North West London Trauma Network Spinal Pathway and Protocols

Transcription

1 North West London Trauma Network Spinal Pathway and Protocols 1. Spinal Clearance in the Trauma Patient Inclusions: All trauma patients who are not alert and orientated, unable to cooperate (including intoxication) or who have distracting injuries precluding reliable clinical assessment. Exclusions: Children under the age of Protection and immobilisation of entire spine From arrival of patient until appropriate clinical or radiological clearance of spinal injury. Immobilisation using all of the following: Semi-rigid collar (Miami J collar) (Stif-Nek collar to be replaced within 2 hours of arrival); 1 litre fluid bags (as blocks) and tape; firm mattress; entire bed may be tilted head up to 30 degrees, but no break in the bed at the patient s waist Documentation In all at risk patients, documentation of the neurological status and a clinical examination of the entire spine. The ASIA score should be documented within 24 hours of admission Radiological spinal clearance imaging If any symptom or sign of spinal cord injury, or anticipated that a patient will remain unconscious, unassessable or unreliable for clinical examination for more than 48 hours. Cervical spine: 2-3mm (thin slice) helical CT scan from the base of the skull to T4/5 with both sagittal and coronal reconstructions. This should be undertaken with the first CT brain in all head injured patients with an altered level of consciousness. Thoracic and lumbar spine: Either sagittal and coronal reformatting of <5mm slice helical CT scans of chest, abdomen and pelvis, or AP and lateral plain radiographs. A senior radiologist must report spinal clearance images prior to withdrawal of spinal protection precautions. Ideally completed within 12 hours, but within a maximum of 48 hours. 2. Detection of spinal cord injury If a spinal cord injury is detected, a neurological assessment must be repeated 2 hourly, and a telephone referral made to the Spinal Cord Injury Centre within 4 hours of arrival ( ). Consider urgent MRI if the neurological deficits are secondary to spinal cord injury. All must be admitted to HDU for invasive BP monitoring aiming for normotension and good oxygenation. North West London Trauma Network 1

2 Spinal Evaluation Flow Diagram Clinical assessment 1 Alert and orientated (GCS 15/15) 2 No sedation/intoxicants/alcohol/opioid 3 No distracting pain from other injuries 4 No tenderness / step / deformity on examination entire bony spine 5 No neurological deficit referable to spinal injury Group 1 Yes to all 5 Group 2 No to 1 or more Group 3 Neurological deficit referable to spinal injury, or step/deformity of spine No neck or back pain on active movement Maintain spine immobilization, perform spinal imaging, radiology report within hr: Cervical spine Fine cut (2-3mm) helical CT scan to T4/5, with sagittal & coronal reconstructions & Thoracic & Lumbar spine if unconscious or intubated, or mechanism of injury suggests high risk of spinal injury, or C spine fracture <5mm slice helical CT scan with sagittal & coronal reconstructions, or AP and lateral plain radiographs Maintain whole spine immobilization Perform CT of cervical, thoracic & lumbar spine and consider urgent MRI of spine Contact Spinal Cord Injury Service on within 4 hours Admit to HDU for invasive BP monitoring aiming normotension + good oxygenation Uninjured spine Removal of immobilisation with close observation ** within hr Development of weakness, paraesthesia or pain may indicate a missed injury, reinstate immobilization Reported as clear by senior radiologist Reported as abnormal by senior radiologist Cervical spine injury Continue immobilisation with Miami J collar, fluid bags & tape. Can sit up 45 degrees if isolated C spine injury. Thoracic/Lumbar injury Continue immobilization with log rolling, firm mattress & flat bed rest. Entire bed can be tilted head up to 30 degrees. Seek orthopaedic/neurosurgical advice ** Radiologically clear C spine incidence of unstable cervical injury <0.5%. Hence all intubated patients must have head in midline position with fluid bags & tape (collar can be removed). Miami J should be replaced immediate before sedation hold/extubation. Radiologically clear T & L spine incidence of T & L ligamentous injury <0.05%, hence NO T/L immobilization. North West London Trauma Network 2

