Advanced Trauma Life Support ATLS Student Course Manual 2018

RIGHT
INTERNATIONAL STANDARDS FOR NEUROLOGICAL
CLASSIFICATION OF SPINAL CORD INJURY
(ISNCSCI)
Patient Name_____________________________________ Date/Time of Exam _____________________________
Examiner Name ___________________________________ Signature _____________________________________
C7
C7
DorsumC6
C8
DorsumC6 C8
C7
C7
DorsumC6
C8
DorsumC6 C8
C7
C7
DorsumC6
C8
DorsumC6 C8
LEFT
MOTOR
SENSORY
SENSORY
MOTOR
KEY SENSORY POINTS
KEY MUSCLES
KEY SENSORY POINTS
KEY MUSCLES
Light Touch (LTR) Pin Prick (PPR)
Light Touch (LTL) Pin Prick (PPL)
INTERNATIONAL STANDARDS FOR NEUROLOGICAL
Patient Name_____________________________________ Date/Time of Exam _____________________________
C2
C2
CLASSIFICATION OF SPINAL CORD INJURY
C3
Examiner Name ___________________________________ C3
Signature _____________________________________
(ISNCSCI)
C4
C2
C4
MOTOR
SENSORY C3
Elbow flexors C5
SENSORY C5 Elbow flexors MOTOR
KEY SENSORY POINTS
RIGHT KEY MUSCLES
KEY SENSORY POINTS
UER
Wrist extensors
C4
C6
Light Touch (LTR)
C6 Wrist extensors KEY MUSCLES UEL LEFT
Pin Prick (PPR)
Light Touch (LTL) Pin Prick (PPL)
(Upper Extremity Right)
INTERNATIONAL STANDARDS FOR NEUROLOGICAL
Patient Name_____________________________________ Date/Time of Exam _____________________________
T2
Elbow extensors C7
T3
C2
C7 Elbow extensors (Upper Extremity Left)
CLASSIFICATION OF SPINAL C2 CORD INJURY
T4
C5
Finger flexors C8
Examiner Name ___________________________________ C2
0 = absent
C8 Finger flexors Signature _____________________________________
(ISNCSCI) C3
T5
C3
Finger abductors (little finger) 1 = altered
T1
T6
T1 Finger abductors (little finger)
2 = normal
C4
C2
C4
NT = not testable
T7
T2
C3
Comments (Non-key Muscle? Reason for NT? Pain?):
MOTOR SENSORY
T2 SENSORY
T8
C3
Elbow flexors C5
MOTOR MOTOR C5 Elbow flexors
T3
KEY MUSCLES
KEY SENSORY POINTS
KEY SENSORY POINTS
RIGHT
0 = absent T9
T1
T3
C4
(SCORING ON REVERSE KEY MUSCLES SIDE)
LEFT
UER
Wrist extensors C6 Light 1 Touch = altered (LTR) Pin Prick (PPR)
Light Touch (LTL) Pin Prick (PPL)
C4
C6 Wrist extensors UEL
2 = normal T10
C6
(Upper Extremity Right) T4
T2
T4 0 = total paralysis
Elbow extensors C7
T3
C2
C7
(Upper Extremity Left)
NT = not testable T11
Elbow extensors
T5
C2
T4
C5 T5
1 = palpable or visible contraction C2
Finger flexors C8 0 = absent
T12
C8 Finger flexors
T6
C3
2 = active movement, gravity
T5
1 = altered
T6
C3 eliminated
0 = absent
Finger abductors (little finger)
L1
3 = active movement, against gravity
T1
C2 T6
T1 Finger abductors (little finger)
2 = normal C4
Palm
1 = altered
4 = active movement, against C4 some resistance
T7
NT = not testable
T7
T7
2 = normal
T2
C3
Elbow flexors
5 = active movement, against
C3
T2 full resistance
NT = not testable Comments (Non-key Muscle? Reason for NT? Pain?): C5
T8
T8
T8
C5 Elbow flexors
5* = normal corrected for pain/disuse MOTOR
T3
0 = absent C4 T9
T1
UER
Wrist extensors C6
S3
NT = not testable T3
(SCORING ON REVERSE SIDE)
T9
1 = altered C4
T2
