Good afternoon, I am Heather Sieracki. Welcome to our webinar on spinal cord injuries, part two of a seven part series. My name is Heather Sieracki again. I am the Regional Director of Trauma and Forensics in the Temple region for Baylor Scott & White Health. We have a level one center and a level two pediatric trauma center and a standalone forensic program here. Today we have a couple of speakers that will be speaking on this. According to the National Spinal Cord Injury Model Systems, in 2021 approximately 18,000 new spinal cord injuries occur every year. These numbers only reflect those patients that come into the ED. So data from 2015 shows length of stay declined to an average of 12 days for inpatient stays and 32 for rehab included. How many healthcare providers would care for spinal cord injuries over a 12 day stay is a question that comes up. What education do you need? So based on evaluating data from TCAA on needs of committee members, there was an ask for additional education on spinal cord injuries. So the education committee came up with this seven part series with sections on coding injuries, how to prevent them. The series started in, I believe, August, maybe September, and it will run through February of 2024. So it's going to highlight healthcare providers across the United States going from pre-hospital all the way through rehab and just hopefully provide valuable information for you all. The first, we have two speakers. Gay will start out. She has 24 plus years of nursing experience, served the profession in many roles, including an ICU nurse, critical care nurse educator, associate chief nurse, trauma nurse, and ED nurse manager in a level one trauma center. She currently serves as a trauma program manager, Baylor Scott and White Health in Taylor, Texas. She is also certified in Lean Six Sigma Black Belt and continues to use these skills to improve processes across the healthcare continuum. Although most of her care was spent in ICU, she transitioned to trauma nursing six years ago and fell in love with it. On a personal note, Gay has four daughters. She enjoys playing soccer and volleyball and serves on medical mission trips in remote villages across Haiti, Mali, Uganda, and Kenya. So she'll be the first speaker. I'm going to go ahead and introduce Dr. Greenberg, who will do the second part of this webinar. Dr. Greenberg, physician fellow of the American College of Health Emergency Physicians, is the vice president and chief medical officer for emergency services, Central Texas Division of Baylor Scott and White Health. He's also an associate professor for Texas A&M Sciences Center, College of Medicine in Temple, Texas. Dr. Greenberg received his BS in medical technology from Northeast Louisiana University in Monroe, Louisiana, and he received his MD from Louisiana State University Medical Center, Shreveport, and completed specialty training in emergency medicine at the University of Cincinnati Hospital. He continues to practice clinically in multiple EDs across the region, and including adult and pediatric designated trauma centers. He's a past president of the Texas College of Emergency Physicians, past chair of the Governor's EMS and Trauma Advisory Council, in addition to other state-level activities. He currently serves as the chair of the Texas Department of Criminal Justice Correctional Healthcare Committee. So please welcome Dr. Greenberg and Gay Kurtz, and they will give you this webinar. Please, if you have questions throughout, put them in the chat, and I will be sure to bring them up at the end of the webinar, and we'll have kind of a little Q&A session. So here you go, Gay. Wonderful. Thank you, Heather. All right, so I think first we need to just discuss our disclosures, and onto the next slide. Dr. Greenberg is a trauma site surveyor for the American College of Surgeons in the state of Colorado, and I have no disclosures. And so thank you for allowing us to speak today on part two. I'm not going to bore you with reading the objectives, but just know we're going to talk a little bit about the nurses, the first nurse role in the ER, as well as some detailed physical and neurological exams. We're going to talk a little bit about spinal motion restriction and some guidelines, and that's going to be a very interesting topic Dr. Greenberg will discuss, as well as some imaging diagnostic tests that we can perform in the emergency department. We're going to talk a little bit about complete and incomplete spinal cord syndromes and just, in general, a number of different topics related to the care of these type of patients inside the emergency room. So patient presentation, and you can go on to the next slide. There you go. As they discussed in part one, the number one cause of spinal cord injuries is generally motor vehicle accidents or collisions. The number two cause is falls. And so just keeping that in mind, there are a number of reasons why the patient will present to our emergency room a number of injuries. So if you're a trauma program manager or a trauma surgeon, understanding what to look for in your PI process, really a good portion of that should be the very initial presentation. How are the staff at the bedside really moving that patient along through that trauma process and activating when they need to? Are they doing that efficiently? Are they recognizing the mechanisms of injury and the seriousness? So those are all things to look at when you're going through your PI process in