RCoA PHEM & Motorsport Day Disability: Spinal Cord & Brain Injury

Transcription

1 RCoA PHEM & Motorsport Day Disability: Spinal Cord & Brain Injury Matt Wiles Consultant Neuroanaesthesia/Critical Care, Sheffield Editor, Anaesthesia

2 Objectives 1. Anatomy of spinal cord injury 2. Evidence for protection of the spinal cord a. Cervical collars b. Manual in-line stabilisation c. Tracheal intubation d. Extrication devices 3. Diagnosis and management of concussion

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4 NICE Spinal Injury Guidelines 2016

5 Winning hearts and minds Newman. J Emerg Med 2007; 50: Semmelweiss Reflex The reflex-like tendency to reject new evidence of knowledge because it contradicts established norms, beliefs or paradigms Pseudoaxioms False principles or rules handed down through generations of medical providers and accepted without serious challenge or investigation

6 Epidemiology of SCI Thompson et al. J Spinal Cord Med 2015; 38: patients in Canada 13 year increase in mean age from > 60% patients aged > 55 years 80% tetraplegia Increase in central cord syndrome

7 Asymptomatic cervical spine disease Brinjikji et al. Am J Neuroradiol 2015; 36:

8 Epidemiology of SCI Hasler et al. J Trauma 2011; 72: RTC Fall > 2m Fall < 2m Sports Other All Injuries Cord Injuries

9 Cervical Collars & Spinal Boards The best place for cervical collars is in the bin Dr Per Kristian Hyldmo

10 The Argument for Cervical Immobilisation Patient may have an unstable injury Further movement of the cervical spine may further damage the spinal cord Cervical immobilisation is a harmless intervention Collars prevent movement of the cervical spine

11 Epidemiology of SCI Hasler et al. J Trauma 2011; 72: Median age 47.2 years 66% male 3.5% had cervical spine injuries 10.3% in those with GCS 3 to 8 only 23% had neurological symptoms [0.8% of total]

12 Epidemiology of SCI Hasler et al. J Trauma 2011; 72: Median age 47.2 years 66% male 3.5% had cervical spine injuries 10.3% in those with GCS 3 to 8 only 23% had neurological symptoms [0.8% of total] 25% had injuries to other regions 16% head 16% extremities 14% chest

13 Cervical Collars & Spinal Boards Sundstrøm et al. J Neurotrauma 2014; 31: Bednar. Can J Surg 2004; 47: Most spinal injuries are stable; those that are unstable have already caused irreversible damage

14 Cervical Collars & Spinal Boards Sundstrøm et al. J Neurotrauma 2014; 31: Bednar. Can J Surg 2004; 47: Most spinal injuries are stable; those that are unstable have already caused irreversible damage Exaggerated rate of secondary SCI without collars Numerous associated complications: Pressure sores/sepsis (6-67%) Airway management difficulties Increased ICP Agitation & discomfort Difficulties with inventions/care bundles

15 Efficacy of Immobilisation Techniques Horodyski et al. J Emer Med 2011; 41:

16 Extrication Techniques Engsberg et al. J Emer Med 2013; 44:

17 Cervical Collars & Spinal Boards Fattah et al. Scand J Trauma Resusc Emerg Med 2011; 19: 45

18 Cervical Immobilisation Oteir et al. Injury Int J Care Injured 2015; 46: Systematic review of pre-hospital immobilisation 4 studies from 1471 citations (no RCTs) Increased mortality in penetrating trauma (OR 2.77) Increased risk of neurological injury (AOR 2.03) Scene time doubled Longer ICU stay (7.5 vs. 2.3 days)..lack of high-level evidence on the effect of pre-hospital cervical spine immobilisation on patient outcomes

