Wilderness and Rescue Medicine 8th Edition

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Section IV: Trauma

General Principles

General Principles

Spine Structure

Spine Injury Field Assessment

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body of vertebra

• Mental status • New s ymptoms • Exam

capillaries (venous and arterial) spinal cord

cerebrospinal fluid

spinous process

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spinal nerve root

Wilderness Perspective

transverse process

Low Risk

High Risk

?

intervertebral disc

© 2018 WMA

© 2018 WMA

The trauma patient with a positive MOI and altered level of consciousness (V, P, U on AVPU) is considered to have a spine injury until proven otherwise. Treatment should include protecting the spine from further trauma as best you can while managing other medical and logistical problems. However, it should not take priority over airway control and ventilation, bleeding control, or preservation of body core tempera- ture. Stabilization protocols should not interfere with rapid extrication from an unstable scene like avalanche terrain or cold water. The procedure should not substantially increase risk to rescuers. This is one of many areas where blind obedience to conventional protocol can kill people in the unconventional setting! Field Assessment of Spine Injury The trauma patient who is A on AVPU offers an opportunity to refine our problem list and risk vs benefit analysis. In any case, spine assessment is not an emergency treatment; it is a specific and meticulous examination performed after the scene is stabilized and critical system problems have been treated or ruled out. Until you are very comfortable with your routine examination you should perform the spine exam separately rather than incorporated into the rest of your second- ary assessment. The first step is to determine how reliable the exam will be. A patient who is awake and cooperative with normal mental status can be considered reliable and will report pain or neurologic symptoms. It

is highly unusual for a significant spine injury to go unnoticed if the patient is talking to you, even in the presence of other painful injuries. However, the patient with altered mental status from acute stress reaction or traumatic brain injury may not reliably report signs and symptoms and may not follow your instructions when performing motor and sensory tests. Even then, a spine exam can still be useful if the patient can demonstrate normal motor and sensory function. If you are an experienced emergency practitio- ner, you have likely adopted a neurologic exam that is comfortable, familiar, and complete. If not, the WMA International Spine Assessment Criteria can serve that purpose. Conscientiously applied, it will reliably detect all significant spine injury. Each element of the WMA International Spine Assessment Criteria is important. You are looking for evidence of injury to the spinal column as well as injury to the spinal cord. You are also trying to determine how serious an injury might be to help you judge the risks and benefits of treatment and evacuation. Your spine assessment really starts with your first impression. The patient who is up and walk- ing around may still have a spine injury, but at least you know that moving and bearing weight is possible. A patient who is splinting (holding the neck and back stiffly) may be involuntarily pro- tecting a spinal column injury. A patient will full mobility, no splinting, and no apparent discom- fort is very unlikely to have a spine injury at all. You should ask specifically about new symp- toms. “Does your neck or back hurt? Do you have