Pre hospital managrment of spinal cord injury presentation.pptx

Spinal cord injury

1. PRE HOSPITAL CARE FOR SPINAL CORD INJURY : PITFALLS AND DEVELOPING FRAMEWORK IN INDIA /DEVELOPING COUNTRIES DR.NEERAJ GUPTA M.B.B.S, DNB ORTHO FNB (SPINE SURGERY )

2. INCIDENCE In India, approximately 1.5 million people live with SCI. Approximate 20,000 new cases of SCI are added every year and 60-70% of them are illiterate, poor villagers. Majority of them are males in the age group of 16-30 years, signifying higher incidence in young, active and productive population of the society. Singh, R.. (2012). Epidemiology of spinal cord injuries: Indian perspective. Epidemiology of Spinal Cord Injuries. 157-168.  The prevalence of SCI was highest in the United States of America (906 per million) and lowest in the Rhone- Alpes region, France (250 per million) Singh A, Tetreault L, Kalsi -Ryan S, Nouri A, Fehlings M. Global prevalence and incidence of traumatic spinal cord injury .  Clin Epidemiol . 2014;6:309-331.https://doi.org/10.2147/CLEP.S68889

3. PRE- HOSPITAL MANAGEMENT Examination of the patient Spinal immobilisation Careful airway management(intubation, if indicated, using manual in-line stabilisation ) Cardiovascular support (maintenance of mean arterial blood pressure above 90 mmHg)

4. Examination of the patient Improper or lack of immobilization : stable vertebral fracture → unstable fracture → secondary injury. Significant mechanism of injury Unreliable patient Difficulty to participate in a spinal clearance protocol assessment. Pain or tenderness in any location along the length of the spine Any motor or sensory deficit Immobilization onto a spine board.

5. An unreliable patient : acute stress reaction Drug/ Alcohol intoxication Head injury Language barrier Communication gap Distracting injury (e.g. extremity fracture). The NEXUS rules identified five low risk criteria which, if met, could exclude injury: no midline tenderness no focal neurological deficit normal alertness no intoxication no painful distracting injury

6. Spinal immobilisation Scoop stretcher Spine board with head immobiliser Cervical collar Kendrick extrication device Manual in-line stabilisation

7. Careful airway management Establish and maintain a patent airway. Assess tidal volume and rate of respiration. Tidal volume / rate inadequate → positive pressure ventilation with supplemental oxygen Respirations adequate → oxygen based on the SpO2 reading and patient signs and symptoms of hypoxia or respiratory distress. If SpO2 < 95 percent on room air / signs of hypoxia : administer oxygen via a non- rebreather mask at 15 Lpm . Inadequate airway /inadequate ventilation/ poor oxygenation → hypoxia, hyper- carbia and acidosis → secondary spinal cord injury.

8. Cardiovascular support (MAP > 90 mmHg ) Reverse hypotension : i.v . infusion of NS or RL with a large bore catheter and macrodrip tubing. Maintain SBP of at least 90 mmHg. Vasogenic component of spinal shock : SBP of ≈ 80 mmHg Fluid infusion → No ↑ SBP / profound signs of hypoperfusion → vasopressor agent (e.g. dopamine). Begin at 5 mcg/kg/minute and titrate up quickly. At lower doses, dopamine primarily has a beta effect. Once a dose of 10 mcg/kg/minute → alpha stimulation → systemic vasoconstriction.

9. Demographics The demographic profile of SCI in this cohort reflects that observed in past studies 5-8 .Previously Singh et al 5 suggested the M:F of SCI was equalising as gender roles evolve in Indian society. However this trend was not observed in this study, potentially due to the smaller sample size. Government data 9 also reports women are less likely to be admitted to hospital than men, a further potential explanation for the gender bias. Although twice as many people live in rural than urban India 10, 70% of this cohort sustained injuries in an urban setting. It is not possible to determine whether this is due to a higher incidence rate in urban areas or the inability of rural residents to reach an urban care facility. A seasonal variation in SCI is observed in this cohort. This presents the opportunity to provide educational reminders at certain times of the year. Pre-Hospital Care of Spinal Cord Injuries in India. Kasha Rogers-Smith 1 , Dr Chris Turner (ED Consultant) 2 and Dr HS Chhabra (Spinal Surgeon) 3.1 University of Warwick; 2 University Hospital Coventry and Warwickshire (UHCW); 3 Indian Spinal Injuries Centre, New Delhi, India

10. Injury RTAs were the commonest cause of SCI in this study. As the country undergoes urbanisation and increased vehicular use the % of total SCI from RTA has increased whilst those due to falls from height has decreased. 53.3% of SCI were caused by RTAs in this study compared to 24.4% in a UK study 11 . The use of seatbelts reduces SCI 12 , although seatbelts are mandatory for front seat passengers this is not the case for rear passengers and those travelling in older vehicles 13 . Educating citizens on the life-saving value of a seatbelt may present a simple intervention to reduce deaths and disability from RTAs. 50% of accidents affected vulnerable road users (pedestrians, bicycles, motorcycles), in agreement with data from WHO 14.