2 = normal T3 T10
C6
T4
L2 • Key Sensory
T9
C6 Wrist extensors UEL
(Upper Extremity Right) Elbow extensors
T4
C2
0 = total paralysis
(Upper Extremity Left)
C7
S4-5
T10
NT Points = not testable
T4
T11
C5
T5
T10
C7 Elbow extensors
SENSORY T5
1 = palpable or visible contraction
Finger flexors C8 0 = absent
T5 T12
2 = active movement, gravity eliminated
T11
1 = altered T6
T11 (SCORING ON REVERSE C8 SIDE)
Finger flexors
Finger 0 abductors = absent (little finger) T1
T6
T6
2 = normal
L1
3 = active movement, against gravity
T12 1 = altered
T7
Palm
4 = active movement, against some resistance
NT = not T7 testable
2 = normal
S2
L3
T12
0 = absent
2 = normal T1 Finger abductors (little finger)
T2
C3
1= altered T7
T8
T2 NT = not
5 =
testable
active movement, against full resistance
Comments (Non-key Muscle? L1 NT = not testable Reason for NT? Pain?):
T8
L1
0 = absent T9
T1
T8 5* = normal corrected
MOTOR
for pain/disuse
T3
T3
S3
1 = altered C4
NT = not (SCORING testable ON REVERSE SIDE)
Hip flexors L2
T9
2 = normal
T10
C6
T4
L2 • Key Sensory L2 Hip flexors T9 T4 0 = total paralysis
NT = not S4-5 testable T11
Knee extensors
T10
Points L3
T10
LER
L3
T5
Knee extensors T5 1 = palpable or SENSORY
visible contraction
L4
T12
2 = active LEL
T11
T11 (SCORING movement, ON gravity REVERSE eliminated SIDE)
(Lower Extremity Right) Ankle dorsiflexors L4
T6
0 = absent
L1
L4 Ankle dorsiflexors T6 (Lower 3 = active Extremity movement, Left) against gravity
L5
Palm
1 = altered
T12
2 = normal
S2
L3
T12
0 absent
2 = normal
Long toe extensors L5
4 = active movement, against some resistance
T7
L5 Long toe extensors T7 1= altered
NT = not testable
S1
5 = active movement, against full resistance
Ankle plantar flexors S1 NT = not testable
T8 L1L5
S1 Ankle plantar L1 T8 flexors 5* = normal corrected for pain/disuse
S3
S2 Hip flexors L2
L2 • Key Sensory
NT = not testable
T9
S2
T9 L2 Hip flexors
S4-5
Points
Knee extensors
LER S3
L3 T10
S3
T10 L3 Knee extensors SENSORY
(VAC) Voluntary anal contraction
L4
(DAP) Deep anal pressure
LEL
(Yes/No) (Lower Extremity Right) S4-5 Ankle dorsiflexors L4 T11
S4-5
T11 (SCORING ON REVERSE SIDE)
L4 Ankle dorsiflexors (Lower Extremity Left)
L5
(Yes/No)
Long toe extensors L5 T12
S2
L3
T12
0 = absent
2 = normal
L5 Long toe extensors
RIGHT TOTALS
S1
LEFT TOTALS
1= altered
NT = not testable
Ankle plantar flexors S1 L1
L5
L1 S1 Ankle plantar flexors
(MAXIMUM)
(MAXIMUM)
Hip flexors L2 S2
S2
MOTOR SUBSCORES
L2 Hip flexors
S3
SENSORY SUBSCORES
S3
(VAC) Voluntary anal contraction
L4
(DAP) Deep anal pressure
UER + UEL = UEMS TOTAL LER
Knee extensors L3
L3 Knee extensors
LER + LEL
(Yes/No)
S4-5 = LEMS TOTAL
LEL
LTR + LTL = LT TOTAL PPR + PPL S4-5
(Lower Extremity Right) Ankle dorsiflexors L4
= L4 PP TOTAL Ankle dorsiflexors
L5
(Yes/No) (Lower Extremity Left)
MAX (25) (25) (50) MAX (25) (25) (50)
Long toe extensors L5
MAX (56) (56) (112) MAX (56) (56) (112)
RIGHT TOTALS
L5
S1
LEFT Long TOTALS toe extensors
NEUROLOGICAL
L5
R L Ankle plantar flexors S1
(In complete injuries only)
3. NEUROLOGICAL
(MAXIMUM)