your trauma systems. The patients, if we get an EMS report, that's great. As a nurse at the bedside, it was wonderful to know that a patient with a very serious mechanism of injury is coming to your facility so that you're prepared. You can activate ahead of time. You have all the people at the bedside. If it's a very obvious injury, like a highway speed head-on collision, you generally know that you're going to have some pretty serious injuries, especially if there are any deaths on the scene. And so those are very easily transitioned from presenting to starting the trauma process. But the ones that are a little more tricky are those ones that show up at your front door. I currently work in a very rural area, rural America, critical access level four hospital. And coming from a level one where most of our patients arrived by EMS, if you work in a small facility like I do now, those patients, they can be very serious, but they show up POV. They'll show up, their friends will throw them in the back of their vehicle. They'll show up in the back seat and the friend will run in and just try to get your attention. And then you have to go out there and try to figure out what's going on. The one thing that I really recommend for those first nurses who are going to the vehicle to try to identify what's happening and how serious this patient is, is don't get in too big of a hurry. Unless that patient is really unresponsive and it's an obvious CPR type situation, you don't want to just, you know, willy-nilly go in there and start trying to grab this patient, pull them out of the back seat. Listen to the story. If you have time, if they're mentating and they can tell you what's hurting or what happened, was it an ATV rollover and they got pinned underneath and their friend pulled them out and their back is, you know, hurting or they can't feel their feet or those are important things that you need to know before you start trying to pull a patient out. And so one of the things that I try to teach the staff is not, don't just go grab the biggest, strongest person and try to start getting this patient out. Get the story a little bit. If you need to, go get the provider. You should have a good relationship with your ED providers. Go get them and ask them, hey, you know, if that patient is stable and mentating, you probably have time to assess it a little more so that you can do it in a safe manner. And so the provider can come also, hopefully they are working with you well and you have good relationships there and they can come to the car and even help figure out the best way to do this. We had a patient recently that fell from a tree, not recently, at this facility, sorry, at another facility, but they fell from a tree while cutting limbs and they hit a limb on the way down, but they were about 20 feet up. So it was a pretty big fall. The friend, of course, got them into their pickup truck and then we had to figure out how to get the patient out. So having a backboard available, trying to do this while maintaining, you know, spinal precautions is best until you can get the patient assessed. So activate as soon as possible. Once you know a patient meets activation criteria, your first nurse should be very qualified to make that decision and actually activate. They should know your trauma activation criteria and activate so that you can get everybody to the bedside that needs to be and get the patient the care they need in a quick manner. So just a trivia question, and you can put the answer in the chat if you want, or if you just want to listen to the answer, I can tell you in a minute, but how far apart are the rungs of a ladder? So we get a lot of patients that come in, they had been on a ladder somewhere, they fell, and the staff are always trying to figure out, like, how far did you fall? And generally they can tell you, like, what rung of the ladder they were on, but then the nurses really need to be able to put that into, you know, how tall, how far was the actual fall? I see a lot in the chat, anything from one foot, 14 inches, 18 inches. So OSHA standards are, these are great guesses, actually. OSHA standards say that the rungs have to be between 10 and 14 inches. And so what I teach my staff is just consider each rung. If they can tell you they were on the third rung or they fell from the third step, that's about one foot. And so a lot of our activation criteria will have a fall by height, whether it's one times the height, two times the height, that's an easy way to figure out the height of the fall to determine if it really was how bad of a fall it was, and should you have a higher suspicion of injury than somebody who fell from standing. Okay, moving on to the next slide. So our initial assessment, once we know that this patient did need to be activated, needs to get to a room, you're going to go through your ABCs. We generally do this for every patient that is injured. Some special considerations for spinal cord injuries are, you're not just looking for the life-threatening conditions, like do they have a pneumo, are they bleeding, you're doing that as well, and you're going to address those when you find them as well. But one thing to keep in mind is any sign of hypoxia at all, you want to have a really low threshold for putting oxygen on these patients. So hypoxia with a cord injury really can affect your overall outcome later on down the road, so you really want to keep these patients oxygenated. As far as neurologic status