19 Manual In-line Stabilisation Manoach & Paladino. Ann Emerg Med 2007; 50: Origin uncertain ATLS guidance 1984 Data from cadaveric studies, healthy volunteers and case series (n=96) Several studies suggest MILS has no effect on cervical segment movement Study Method Grade 1 Grade II Grade III Grade IV Nolan & Wilson. Anaesthesia 1993; 48: Heath. Anaesthesia 1994; 49: Optimal position MILS Optimal position 46 4 MILS Collar/tape/sandbags

20 Anatomy of Spinal Cord Injury Crosby. Anesth 2006; 104: Space available for spinal cord (SAC): 1/3 odontoid; 1/3 cord; 1/3 space

21 Risk of Laryngoscopy Hindman et al. Anesth 2011; 114: McLeod & Calder. Br J Anaes 2000; 84: case reports of worsening SCI after intubation Little to implicate laryngoscopy as cause Closed Claims Analysis: (n=7740) 48 cases identified (0.9% of GA claims) Majority (>75%) had stable c-spines prior to procedure Nine had unstable cervical spines Two cases of cord injury with direct laryngoscopy implicated Two cases occurred despite AFOI

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23 Cervical Spine & Airway Manoeuvres Donaldson et al. Spine 1997; 22: Donaldson et al. Spine 1993; 18: Cadavers with unstable C1-2 MILS Glottic view achieved not stated Space available for cord assessed Jaw thrust > chin lift > laryngoscopy Cadavers with unstable C5-6 No MILS Glottic view achieved not stated Cervical spine motion assessed Chin lift/jaw thrust cricoid pressure laryngoscopy

24 Cervical Spine & BVM Ventilation Hauswald et al. Am J Emerg Med 1991; 9: Cadavers studied within 40 min of death Collar, spinal board, tape Glottic view achieved not stated Neck maintained in neutral Mask ventilation >> tracheal intubation [P= ] Mask A Mask B Miller 3 MacIntosh 3 FOI Oral FOI Nasal

25 Cervical Spine & Direct Laryngoscopy McCahon et al. Anaesthesia 2015; 70: Odontoid peg fracture in cadavers Minimal glottic exposure MILS Assessed space available for spinal cord Airtraq, McCoy & Mac 3 no significant difference

26 Cervical Spine & Other Airway Techniques LMA [Kilic et al. Am J Emerg Med 2013; 31: ] Done in cervical collars LMA & ilma similar to Macintosh GlideScope [Robitaille et al. Anesth Analg 2008; 106: ] MILS No difference between Macintosh and GlideScope Fibreoptic intubation [Sahin et al. EJA 2004; 21: ] No MILS Best possible glottic view achieved FOI significantly less movement at C1/2 (8 ) but not C2/3 compared to direct laryngoscopy

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28 Chronic Traumatic Encephalopathy

29 Why don t woodpeckers get TBI?

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31 Concussion in Motorsport Fernandes et al. J Eng Med 2015; 229:

32 Concussion in Motorsport Dowd et al. Trauma 2013; 15: Minoyama et al. Br J Sports Med 2004; 38:

33 Impact Brain Apnoea Atkinson. Mayo Clin Proc 2000; 75: 37-47

34 Concussion Diagnosis 1. American Medical Society for Sports Medicine position statement: Concussion in sport (Clin J Sport Med 2013; 23:1-18) 2. American Academy of Neurology summary of evidence-based guideline update: Evaluation and management of concussion in sports (Neurology 2013; 80: ) 3. Consensus statement on concussion in sport: The 4th International Conference on Concussion in Sport held in Zurich, November 2012 (Br J Sports Med 2012; 47: )

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36 Concussion in Motorsport Auto-Cycle Union Handbook 2016

37 Summary Maximal insult to the spinal cord occurs at the time of injury

38 Summary Maximal insult to the spinal cord occurs at the time of injury Hypotension & hypoxia will worsen spinal cord injury to a greater extent than any movement Don t delay life-saving treatment(s) to adhere to non-evidenced based guidelines Impact brain apnoea is more common that is thought and is easily treated