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Acute Management of Head and Spine Injuries

Acute Management of Head and Spine Injuries. Ron Courson, ATC, PT, NREMT-I, CSCS Senior Associate Athletic Director - Sports Medicine University of Georgia Athens, GA. Enormous Impact A ssociated With Catastrophic Cervical Spine Injuries Physical : pain and suffering

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Acute Management of Head and Spine Injuries

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  1. Acute Management ofHead and Spine Injuries Ron Courson, ATC, PT, NREMT-I, CSCS Senior Associate Athletic Director - Sports Medicine University of Georgia Athens, GA

  2. Enormous Impact Associated With Catastrophic Cervical Spine Injuries • Physical: • pain and suffering • permanent disabilities for remainder of life • Financial: • significant medical costs • other associated costs (i.e. home and auto modifications, attendants, wheelchair, etc...) • loss of income for parents/guardians • Emotional: • mental stress and anguish for student-athlete, family, friends, teammates, coaches

  3. Objective • Provide guidelines for the pre-hospital care of an athlete with a suspected head and/or spine injury University of Georgia Sports Medicine

  4. Background • Variety of healthcare professionals may be involved in on-field management of suspected head and/or spine injury • Important to develop standard guidelines to be used by all providers of pre-hospital care to ensure safe management University of Georgia Sports Medicine

  5. TEAMWORK • When dealing with a potential life-threatening situation such as a head or c-spine injury, the scene of the injury is not the time nor the place for healthcare professionals to decide on appropriate treatment on such a controversial area University of Georgia Sports Medicine

  6. Emergency Preparation • Healthcare providers for athletic competition (MDs, EMTs, ATCs) should develop emergency plan and protocol for dealing with such injuries when they occur and rehearse on regular basis University of Georgia Sports Medicine

  7. Emergency Assessment • organized process to quickly obtain information vital to care • primary survey • assess LOC-CAB • provide immediate basic life support measures as needed • quickly make decision regarding transportation • secondary survey (more detailed) performed either on-site or during transport University of Georgia Sports Medicine

  8. Emergency Assessment • Neurologic assessment should be performed before and after full-body immobilization ! • PMSC • Pulse • Motor • Sensation • Capillary refill University of Georgia Sports Medicine

  9. Emergency Assessment • Heightened suspicion of potentially catastrophic spine injury: • MOI • unconscious or altered level of consciousness • neurological complaints and/or deficits • significant midline spine pain • obvious spinal column deformity University of Georgia Sports Medicine

  10. Emergency Assessment • Heightened suspicion of potentially catastrophic spine injury: • priaprism • respiratory distress • “tracheal tugging” • accessory respiratory muscles • neurogenic shock • decreased blood pressure • increased pulse University of Georgia Sports Medicine

  11. Cervical Spine Injury Case Study • Not all c-spine injuries present in acute distress! • 22YOBM college football player (DB/kick returner) • returned kick-off in game • MOI: helmet to helmet contact • returned to sideline without apparent injury • c/o neck pain/stiffness • no neurologic complaints University of Georgia Sports Medicine

  12. Cervical Spine Injury Case Study University of Georgia Sports Medicine

  13. Cervical Spine Injury Case Study University of Georgia Sports Medicine

  14. Black & White or Gray ? • Every emergency situation and every patient is different • Individual circumstances must dictate appropriate actions • No such thing as “always” and “never” James R. Andrews, MD University of Georgia Sports Medicine

  15. Neutral Alignment Current recommendations for the acute treatment of the cervical-spine injured athlete are to immobilize the head and neck in neutral alignment prior to transfer to an emergency facility and to minimize the motion that occurs throughout this process University of Georgia Sports Medicine University of Georgia Sports Medicine

  16. Sustained Spinal Cord Compression “Sustained compression of the spinal cord is a crucially important factor in the secondary injury process” “Longer duration of compression is associated with increased pathological changes and decreases in neurologic recovery” “Damage to the spinal cord depends strongly on the duration of displacement and timing of treatment” University of Georgia Sports Medicine University of Georgia Sports Medicine

  17. Cervical Immobilization Device (CID) • Always use cervical collar if feasible • Measure for cervical collar • Adjustable c-collar University of Georgia Sports Medicine

  18. Spine Board • Standard fiberglass spine board • Oversize fiberglass spine board with pins for speed clips • Scoop stretcher • Miller full-body splint University of Georgia Sports Medicine

  19. Spine Board Accessories • Spine board kit • CID • HID • body immobilization straps • facemask removal tools • wrist straps • tape • padding University of Georgia Sports Medicine

  20. Head Immobilization Device (HID) Variety of designs to secure head to spine board; be skilled in use of design you select Always secure head last to spine board University of Georgia Sports Medicine