for your D, head injuries, you're looking for your level of consciousness, your GCS, your pupils, all of those things. Sometimes we will ask about their head, neck, or where are they hurting, essentially, or they're just telling us they're hurting. You want to also look, are there any preliminary absence or unequal findings as you're going through some real quick motor and sensation type assessments. You're still going to be exposing these patients. They can often have distracting injuries. They may not even know their back is broken or they have some sort of spinal cord injury because they have a broken femur or something else that's really hurting really bad, they can feel that. And so it can be a distracting injury for us as healthcare workers, as well as for the patient, so you got to keep that in mind. So really expose them, you're wanting to look for everything, but also remember to add warmth to that patient. Your rooms should be warm. You need to be sure and add warm blankets, something, warm fluids, keep those patients warm. Next. Okay. So moving on through your assessments, you're going to get your full set of vital signs. Again, treat that hypoxia really early. You do want to keep in mind, make sure your staff have a good understanding of neurogenic shock. It's not something you see every day, but when you see it, you want them to recognize it, providers and nurses as well. In my nursing career, I've only seen neurogenic shock two times, and one was from a construction. A gentleman fell from, he was kind of on the roof of a one-story building they were constructing and fell, landed on his hands and knees, but then the trusses fell on top of him on his back and had some pretty significant injuries and spinal cord injuries as well. And he went into neurogenic shock there in the ER with us. And so recognizing that is very important. You got to remember that those patients will generally be bradycardic as well as hypotensive. And then, are y'all hearing me? Somebody's saying there isn't any sound. I can hear you fine. Okay, good. I saw somebody in the chat say that. I want to make sure. No, you sound good to me. Okay. All right. So as you're moving through your head-to-toe assessment, you're going to be working with the providers and log rolling. One thing that I think I took for granted coming from a level one trauma center to a level four is the knowledge of the staff on what a true log rolling is, how to hold C-spine precautions. It was just ingrained in us as nurses at a level one facility. And so when you move into the other lower levels of trauma centers or just a freestanding ER, understanding and teaching how to hold C-spine, it's a very controlled process. There should be one person at the head. That's the person that is generally calling out when we're going to turn them on the count of three, making sure that we have everybody holding the right body parts and turning all in a systematic manner. So don't take for granted that everybody knows that. So make sure that you're assessing the knowledge there. Very important for spinal cord injuries that we do that correctly. Neurologic injuries, you're also going to be assessing, and we're going to go into a little more detail about this in a minute, but you do want to figure out the level and the severity of the deficit. And that's our main goal. When we start going through a really detailed neuroassessment, we are looking for, is there any cervical, thoracic, lumbar, sacral, any of those injuries? What level is it and what type of deficit is it? And so you're looking for motor and sensation primarily. So is there good muscle tone? Is there a lot of spasticity or incoordination or paralysis? They just can't move at all. And then is there some deficit in their sensation? And so we're going to go into that next. One question on here, what level of injury is most often associated with the incidence of neurogenic shock? Anybody have any guesses? I have a T12. Usually it is a T6 or above is usually where you're going to see the neurogenic shock. So a lot of literature will also say like cervical injuries. It can also be high thoracic as well is where you're going to see that. Okay, next. One more slide. That's what we're about to talk about. So this is the ASIA assessment. You might hear providers talk about the ASIA score. Just know if you are a nurse, we don't generally use this, but the providers might use this as a good way to kind of determine what the deficits are and what level they're at. And so it's just good to kind of know what they're assessing for. It's good for us also so that we're helping assist the providers in these assessments and reassessments. So we need to have a good knowledge of how that's done. Okay, next slide. So what we're going to do, this is kind of beyond your just palpating, feeling the midline for any tenderness, step offs. This is beyond that. It's just one step, a little more detailed here. But when you're looking at your cervical spine, we all know C1 and C2, any kind of major injury with a C1, C2, the atlas or axis, those are generally fatal. They don't often make it to our facilities. But C3, C5, those innervate the diaphragm. So the things that you're looking for are your inspiration. Are they showing any signs of respiratory insufficiency or tachypnea, any kind of diaphragmatic breathing? So that's something that's super important to look for when you're assessing kind of the C3, C5. C4 to T1, remember those innervate the