVENTION providers to
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BIOMECHANICS OF INJURY Injuries occ
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402 BIOMECHANICS OF INJURY Ejection
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404 BIOMECHANICS OF INJURY •• A
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406 BIOMECHANICS OF INJURY in a 30-
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408 TETANUS IMMUNIZATION •• Wou
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410 TETANUS IMMUNIZATION Summary Gu
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SAMPLE TRAUMA FLOW SHEET Page 1 of
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414 SAMPLE TRAUMA FLOW SHEET Page 3
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420 SAMPLE TRAUMA FLOW SHEET Some h
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Advanced Trauma Life Support ATLS Student Course Manual 2018

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