11. Pre-hospital transport Half of the patients were transported to hospital by ambulance, supporting a trend of their increasing use in the last decade 15-16. The remaining patients were transported in unsuitable vehicles placing an increased risk of secondary injury. Ambulance transfer times in urban and rural areas varied greatly. To achieve uniformity in EMS across such a vast country, a strong focus on developing infrastructure in rural regions is required.

12. PRE-HOSPITAL CARE Despite being transported by ambulance only a minority of these patients received pain relief or were immobilised. There are huge inconsistencies in the training of ambulance personnel 17-19 . A significant impact could be made by adopting a country wide universal ambulance technician qualification. 16.67% of this cohort received pre-hospital care (defined as: analgesia or immobilisation). Previous studies reported between 11% 4 and 73% 20 demonstrating huge variability across the country. However these studies failed to define what is meant by pre-hospital care.

13. Clinical Pathway 73.3% of patients presented initially to government hospitals, this may be because private hospitals are reluctant to accept emergency cases for medico-legal reasons 6 . A minority of patients went home following injury suggesting an opportunity to educate the general public on SCI awareness. Patients moved hospital several times and on average presented to ISIC 45 days after initial injury. This may be due to a lack of information of how to manage a SCI patient. It presents an opportunity for a more co-ordinated medical infrastructure with the identification of specialists and specialist centres for advice.

14. Eighty-five per cent of the spinal cord injured patients were males and the mean age was 34 years (range 13-56 years). Twenty-nine (48.33%) of the spinal injuries occurred due to fall from height. There was an average of 45 days (range 0-188 days) of delay in presentation to a specialized spinal unit and most of the time the cause for the delay was unawareness on the part of patients and/or doctors regarding specialized spinal units. In 38 (62.5%) cases the mode of transportation of the spinal cord injured patient to the first visited hospital was by their own conveyance and the attendants of the patients did not have any idea about precautions essential to prevent neurological deterioration. Seventeen (28.33%) patients were given injection solumedrol with conservative treatment, 35 (60%) patients were given only conservative treatment and seven patients were operated (11.66%) upon at initially visited hospital. Of the seven patients operated five were fixed with posterior Harrington instrumentation (71.42%) and two (28.57%) were operated by short segment posterior pedicle screw fixation. None of the patients were subjected to physiotherapy-assisted transfers or wheel chair skills or even basic postural training, proper bladder/ bowel training program and sitting balance. Conclusion: Awareness on the part of the general population, attendants of the patients, clinical and paraclinical team regarding spinal cord injury needs to be addressed. Safe mode of transportation of spinal cord injured patient and early presentation at tertiary spinal care center with comprehensive spinal trauma care team should be stressed upon Pandey V, Nigam V, Goyal TD, Chhabra H. Care of post-traumatic spinal cord injury patients in India: An analysis . Indian J Orthop . 2007 Oct;41(4):295-9. doi : 10.4103/0019-5413.36990. PMID: 21139781; PMCID: PMC2989513.

15. There was no uniform opinion about spinal immobilization of patients with suspected TSCI. The novel lateral trauma position and one of two High Arm IN Endangered Spine (HAINES) methods are preferred methods for unconscious patients. Controlled self-extrication for patients with stable hemodynamic status is recommended. Early and proper identifying of potential TSCI by PHC providers can significantly improve patients’ outcomes and can result in avoiding unwanted spinal immobilization. Future prospective studies with a large sample size in real-life settings are needed to provide clear and evidence-based data in PHC of patients with suspected TSCI. Cite this article Habibi Arejan , R., Asgardoon , M.H., Shabany , M.  et al.   Evaluating prehospital care of patients with potential traumatic spinal cord injury: scoping review .  Eur Spine J   31 , 1309–1329 (2022). https://doi.org/10.1007/s00586-022-07164-4

16. PITFALLS NEGLECTING MEASURES FOR INJURY PREVENTION INAPPROPRIATE EXTRICATION IMPROPER IMMOBILISATION INAPPROPRIATE PRE HOSPITAL TRANSPORT UNTRAINED STAFF /AMBULANCE PERSONEL

17. SUMMARY INJURY PREVENTION : SEAT BELT ,HELMET PROPER IMMOBILISATION : CERVICAL COLLAR ,SPINE BOARD PROPER TRANSPORT : AMBULANCE WITH BLS PROPER TRAINED AMBULANCE PERSONEL