6. Primary survey
Airway : Alert ,can speak ,O2 sat. 98% ,C-spine tenderness at C6-
C7 level
Breathing : RR 22 /min , symmetrical chest movement ,no
cyanosis ,chest compression test : negative
Circulation : BP 141/69 mmHg , Pulse 92 bpm full regular ,good
consciousness ,warm skin ,no active bleeding
Disability : GCS E4V5M6 ,Pupil 3 mm RTLBE
Exposure : Abrasion wound at posterior lower neck ,Rt.forearm
And Rt. shoulder
7. Initial management
• On philadaphia collar
• Film C-spine AP,Lat,Swimming view
• Film T-L spine AP,Lat
• Film CXR
8.
9.
10.
11.
12.
13.
14. Past history
Allergy : ไม่แพ้ยา/อาหาร
Medication : ไม่มียารับประทานประจา
Past illness : ปฎิเสธโรคประจาตัว
Last meal : 4 ชั่วโมง
Environment/Event : MC ล้มบนถนน มีแผลถลอกที่คอเล็กและแขนเล็กน้อย
15. Secondary survey
Head : good of consciousness
no fractures
Maxillofacial : no deformities
Cervical spine : Contusion and mark tenderness
at C-spine with limited motion
Chest : symmetrical chest movement , trachea in midline ,resonance on percussion ,
clear ,no adventitious sound
Abdomen : Soft, not tender
Perineum :
Rectum good sphincter tone
normal perianal sensation
Bulbocavernosus positive
16. Neurological Examination
Mental status : Alert, well cooperative
Cranial nerve : Pupil 3 mms RTLBE ,Full EOM ,No facial palsy ,no dysarthria
Motor : flaccid tone both upper extrimities
Sensory : Decrease pinprick sensation both hand
Normal propioception
DTR 2 all
Others
Bulbocavernosus reflex : positive
BKK : negative
17. Musculoskeletal : Motor
elbow flexors gr. V R=L
wrist extensors gr. II R=L
elbow extensors gr. II R=L
finger flexors gr. 0 R=L
finger abductors gr. 0 R=L
hip flexors gr. V R=L
knee extensors gr. V R=L
ankle dorsiflexors gr. V R=L
big toe extensors gr. V R=L
ankle plantarflexors gr. V R=L
42. Emergency Department Management
Airway management
The cervical spine must be maintained in neutral alignment at all times.
Clearing of oral secretions and/or debris is essential to maintain airway patency and to prevent
aspiration.
The modified jaw thrust and insertion of an oral airway may be all that is required to maintain an airway
in some cases.
43. Emergency Department Management
Hypotension, hemorrhage, and shock
Hypotension may be hemorrhagic and/or neurogenic in acute spinal cord injury. Because of the
vital sign confusion in acute spinal cord injury and the high incidence of associated injuries, a
diligent search for occult sources of hemorrhage must be made.
The most common sources of occult hemorrhage are injuries to the chest, abdomen, and
retroperitoneum and fractures of the pelvis or long-bones. Appropriate investigations, including
radiography or computed tomography (CT) scanning, are required. In the unstable patient,
diagnostic peritoneal lavage or bedside FAST (focused abdominal sonography for trauma)
ultrasonographic study may be required to detect intra-abdominal hemorrhage.
44. Comparison of neurogenic and hypovolemic
shock
Neurogenic Hypovolemic
Etiology Loss of sympathetic outflow Loss of blood volume
Blood pressure Hypotension Hypotension
Heart rate Bradycardia Tachycardia
Skin temperature Warm Cold
Urine output Normal Low
45. Neurogenic Shock
Temporary loss of autonomic function of the cord at the level of injury
◦ results from cervical or high thoracic injury
Presentation
◦ Flaccid paralysis distal to injury site
◦ Loss of autonomic function
◦ hypotension
◦ vasodilatation
◦ loss of bladder and bowel control
◦ loss of thermoregulation
◦ warm, pink, dry below injury site
◦ bradycardia
46. Spinal shock
• Immediately after a spinal cord injury.
•Physiological loss of spinal cord function caudal to the level of injury.
• Flaccid paralysis
• Anethesia
• Absent bowel and bladder control
• Loss of reflex activity
47. Emergency Department Management
Neurogenic shock management
O2 supplement
Retain foley catheter >> Monitor urine output keep > 30 ml/hr
Fluid replacement with isotonic crystalloid solution to a maximum of 2 L
Hemodynamically significant bradycardia may be treated with atropine.
Rarely, inotropic support with dopamine or norepinephrine is required.low
doses of dopamine in the 2- to 5-mcg/kg/min.
Prevent hypothermia
48. Emergency Department Management
Head injuries and neurologic
Pulmonary complication
Weakness of diaphragm or chest wall muscle
Ileus
50. Indication for surgery
1. Unstable fracture-dislocations with spinal cord injury
2. Progressive neurologic deficit with persistent fracture and/or dislocation, not corrected by
closed methods
3. Persistent of incomplete spinal cord injury with continued impingement on neural tissue
4. Late instability or deformity with continued cord percussion and neurologic deficitor chronic
pain
51. Principles of Surgical Treatment for Acute
Spinal CordInjury
1. Decompressionเพื่อลดการกดทับต่อไขสันหลังและรากประสาท
2. Realignment เพื่อจัดกระดูกและข้อเคลื่อนให้อยู่ในแนวตรงให้มากที่สุด ลดความเจ็บปวด และลดการกดทับต่อระบบประสาท
◦ Open or Close method
3. Stabilization & Fusion เพื่อยึดตรึงกระดูกสันหลังที่แตกหักหรือข้อเคลื่อนให้มีความ มั่นคง
◦ External stabilization & rigid orthosis
◦ Internal fixation