  21. Facemask Removal:Combined Tool Approach • Facemask should be removed prior to transportation, regardless of current respiratory status • Facemask removal tools should be readily available • Combined tool approach University of Georgia Sports Medicine

  22. Facemask Removal Prior to facemask removal, pocket mask may be positioned through facemask for ventilatory assistance University of Georgia Sports Medicine

  23. Facemask Removal Following facemask removal, bag-valve-mask may be utilized for ventilatory assistance Utilize oxygen if available University of Georgia Sports Medicine

  24. Facemask Removal • Do not “flip” mask ! • studies show increased movement from torque involved in rotating facemask • facemask acts as lever arm with helmet, increasing risk of c-spine movement if moved University of Georgia Sports Medicine

  25. Facemask Removal • Be familiar with all types of equipment utilized by your athletes • Utilize quick release facemask clips if possible • Riddell • Schutt University of Georgia Sports Medicine

  26. Facemask Removal:Quick Release Clips University of Georgia Sports Medicine

  27. Spinal Immobilization Techniques • Log roll • Lift and slide University of Georgia Sports Medicine

  28. Spinal Immobilization Techniques • Log roll vs. lift and slide • research compared techniques to assess movement in healthy individuals and destabilized c-spines of cadavers University of Georgia Sports Medicine

  29. Spinal Immobilization Research • Del Rossi, Heffernan and Horodyski; Spine J 2004; 29(7); E134-8 • Del Rossi, Horodyski and Heffernan; J Ath Tr; 38(3); 204-208 • Both techniques created movement; more with log roll University of Georgia Sports Medicine

  30. Supine Log Roll University of Georgia Sports Medicine

  31. Prone Log Roll • In-line c-spine stabilization • Thumbs toward face • If c-spine not in neutral, gently correct unless resistance met • Airway takes priority over c-spine University of Georgia Sports Medicine

  32. Prone Log Roll • Pull technique University of Georgia Sports Medicine

  33. Prone Log Roll • Push technique University of Georgia Sports Medicine

  34. Centering on Spine Board • Position top of board ~ 10-12 inches above athletes’ head to allow for further centering movement when positioned on board University of Georgia Sports Medicine

  35. Centering on Spine Board • Various techniques • angled centering • over and up on angle • avoid straight lateral movements University of Georgia Sports Medicine

  36. Centering on Spine Board • Athlete may be straddled by one or multiple rescuers and clothing gripped to facilitate centering University of Georgia Sports Medicine

  37. Lift and Slide • May be lifted from sides or by straddling athlete • Requires multiple rescuers (6-8) University of Georgia Sports Medicine

  38. Straps & Strapping Technique • Pin and speed clip system • requires customized spine board • allows for multiple strapping techniques • rapid fixation to spine board University of Georgia Sports Medicine

  39. Straps & Strapping Technique • Velcro “Spider” Straps” University of Georgia Sports Medicine

  40. Securing to Spine Board • X-strapping technique from top of shoulder under opposite axilla • Minimizes translation on spine board • important with acceleration/ deceleration of ambulance University of Georgia Sports Medicine

  41. Securing to Spine Board • Effectiveness of Strapping Techniques in Spinal Immobilization • Annals of Emergency Med. Mazolewski and Manix. 23:6 June 1994 University of Georgia Sports Medicine

  42. Securing to Spine Board • Head should be last body segment secured to spine board • Use circumferential taping technique for top of head • Eyebrows as landmark if no helmet • Secure chin • Secure wrists together • outside of spine board straps University of Georgia Sports Medicine

  43. Athletic Equipment Removal • Many EMTs in past have advocated removal of helmets or headgear • Many ATCs in past have advocated leaving athletic helmet or headgear in place • Both schools of thought provide rationales for that course of treatment • “All or none” principle ? University of Georgia Sports Medicine

  44. Paradigm Shift in Equipment Removal ? Full Body Immobilization With andWithout Equipment

  45. Transfer to Spine Board

  46. Helmet Removal

  47. Shoulder Pad Removal University of Georgia Sports Medicine

  48. Shoulder Pad Removal

  49. Emergency Room Education • Medical team may choose to remove athletic equipment following transportation to an emergency facility and following the evaluation and diagnostic testing • Emergency room workers should be trained in athletic equipment removal University of Georgia Sports Medicine

  50. Conclusion • Important to develop standard guidelines • Carefully weigh all factors and make educated decision on what fits best into individual situation • Proper planning and preparation • Sports medicine team concept • Further research and training needed in spinal immobilization and equipment removal techniques University of Georgia Sports Medicine

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