4. COMPLETE OR INCOMPLETE?
S1(MAXIMUM)
Ankle R plantar L flexors
LEVELS 1. SENSORY MOTOR SUBSCORES
S2
Incomplete = Any sensory or motor function in S4-5
ZONE OF PARTIAL
LEVEL OF INJURY
S2 SENSORY
SENSORY SUBSCORES
Steps 1-5 for classification
as on reverse 2. MOTOR
(NLI) S3
5. ASIA IMPAIRMENT SCALE (AIS)
PRESERVATION S3MOTOR
(VAC) UER Voluntary + UEL Anal Contraction = UEMS TOTAL
LER + LEL = LEMS TOTAL
Most caudal level with any innervation
S4-5
LTR + LTL = LT TOTAL S4-5 PPR + PPL (DAP) Deep = Anal PP TOTAL Pressure
MAX (25) This (25) form
(Yes/No)
may be copied freely (50) but should MAX not (25) be altered without (25) permission from the (50) American Spinal MAX Injury (56) Association. (56) (112) MAX (56) REV (Yes/No)
02/13(56) (112)
NEUROLOGICAL RIGHT TOTALS
LEFT TOTALS
R L (In complete injuries only)
3. NEUROLOGICAL
4. COMPLETE OR INCOMPLETE?
R L
LEVELS 1. SENSORY (MAXIMUM)
Incomplete = Any sensory or motor function in S4-5
ZONE OF PARTIAL (MAXIMUM)
LEVEL OF INJURY
SENSORY
MOTOR Steps 1-5 SUBSCORES
for classification
as on reverse 2. MOTOR
(NLI)
5. ASIA SENSORY IMPAIRMENT SUBSCORES
SCALE (AIS)
PRESERVATION
MOTOR
Most caudal level with any innervation
UER + UEL = UEMS TOTAL
LER + LEL = LEMS TOTAL
LTR + LTL = LT TOTAL PPR + PPL = PP TOTAL
This form may be copied freely but should not be altered without permission from the American Spinal Injury Association.
REV 02/13
MAX (25) (25) (50) MAX (25) (25) (50) MAX (56) (56) (112) MAX (56) (56) (112)
NEUROLOGICAL
4. COMPLETE OR INCOMPLETE?
R L
LEVELS
Incomplete = Any sensory or motor function in S4-5
Steps 1-5 for classification
A
as on reverse
1. SENSORY
2. MOTOR
R L 3. NEUROLOGICAL
LEVEL OF INJURY
(NLI)
5. ASIA IMPAIRMENT SCALE (AIS)
This form may be copied freely but should not be altered without permission from the American Spinal Injury Association.
ANATOMY AND PHYSIOLOGY 133
(In complete injuries only)
ZONE OF PARTIAL
PRESERVATION
Most caudal level with any innervation
SENSORY
MOTOR
REV 11/15
Muscle Function Grading
0 = total paralysis
1 = palpable or visible contraction
2 = active movement, full range of motion (ROM) with gravity eliminated
3 = active movement, full ROM against gravity
4 = active movement, full ROM against gravity and moderate resistance in a muscle
specific position
5 = (normal) active movement, full ROM against gravity and full resistance in a
functional muscle position expected from an otherwise unimpaired person
5* = (normal) active movement, full ROM against gravity and sufficient resistance to
be considered normal if identified inhibiting factors (i.e. pain, disuse) were not present
NT = not testable (i.e. due to immobilization, severe pain such that the patient
cannot be graded, amputation of limb, or contracture of > 50% of the normal ROM)
Sensory Grading
0 = Absent
1 = Altered, either decreased/impaired sensation or hypersensitivity
2 = Normal
NT = Not testable
When to Test Non-Key Muscles:
In a patient with an apparent AIS B classification, non-key muscle functions
more than 3 levels below the motor level on each side should be tested to
most accurately classify the injury (differentiate between AIS B and C).
Movement
Root level
Shoulder: Flexion, extension, abduction, adduction, internal C5
and external rotation
Elbow: Supination
Elbow: Pronation
C6
Wrist: Flexion
Finger: Flexion at proximal joint, extension.
