C-Spine For Penetrating Injuries

[AnthonyM83]

I was thinking mainly traffic collisions at high speed or even medium speed lateral impacts where the body might bend in an over-flexed sideways direction. Or am I still thinking too Los Angeles County?

We only went over cavitation briefly, but the basic points were that energy is dissipated to areas surrounding the bullet's path. Sometimes it's temporary where tissue just bounces back, but permanent cavitation might actually cause some damage. It was mainly in regards to soft tissue...but one girl specifically later seemed upset that they spent time talking about fragmentation and cavitation and how there's more damage than the straighline path of the bullet, yet we don't worry about harm from shrapnel or energy dissipation effecting c-spine.

Also, second part: if neuro deficit is a deciding factor, then why do doctors ask patients about pain when clearing cspine. Isn't that a strong indicator of spinal injury even in absence of neuro deficits? That's why drunks don't get cleared as quickly. Then, wouldn't the distracting injury (of a bullet hole in your chest) invalidate patient's response of no neck/back pain?

[ERDoc]

Bear with me Anthony as I try to answer your many (yet very good) questions. We immobilize in the kind of injuries you are talking about because they have the potential to injury the bony spine. Think a fracture of C1. While there is no neuro deficit now, if the pt is allowed to move that unstable fx the right way they can end up cutting the cord. So there may not be a neuro deficit, but that is because there is no injury to the cord yet. Think of the bony spine as a steel cylinder around the cord. A blunt injury will be able to easily disrupt the integrity of a large portion of that steel cycliner, thus making it unstable. As Dust said, there are very few reasons to immobilize the cspine in strictly blunt thoracic trauma (think a baseball bat to the back). It is all about how the forces are spread. In an injury from a fall or MVA you have these huge forces spread over a large portion of the spine. In a localized blunt trauma (baseball bat) or penetrating injury the forces can be severe, but they will be local. Thus, even if there is disruption of that steel cycliner in the thoracic region, the likelyhood of there being an issue in the cervical portion would be nil. U hope this is making sense.

As for why we ask about pain, we have several clinical rules that we use to clear the cspine without radiologic evaluation. They are the NEXUS criteria and the Canadian Cspine Rules (they have been discussed here many times and can easily be Googled). They each have different, yet similar, criteria. One of which is that they cannot be influence by drugs or alcohol. That is why drunks take longer. One of the criteria that requires imaging is midline cervical tenderness. You can have neck pain and not get xrays as long as you meet the criteria. You are right that one of the other criteria is that they have no distracting injuries. Again, if you have a penetrating injury, if it has done enough damage to disrupt the integrity of the steel cylinder it will also damage the cord and you will have neuro deficits. Again, a penetrating injury is a local injury and will not affect the rest of the spine. I guess you could have the mysterious bullet that enters the spinal canal in the thoracic area and then take a northward turn and end up in the cervical canal. Something like that will do so much damage that you will have a neuro deficit.

I hope I have been able to make this as clear as mud for you.

[AnthonyM83]

Thanks for the reply.

So to keep track of blunt with penetrating and cervical with rest of the spine:

When considering blunt trauma, localized force to the lower back would not usually be cause to immobilize cervical spine (except in with neuro deficit or extreme cases, such as the baseball bat to the back example), but obviously localized force to the cervical area would indicate c-spine immobilization despite lack of neuro deficit since damage could occur later? Or is pain complaint for A&O subject always there when there's damage.

When considering penetrating trauma, localized penetrating force to the lower back would not indicate c-spine immobilization without neuro deficit since damage is caused immediately. I would imagine penetrating force to neck would have the same rules?

Even if the penetrating trauma caused some injury from dissipating energy from the object (what I was referring to as blunt trauma from the bullet energy to surroundings), it would be localized to lower spine, thus no cervical spine immobilization. BUT if the bullet went through the neck, though it obviously missed the spine, there would be need for c-spine immobilization due to dissipation of force or cavitation?

The last concern was bullet fragmentation, which would be treated exactly like the cavitation? Possible fragments from a GSW to the neck would make us immobilize cpsine, but possible fragments from a GSW to the lower back would not indicate cspine, because bullets don't fragment that powerfully.

Is everything I wrote valid and what you were saying?

I italicized parts I specifically wanted to confirm.

Also, a follow-up:

Why are we not as worried about injury to lower spinal cord? It could still cause paralysis from the fracture point down, right? (Though it's probably harder to injure) Do people immobilize only thoracic downward, ever? In a GSW to thorax, should we be doing thoracic immobilization?

[MeekoBB]

There is a hospital near me that doesn't want a large majority of their patients boarded regardless. It's really crazy, though in certain cases they do accept it.

[fiznat]

I'm not sure I agree with the concept that penetrating trauma causes injuries that are "always" immediately translated into neuro deficits. Why cant it be that the penetrating force causes an unstable disruption to the spine just like any other kind of injury might? This seems like a generalization that is usually - but definitely not always - true, and not suitable for a c-spine rule-out criteria.

