RCoA PHEM & Motorsport Day Disability: Spinal Cord & Brain Injury
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1 RCoA PHEM & Motorsport Day Disability: Spinal Cord & Brain Injury Ma< Wiles Consultant Neuroanaesthesia/CriBcal Care, Sheffield Editor, Anaesthesia h<p://sthjournalclub.wordpress.com/
2 ObjecBves 1. Anatomy of spinal cord injury 2. Evidence for protecbon of the spinal cord a. Cervical collars b. Manual in-line stabilisabon c. Tracheal intubabon d. ExtricaBon devices 3. Diagnosis and management of concussion
3
4
5 NICE Spinal Injury Guidelines 2016
6 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 generabons of medical providers and accepted without serious challenge or invesbgabon
7 Epidemiology of SCI Thompson et al. J Spinal Cord Med 2015; 38: pabents in Canada 13 year increase in mean age from > 60% pabents aged > 55 years 80% tetraplegia Increase in central cord syndrome
8 AsymptomaBc cervical spine disease Brinjikji et al. Am J Neuroradiol 2015; 36:
9 Cervical Collars & Spinal Boards The best place for cervical collars is in the bin Dr Per KrisBan Hyldmo
10 The Argument for Cervical ImmobilisaBon PaBent may have an unstable spinal injury Further movement of the cervical spine may further damage the spinal cord Cervical immobilisabon is a harmless intervenbon Collars prevent movement of the cervical spine
11 Epidemiology of SCI Hasler et al. J Trauma 2012; 72: " 45" 40" 35" 30" 25" 20" 15" 10" 5" 0" RTC" Fall">"2m" Fall"<"2m" Sports" Other" All"Injuries" Cord"Injuries"
12 Epidemiology of SCI Hasler et al. J Trauma 2012; 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]
13 Epidemiology of SCI Hasler et al. J Trauma 2012; 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% extremibes 14% chest
14 DistracBng Injuries Rose et al. J Trauma 2012; 73: SensiBvity 99% Specificity 99%
15 Efficacy of ImmobilisaBon Techniques Horodyski et al. J Emer Med 2011; 41:
16 ExtricaBon Techniques Engsberg et al. J Emer Med 2013; 44:
17 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
18 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 complicabons: Pressure sores/sepsis (6-67%) Airway management difficulbes Increased ICP AgitaBon & discomfort DifficulBes with invenbons/care bundles
19 Cervical Collars & Spinal Boards Fa<ah et al. Scand J Trauma Resusc Emerg Med 2011; 19: 45
20 Cervical ImmobilisaBon Oteir et al. Injury Int J Care Injured 2015; 46: SystemaBc review of pre-hospital immobilisabon 4 studies from 1471 citabons (no RCTs) Increased mortality in penetrabng trauma (OR 2.77) Increased risk of neurological injury (AOR 2.03) Scene Bme doubled Longer ICU stay (7.5 vs. 2.3 days)..lack of high-level evidence on the effect of pre-hospital cervical spine immobilisabon on pabent outcomes
21 Manual In-line StabilisaBon 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: OpBmal posibon MILS OpBmal posibon 46 4 MILS Collar/tape/sandbags
22 Anatomy of Spinal Cord Injury Crosby. Anesth 2006; 104: Space available for spinal cord (SAC): 1/3 odontoid; 1/3 cord; 1/3 space
23 Risk of Laryngoscopy Hindman et al. Anesth 2011; 114: McLeod & Calder. Br J Anaes 2000; 84: case reports of worsening SCI ater intubabon Li<le to implicate laryngoscopy as cause Closed Claims Analysis: (n=7740) 48 cases idenbfied (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
24
25 Cervical Spine & Airway Manoeuvres Donaldson et al. Spine 1997; 22: Donaldson et al. Spine 1993; 18: Cadavers with unstable C1-2 MILS Glouc view achieved not stated Space available for cord assessed Jaw thrust > chin lit > laryngoscopy Cadavers with unstable C5-6 No MILS Glouc view achieved not stated Cervical spine mobon assessed Chin lit/jaw thrust cricoid pressure laryngoscopy
26 Cervical Spine & BVM VenBlaBon Hauswald et al. Am J Emerg Med 1991; 9: Cadavers studied within 40 min of death Collar, spinal board, tape Glouc view achieved not stated Neck maintained in neutral Mask venblabon >> tracheal intubabon [P= ] Mask A Mask B Miller 3 MacIntosh 3 FOI Oral FOI Nasal
27 Cervical Spine & Direct Laryngoscopy McCahon et al. Anaesthesia 2015; 70: Odontoid peg fracture in cadavers Minimal glouc exposure MILS Assessed space available for spinal cord Airtraq, McCoy & Mac 3 no significant difference
28 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 FibreopBc intubabon [Sahin et al. EJA 2004; 21: ] No MILS Best possible glouc view achieved FOI significantly less movement at C1/2 (8 ) but not C2/3 compared to direct laryngoscopy
29
30 Chronic TraumaBc Encephalopathy
31 Why don t woodpeckers get TBI?
32
33 Concussion in Motorsport Fernandes et al. J Eng Med 2015; 229:
34 Concussion in Motorsport Dowd et al. Trauma 2013; 15: Minoyama et al. Br J Sports Med 2004; 38:
35 Impact Brain Apnoea Atkinson. Mayo Clin Proc 2000; 75: 37-47
36 Concussion Diagnosis 1. American Medical Society for Sports Medicine posibon statement: Concussion in sport (Clin J Sport Med 2013; 23:1-18) 2. American Academy of Neurology summary of evidence-based guideline update: EvaluaBon and management of concussion in sports (Neurology 2013; 80: ) 3. Consensus statement on concussion in sport: The 4th InternaBonal Conference on Concussion in Sport held in Zurich, November 2012 (Br J Sports Med 2012; 47: )
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38 Concussion in Motorsport Auto-Cycle Union Handbook 2016
39 Summary Maximal insult to the spinal cord occurs at the Bme of injury
40 Summary Maximal insult to the spinal cord occurs at the Bme 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 than is thought and is easily treated
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