Advanced Trauma Life Support ATLS Student Course Manual 2018

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CHAPTER 7 n Spine and Spinal Cord Trauma
Logroll video on MyATLS mobile app). The team leader
determines when in resuscitation and management of
the patient this procedure should be performed. One
person is assigned to restrict motion of the head and
neck. Other individuals positioned on the same side
of the patient’s torso manually prevent segmental
rotation, flexion, extension, lateral bending, or sagging
of the chest or abdomen while transferring the patient.
Another person is responsible for moving the patient’s
legs, and a fourth person removes the backboad and
examines the back.
Intravenous Fluids
If active hemorrhage is not detected or suspected,
persistent hypotension should raise the suspicion of
neurogenic shock. Patients with hypovolemic shock
usually have tachycardia, whereas those with neurogenic
shock classically have bradycardia. If the
patient’s blood pressure does not improve after a
fluid challenge, and no sites of occult hemorrhage
are found, the judicious use of vasopressors may be
indicated. Phenylephrine hydrochloride, dopamine,
or norepinephrine is recommended. Overzealous
fluid administration can cause pulmonary edema in
patients with neurogenic shock. If the patient’s fluid
status is uncertain, ultrasound estimation of volume
status or invasive monitoring may be helpful. Insert a
urinary catheter to monitor urinary output and prevent
bladder distention.
Medications
There is insufficient evidence to support the use of
steroids in spinal cord injury.
Transfer
When necessary, patients with spine fractures or
neurological deficit should be transferred to a facility
capable of providing definitive care. (See Chapter 13:
Transfer to Definitive Care and Criteria for Interhospital
Transfer on MyATLS mobile app.) The safest procedure
is to transfer the patient after consultation with
the accepting trauma team leader and/or a spine
specialist. Stabilize the patient and apply the necessary
splints, backboard, and/or semirigid cervical collar.
Remember, cervical spine injuries above C6 can result
in partial or total loss of respiratory function. If there
is any concern about the adequacy of ventilation,
intubate the patient before transfer. Always avoid
unnecessary delay.
TeamWORK
••
The trauma team must ensure adequate
spinal motion restriction during the primary
and secondary surveys, as well as during
transport of patients with proven or suspected
spinal injury.
••
As long as the patient’s spine is protected, a
detailed examination can safely be deferred
until the patient is stable.
••
Although there are often many competing
clinical interests, the trauma team must
ensure that a complete and adequate examination
of the spine is performed. The team
leader should decide the appropriate time for
this exam.
Chapter Summary
1. The spinal column consists of cervical, thoracic,
and lumbar vertebrae. The spinal cord contains
three important tracts: the corticospinal
tract, the spinothalamic tract, and the dorsal
columns.
2. Attend to life-threatening injuries first, minimizing
movement of the spinal column. Restrict
the movement of the patient’s spine until
vertebral fractures and spinal cord injuries
have been excluded. Obtain early consultation
with a neurosurgeon and/or orthopedic
surgeon whenever a spinal injury is suspected
or detected.
3. Document the patient’s history and physical
examination to establish a baseline for any changes
in the patient’s neurological status.
4. Obtain images, when indicated, as soon as lifethreatening
injuries are managed.
5. Spinal cord injuries may be complete or incomplete
and may involve any level of the
spinal cord.
6. When necessary, transfer patients with vertebral
fractures or spinal cord injuries to a facility
capable of providing definitive care as quickly
and safely as possible.
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