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4 SPINAL CORD INJURY Spinal cord injury may be recorded using the American Spinal Injury Association (ASIA) chart. This is how all spinal-injured patients are assessed at St. Mary s MTC. It has a number of benefits: - It provides a quick reference guide to dermatomes and myotomes when performing a neurological examination for suspected spinal cord injury; - The patient s neurological status can be given motor and sensory scores (ASIA score) which helps describe a breakdown of the severity of injury; - Scoring on the ASIA Impairment Scale (A E, see below), can be done to present a broader picture of the spinal cord lesion; - These scores can be repeated to track any changes in the spinal cord lesion; - Using the ASIA chart and the standardised terminology therein facilitates discussions with the Neurotrauma team when referring patients, as this is the language used for the assessment of spinal cord trauma patients at the MTC. North West London Trauma Network 4

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6 Spinal clearance checklist Complete at admission and amend over time. 1) History Given the mechanism of injury, is there risk of spinal injury? Yes / No 1. Name Date of birth Hospital no. 1 High energy mechanism (e.g. fall >2m, pedestrian or any road traffic accident, polytrauma) Yes / No 2 Admission GCS <15/15 or abnormal brain CT scan Yes / No 3 Associated distracting injures Yes / No 2) Examination Is there risk of spinal injury? Yes / No 1 Neck or back pain Yes / No 2 Spinal tenderness, deformity or steps on log roll Yes / No 3 neurological signs referrable to spinal injury Yes / No (systolic bp <90, loss perianal sensation or anal tone, priapism, abnormal upper or lower limb power & reflexes) 3) Radiological clearance Reported by senior radiologist within hours C spine: Fine cut (2-3mm) helical CT scan to T4/5, with coronal & sagittal reconstructions T&L spine: <5mm slice helical CT scan with coronal & sagittal reconstructions, or AP & lateral Xrays C spine Required Radiological clearance Date By whom Yes No Yes No, unstable / stable Injuries are: T&L spine 4) Spinal Immobilisation This will progress to no precautions over time. C spine Required Immobilisation: full / limited / none Date By whom Yes No Full: Miami J collar, fluid bags & tape, midline position, logroll, sit up 45 degrees if isolated C spine injury Limited: either none, or midline position, fluid bags & tape; replace Miami J collar just prior to extubation Limited: mobilise with Miami J collar T&L spine Full: log roll, supine flat bed rest, tilt entire bed head up 30 degrees, scoop stretcher, firm mattress Updates / changes Limited: mobilise with brace, ambulatory X ray North West London Trauma Network 6

7 Further management Name Date of birth Hospital no. Neurological assessment Document every hours Contact bleep if neurological deterioration ASIA score If neurological deficit MRI of spine Contact Spinal Cord Injury Service ( ) Follow Spinal Cord Injury protocol Oxygen mask; Aim systolic blood pressure > Anti thrombosis prophylaxis TEDS plus Flowtrons or TEDS plus tinzaparin (stop tinzaparin 24 hours prior to spinal surgery, restart 48 hours postop, use TEDS plus Flowtrons periop) If surgery, post operative instructions & imaging Clinic follow up Complications associated with spinal precautions Pressure sore Respiratory Raised ICP Halo, Miami J or TL brace management Application Size Fitted by Lying with spinal immobilisation Lying Sitting Duration of use 24 hours / day Only when mobilising / sitting Time period of use weeks Until clinic review Night time only Washing Supine with spinal precautions Sitting with neck still, +/- assistance Remove, no restrictions Date By whom North West London Trauma Network 7

