ABC in Spine Trauma

At present the annual incidence of spinal cord injury within the United Kingdom isabout 10 to 15 per million of the population. In recent years there has been an increase in the proportion of injuries to the cervical spinal cord, and this is now the mostcommon indication for admission to a spinal injuries unit. Only about %5 of spinalcord injuries occur in children, mainly following road trauma or falls from a heightgreater than their own, but they sustain a complete cord injury more frequently thanadults. Although the effect of the initial trauma is irreversible, the spinal cord is at riskfrom further injury by injudicious early management. The emergency services mustavoid such complications in unconscious patients by being aware of the possibilityof spinal cord injury from the nature of the accident, and in conscious patients bysuspecting the diagnosis from the history and basic examination. If such an injury issuspected the patient must be handled correctly from the outset.The unconscious patient: Although the spine is best immobilised by placing thepatient supine, and this position is important for resuscitation and the rapidassessment of life threatening injuries, unconscious patients on their backs are atrisk of passive gastric regurgitation and aspiration of vomit. This can be avoidedby tracheal intubation, which is the ideal method of securing the airway in anunconscious casualty. If intubation cannot be performed the patient should be logrolled carefully into a modified lateral position 80–70˚ from prone with the headsupported in the neutral position by the underlying arm. The indications for trachealintubation in spinal injury are similar to those for other trauma patients: the presenceof an insecure airway or inadequate arterial oxygen saturation (i.e. less than %90)despite the administration of high concentrations of oxygen. With care, intubationis usually safe in patients with injuries to the spinal cord, and may be performed atthe scene of the accident or later in the hospital receiving room, depending on thepatient’s level of consciousness and the ability of the attending doctor or paramedic.If possible, suction should be avoided in tetraplegic patients as it may stimulate thevagal reflex, aggravate preexisting bradycardia, and occasionally precipitate cardiacarrest (to be discussed later). The risk of unwanted vagal effects can be minimised ifatropine and oxygen are administered beforehand.The conscious patient: The diagnosis of spinal cord injury rests on the symptoms andsigns of pain in the spine, sensory disturbance, and weakness or flaccid paralysis. Inconscious patients with these features resuscitative measures should again be givenpriority. At the same time a brief history can be obtained, which will help to localize the level of spinal trauma and identify other injuries that may further compromise thenutrition of the damaged spinal cord by producing hypoxia or hypovolaemic shock.