C-spine is a huge CYA procedure. We do it to patients who "probably dont" have spinal injuries all the time, not because we think they do but out of respect for the potential. I dont see how penetrating injuries differ in this respect. There is a potential, and given that there is a distracting injury, stress, and most likely AMS, I dont believe these patients should ever be c-spine ruled out by EMS in the field.

[captainstandup]

Have you seen any penetrating injuries in the sandbox Dust? I'll bet you see more in six months that I have seen in 16 years of EMS.

What percentage of GSW injuries you see involve spinal trauma?

[Dustdevil]

Have you seen any penetrating injuries in the sandbox Dust? I'll bet you see more in six months that I have seen in 16 years of EMS.

What percentage of GSW injuries you see involve spinal trauma?

Actually, what you hear on the news about Anbar Province being a success story is very true. I haven't seen a combat casualty in six months. Quite a turnaround from the twice-daily rocket attacks and mass casualty incidents that were the norm when I arrived here a year and a half ago. Unless by chasing all the terrorists out of Baghdad, they drive them back out here again, I am hoping those days are over for me.

Addressing your question, I haven't see any living patients here who were noted to have spinal injuries as a result of penetrating trauma. Of course, the military patients have the benefit of body armour protecting their spine pretty well. But I saw quite a few civilians, Iraqis police, and insurgents too, who weren't so lucky, and don't recall any spinal trauma secondary to penetrating trauma among them either. Not to suggest that a lot of them didn't occur, but never made it to my facility though. But, at least anecdotally, that seems to suggest that it is not a common occurrence, or that those who do suffer it never make it to the hospital.

I have seen a good bit of spinal trauma here though. Mostly the result of vehicular incidents. When your Hummer hits an IED and does a one-and-a half gainer before landing upside down, there are bound to be some sore backs, at the very least, so that was pretty common. Also saw incidents of drivers being distracted by hostile fire, like seeing tracers off to their left, and taking their eyes off the road just long enough to plow into a barrier, or the vehicle stopped in front of them. I had one guy whose 7 tonne truck hit an IED, who sustained several minor shrapnel injuries, but was otherwise okay. However, his truck was quickly engulfed in flames, so he jumped out of the cab, landing on his arse and suffering a lumbar fracture with neuro deficit.

So yeah, there are a lot of ways to hurt your back out here. Heck, I was out for a week with a lumbar strain just from trying to pick up a heavy footlocker, lol. But I haven't seen any incidents of spinal trauma as a result of the dissipating energy from a GSW or shrapnel injury.

[WANTYNU]

Seems like regardless of the area of central injury, restricting movement would be a good idea (limiting internal bleeding, tears, bruising, etc), and it is still part of our protocols, so we really have little choice anyway.

It’s also easer to “scoop and run” with a backboard (on the street with crowd forming) and treat on the way to the trauma center (keeps the golden 10 minutes down).

I did my PHTLS 6 months ago and they were still teaching long board, but I am nowhere near an expert so I’ll ask one, my instructor, if I can get an answer in a reasonable period of time, I will post it here.

Be Safe,

WANTYNU

[AnthonyM83]

Had a multi-victim GSW last shift, medics & FF's were working on the critical patient, so they told us to just take one with a leg wound as our patient. It was one of the few times, I wasn't working in the back as the attendant. My (not regular ) partner wanted to c-spine instead of getting him on the gurney, out of the unstable scene, and transporting. I told him it wasn't indicated (no ALOC, no neuro deficit, no cervical or back pain, no deformity/wound to torso/neck/head), but he insisted again, and since it IS his patient and since I'd rather not argue on-scene we did it. But I realized how frustrating it is when providers aren't on the same level/type of training (which is something I like about my regular partner).

Anyway, since the doc hasn't replied yet, what do you guys do for issue where there's might be lower back injury, but no index of suspicion for cervical injury. Just secure the back? Or c-pine just as part of the process of securing the entire spine?

[zzyzx]

Hey Anthony. I'm sure you get lots of pratice with gun-shot victims in LA. :wink:

"Penetrating injury represents a special consideration regarding the potential for spinal trauma. In general, if a patient did not sustain definite neurologic injury at the moment that the trauma occurred, there is little concern for a spinal injury. This is because of the mechanism of injury and the kinematics associated with the force involved. Penetrating objects generally do not produce unstable spinal fractures as does blunt force injury because penetrating trauma produces little risk of unstable ligamentous or bony injury A penetrating object causes injury along the path of penetration. If the object did not directly injure the spinal cord as it penetrated, he patient will not likely develop a spinal cord injury."

This is from my PHTLS book, and it's nothing new. I took that class nearly 5 years ago.

Rather than spending several minutes on scene putting your patient in spinal immobilization, you can lift the patient onto your gurney and be off scene in less than a minute.

You are not opening yourself up to liability by doing this as long as the patient has no neurological deficits. You are strictly following the guidelines of the American College of Surgeons. There is nothing in the LA County protocols that contradicts PHTLS guidelines.