The long backboard on the side of the roadway is one of the more defining pictures for the public when they think about„EMS providers. The transition from providing first aid in scouts versus those who now provide emergency care starts with the backboard in many cases.
Annually 11,000 spinal injuries occur across the United States and generally cost more than $1 million in lifetime expenses for the victims of vehicle accidents, falls, penetrating trauma and sports injuries. Another important statistic: Up to 25 percent of spinal injuries occur from poor handling of patientsafter the initial injury. However, a new treatment modality — induced hypothermia — has come to the forefront following recent news accounts of a miraculous recovery from spinal cord injury.
The Sept. 9 injury of Buffalo Bills tight end Kevin Everett during a home game against the Denver Broncos brought about newfound interest in spinal cord treatment using induced hypothermia after Dr. Barth Green announced in a television news conference that “he has a good chance to walk again.”
Induced hypothermia is a systematic cooling of the body to a moderate hypothermia level, between 32_C and 34_C, for 20 to 24 hours. The treatment is often considered for adult cardiac arrest during ventricular fibrillation and was a recommendation of the Advanced Life Support Task Force of the International Liaison Committee on Resuscitation in 2002.
According to the Miami Project, a group of scientists and researchers at the„University of„Miami, cooling appears to protect neural pathways, which may be beneficial following a spinal cord injury. Similar to using a cold pack to decrease swelling and cellular damage on an injured extremity, laboratory experiments show that cooling appears to work by slowing the damaging inflammatory processes and decreasing cell damage. In studies conducted by the Miami Project, induced hypothermia has reduced spinal swelling and inflammation, bringing about positive outcomes.
The Miami Project was started in 1985 by Dr. Barth Green and three families who had suffered spinal cord injury including NFL Hall of Fame linebacker Nick Buoniconti.
Typically pre-hospital and hospital-based care has relied on high-dose steroids to regulate spinal cord inflammation in the form of SoluMedrol at doses of 30mg/kg. Many systems have abandoned this approach in part due to the National Association of EMS Physicians statement noting that “evidence on use of high-dose steroids for acute spinal cord injury remains inconclusive.”
However, this was reported to be part of Dr. Andrew Cappucino’s initial treatment of„Everett, along with cooled normal saline in the ambulance followed by a catheter in the hospital to maintain the lower body temperature.
Inflammation is one part of secondary injury that occurs from spinal cord trauma. Another area of research isapoptosis. During the development of the nervous system, some cells serve their purpose for a short time and are then programmed to die. Many studies suggest that apoptosis, essentially a programmed cellular suicide, is reactivated after a spinal cord injury and may cause some cells to die. Mild to moderate hypothermia appears to inhibit this cellular death, thereby limiting spinal injury.
The spinal column
The spinal, or vertebral, column is made up of 33 bones divided into five sections. Those sections are the seven bones of the cervical spine, 12 bones of the thoracic spine, five vertebrae composing the lumbar spine and the five sacral bones, which are fused together. The inferior section of the spine is made of the additional four fused coccygeal bones that form the end of the spinal column. It houses and protects the spinal cord from injury, and it also provides the major structural support to the upper torso, with the rib cage coming off the thoracic vertebrae.
The layers of the spinal bones are similar to the cranial vault and are composed of the dura mater, arachnoid space and the pia mater, looking from the outside of the spine inward.
Inside the column is an area that holds the spinal cord itself, which descends from the brain and is bathed in cerebrospinal fluid and carries the biochemical nerve impulses through the body.
Two generalized tracts of axonal matter carry many of these signals. The ascending tract is a sensory tract that carries signals up to the brain. The descending tract carries muscular signals to those parts of the body that are about to be moved. In addition, the spinal column can act as a reflex center — sending signals out based on certain sensation thereby eliminating the need for signals to travel from the sensation site through to the brain and then back to the injury site.
In addition, spinal nerves come off the spinal column in pair groupings from the spinal column at each vertebrae. Like the spinal column, these nerves are designed to carry motor responses to the musculature and receive sensory input from the distal regions of the body.
Dermantones (sensory) and myotomes (motor) are regions of the body that can provide additional information on your patient_s condition during your assessment. Specific locations of concern for dermatones are the collar region (C-3), the little finger (C-7), the nipple line (T-4), the umbilicus (T-10), and the small toe (S-1). Any sensation deficit at these locations can provide an additional assessment factor that this part of the body is injured. Motor deficits of note include arm extension (C-5), elbow extension (C-7), small finger abduction (T-1), knee extension (L-3) and ankle flexion (S-1). Though not as accurate as dermatones for determination of injury, together they provide valuable assessment insight into patient injuries.
The spinal cord can be injured in any number of ways but, broadly, both blunt and penetrating trauma injury apply to the spine. The No. 1 cause of spinal injuries is motor vehicle collisions, followed by water emergencies and falls. In addition, other mechanisms of injury that should be of concern include pedestrians struck by a vehicle, hangings and other incidents where there is sudden acceleration/deceleration potential. This could include a patient thrown to the ground when a bullet strikes him, an explosion knocking him over or being stopped suddenly during high-speed sports such as football.
Although anecdotal in nature, the success of high-dose steroids and induced hypothermia in Kevin Everett_s case may have EMS reconsidering the cold hard facts that spinal cord injury is forever. Within the past few days, Mr. Everett has taken several steps with the assistance of a walker. Given the nature of his injury, perhaps there is some hope that spinal cord injury will no longer be a condition that is untreatable.
Christopher Suprun, NREMT-P, CCEMT-P, is director of education for Consurgo LLC and active as a street paramedic also. Contact him at„[email protected].
1.„„ Porter R, Bledsoe B, Cherry R: Paramedic Care: Principles and Practice Trauma Emergencies.„Charles„Stuart„University:,„Wagga Wagga,„New South Wales,„Australia. p. 334, 2006.
3.„„ The„Miami Project: Cooling Processes. www.themiamiproject.org/x1356.xml
4.„„ Yu CG, Jimenez O, Marcillo AE, et al: ˙Beneficial effects of modest systemic hypothermia on locomotor function and histopathological damage following contusion-induced spinal cord injury in rats.Ó Journal of Neurosurgery. Jul;93(1 Suppl):85-93, 2000.
6.„„ McSwain N, & Frame S, editors: ˙Prehospital Trauma Life Support.Ó p. 236, 2003.
„JEMS.com Editor_s Note:„ For more, check out the November JEMS Priority Traffic article “‘Cool’ New Treatment.”