C7
Thumb: Flexion, extension and abduction in plane of thumb
Finger: Flexion at MCP joint
C8
Thumb: Opposition, adduction and abduction perpendicular
to palm
Finger: Abduction of the index finger
T1
ASIA Impairment Scale (AIS)
A = Complete. No sensory or motor function is preserved in
the sacral segments S4-5.
B = Sensory Incomplete. Sensory but not motor function
is preserved below the neurological level and includes the sacral
segments S4-5 (light touch or pin prick at S4-5 or deep anal
pressure) AND no motor function is preserved more than three
levels below the motor level on either side of the body.
C = Motor Incomplete. Motor function is preserved at the
most caudal sacral segments for voluntary anal contraction (VAC)
OR the patient meets the criteria for sensory incomplete status
(sensory function preserved at the most caudal sacral segments
(S4-S5) by LT, PP or DAP), and has some sparing of motor
function more than three levels below the ipsilateral motor level
on either side of the body.
(This includes key or non-key muscle functions to determine
motor incomplete status.) For AIS C – less than half of key
muscle functions below the single NLI have a muscle grade ≥ 3.
D = Motor Incomplete. Motor incomplete status as defined
above, with at least half (half or more) of key muscle functions
below the single NLI having a muscle grade ≥ 3.
E = Normal. If sensation and motor function as tested with
the ISNCSCI are graded as normal in all segments, and the
patient had prior deficits, then the AIS grade is E. Someone
without an initial SCI does not receive an AIS grade.
Using ND: To document the sensory, motor and NLI levels,
the ASIA Impairment Scale grade, and/or the zone of partial
preservation (ZPP) when they are unable to be determined
based on the examination results.
Steps in Classification
The following order is recommended for determining the classification of
individuals with SCI.
1. Determine sensory levels for right and left sides.
The sensory level is the most caudal, intact dermatome for both pin prick and
light touch sensation.
2. Determine motor levels for right and left sides.
Defined by the lowest key muscle function that has a grade of at least 3 (on
supine testing), providing the key muscle functions represented by segments
above that level are judged to be intact (graded as a 5).
Note: in regions where there is no myotome to test, the motor level is
presumed to be the same as the sensory level, if testable motor function above
that level is also normal.
3. Determine the neurological level of injury (NLI)
This refers to the most caudal segment of the cord with intact sensation and
antigravity (3 or more) muscle function strength, provided that there is normal
(intact) sensory and motor function rostrally respectively.
The NLI is the most cephalad of the sensory and motor levels determined in
steps 1 and 2.
4. Determine whether the injury is Complete or Incomplete.
(i.e. absence or presence of sacral sparing)
If voluntary anal contraction = No AND all S4-5 sensory scores = 0
AND deep anal pressure = No, then injury is Complete.
Otherwise, injury is Incomplete.
5. Determine ASIA Impairment Scale (AIS) Grade:
Is injury Complete? If YES, AIS=A and can record
ZPP (lowest dermatome or myotome
NO
on each side with some preservation)
Is injury Motor Complete? If YES, AIS=B
NO
(No=voluntary anal contraction OR motor function
more than three levels below the motor level on a
given side, if the patient has sensory incomplete
classification)
B
Hip: Adduction
Hip: External rotation
Hip: Extension, abduction, internal rotation
Knee: Flexion
Ankle: Inversion and eversion
Toe: MP and IP extension
Hallux and Toe: DIP and PIP flexion and abduction
Hallux: Adduction
L2
L3
L4
L5
S1
INTERNATIONAL STANDARDS FOR NEUROLOGICAL
CLASSIFICATION OF SPINAL CORD INJURY
Are at least half (half or more) of the key muscles below the
neurological level of injury graded 3 or better?
NO
YES
AIS=C
AIS=D
If sensation and motor function is normal in all segments, AIS=E
Note: AIS E is used in follow-up testing when an individual with a documented
SCI has recovered normal function. If at initial testing no deficits are found, the
individual is neurologically intact; the ASIA Impairment Scale does not apply.
n FIGURE 7-2 International Standards for Neurological Classification of Spinal Cord Injury. A. Sensory and Motor Evaluation of Spinal Cord.
B. Clinical Classifications of Spinal Cord Injuries.
n BACK TO TABLE OF CONTENTS