8 2. MIAMI J Collar Management Patient Name: Hospital Number: DOB: STABILITY Level of fracture/ Injury: Unstable: Spinal Precautions Required = Head Hold Y / N = Flat Bed Y / N = Log Roll Y / N Stable Application Lying with Spinal Precautions Lying Sitting Duration of Use 24 hours a Day Only when Sitting/ Mobilising At night time only Time Period of Use weeks Until next Outpatient Consultant Review Indefinitely Washing/ Bathing With assistance Without assistance Neurosurgical Consultant: Signed (Consultant or SpR): Date: Collar fitted by: Supine with Spinal Precautions Sitting with Neck Still Sitting with Neck Still Remove with no restrictions Collar Size: North West London Trauma Network 8

9 3. MIAMI TLSO Request form Patient Name: DOB: Hospital Number: Date: STABILITY Level of Fracture / Injury: Type of Fracture/ Injury: Stable Unstable Spinal Precautions Required - Flat Bed Rest Y / N - Log Roll Y / N Is pain relief optimal prior to measurement and fitment. Y / N Reason for requesting Bracing: Application Pain relief Lying with Spinal Precautions Stability post surgery Lying Support Conservative management Sitting Mobilisation Standing Duration of Use 24 hours a Day Only when Sitting/ Mobilising At night only Can be removed for washing. Time Period of Use weeks Until next Outpatient Consultant Review Indefinitely Neurosurgical Consultant: Consultant or SpR Signature: Orthotist: Orthotist Signature: Physiotherapist: Physiotherapist Signature: Lumbar/TLSO brace fitted by: Signature: Type and Size: North West London Trauma Network 9

10 4. SPINAL INJURY / CORD COMPRESSION Use Spinal Management Pathway pack to initiate assessment. Ascertain whether stable or unstable. (Unstable would be log rolling) Consider level of injury & involvement of respiratory / abdominal muscles initiate use of FVC 4 hourly monitoring if <1.5, consider prophyactic IPPB +/- incentive spirometer to ventilate bases If A&E or extrication collar in place change to Miami J within 24 hours. Ensure nursing staff are documenting Bowels closely Ensure nursing staff have ordered pressure mattress Consider use of abdominal binder if level cervical or thoracic to help maintain intra-abdominal pressures Consider teaching manual assisted cough if weak, ineffective cough Discuss referral to Stoke / Stanmore spinal injury unit with team Ensure ASIA completed within 72 hours North West London Trauma Network 10

11 5. Acute Spinal Cord Injury Physiotherapy Management Pathway Name DOB Hospital # Physiotherapist Signature Initial Acute Assessment (See SCI Management Sheet) Criteria Tick or N/A Document date of injury Document spinal injury level Document stability status Document manual handling guidelines Document any additional injury Apply collars / jackets as ordered by medical staff Assess muscle groups on ASIA chart Variance Date & Initial Acute Respiratory Management Criteria Standard Respiratory Assessment Consider SCI level and respiratory muscle innervation to identify risks Ensure regular FVC measurement Instigate treatment & / or prophylactic treatment. Caution with manual / prophylactic techniques with primary lung Ca / bony mets Daily reassessment / liaison with MDT Tick N/A Variance Date & Initial Acute Physical Management (See database forms) Criteria ASIA form Appropriate databases completed: Proprioceptive defecit Full muscle strength chart Range of movement chart Tone Other limiting factors Assess for and supply any necessary splints and record relevant advice given to MDT. Consider Abdominal Binder. Specific positioning requirements & advice to nursing staff are documented Instigate active assisted ROM programme in line with spinal protocol (limb guidelines for unstable) Consider medical management e.g. baclofen Tick N/A Variance Date & Initial North West London Trauma Network 11

12 Spinal Cord Compression Physiotherapy Management Sheet Name DOB Hospital # SCI Level (Bony / Motor / Sensory) Date of Injury; Stable / Unstable (To be documented by Medical Staff); Surgery and Date; Movement Restrictions (eg Log Rolling); Associated Injury; Other Limiting Factor (eg Bony mets); Chest Status; Ensure regular Bowel Monitoring by Nursing Staff Recommendations; Physiotherapist Signature Date North West London Trauma Network 12