bilateral upper extremities. So you're looking for your grip, your sensation at the different levels of your upper arms there. And then in your thoracic spine, so the thoracic area, well, I could go into a whole lot of detail. I'm trying not to go into too much detail. But it innervates the abdominal wall and musculature. So you do want to assess expiration. So are they exhaling well? Or are they having difficulty with that? Also, again, the injuries above T6 can cause the autonomic dysreflexia, which is, again, you're looking for like sudden hypertension, sweating, anxiety, bradycardia. That's kind of your sign of the neurogenic shock. And so there will be different types of treatment for that. And I believe Dr. Greenberg will go into that a little bit more, whether you're looking at kind of assessing whether the patient needs fluids or whether they're going into shock and maybe they need pressors. And so those are some decisions that you'll have to make. And then moving on to the lumbosacral spine. Remember, your spinal cord goes through about L1, L2 level. And then below that is your cauda equina. And so your L2 to S2, those really innervate your bilateral lower extremities, your hips to your ankles. And so it can have any injuries below that. Spinal cord injuries can affect your bladder. So the ability of the patient to release their urine on like voluntarily or involuntarily. So remember that neurogenic bladder is when our bladders reflexively empty. So it does it when it's full and it's not voluntary. And so those are some serious kind of life-altering things that can happen based on those injuries. And then below that, these also, the S2 to S4, those injuries can also interrupt your bladder reflex circuit. And this is where, and one of the reasons we assess when we turn the patient toward their side and we're assessing their back, we're also assessing the sphincter reflex. So very important that you're understanding kind of what nerves would affect, what might've been injured and why we're doing that. Which level of injury is most often associated with priapism? Anybody have any ideas? The patient that I spoke of that went into neurogenic shock, he did come in with priapism as well. And generally, S2 to S4, yeah, surprisingly, it's actually high. In fact, per NIH, and I put the link there, but per NIH, the lesions and injuries of the cervical spinal cord are most frequently associated with priapism. So now it can happen with injuries and lesions below that as well, but most often it is the higher cervical injuries. So just something else to also watch for and is indicative of a spinal cord injury oftentimes. And then I believe I'm handing it over to Dr. Greenberg. All right, thanks, Katie. Let me go on and talk about some other issues related to spinal cord injury. One of the ones I wanna talk about is spinal motion restriction or spinal immobilization as it's been called through the years. This is something that we started doing, I mean, literally decades ago. It was done quite frankly without a great deal of science behind it, but just the pragmatic approach that if we keep somebody from moving their spine and therefore their spinal cord, they'll have less of an injury. Unfortunately, it was just applied 100% across the board to any patient with any trauma and really without any science to look at it going forward initially. It's now totally ingrained into some of our protocols and most importantly, into the culture of a number of services and areas. As you saw through the disclosures, I'm a trauma site surveyor, so I get to go all over the country and now virtually all over the country and hear about different services and out here as provided. I guess I'd say I'm kind of surprised at how variable this practice is, but spinal motion restriction is not a benign intervention. As you can see, Gabe found this picture that maybe is a bit extreme showing what can happen when you put a collar on somebody, but it can put the spine into an unnatural position. So there's been a lot of research done over a long period of time. You'll see some more when I talk about imaging, but spinal motion restriction really should not be used for any patient. Now, we're talking about spinal cord patients, somebody that comes in with a neurologic deficit. Those patients do need spinal cord or a spinal motion restriction, but this is one of those areas where we really have to think before we do things, talk to patients, take a little bit of time before we do an intervention that may hurt them. So indications for spinal motion restriction is if somebody has an altered mental status, either due to injury or intoxicants, if they have distracting injuries or circumstances, as we know, these can be dramatic events, and then if they have tenderness in the middle of their neck or back, not off to the side, but in the middle of their neck or back, obviously focal neurologic signs or any anatomic deformity in the spine. Now, I gotta say, too, anatomic deformities are very difficult to palpate when they're not just grossly obvious. Importantly, too, there's no role for spinal motion restriction in penetrating trauma, and all of those recommendations together come from multiple national groups and were published back in 2018. So that's the American College of Surgeons, National Association of EMS Physicians, American College of Emergency Physicians. We all agree you gotta think ahead before you do spinal motion restriction because of the possible harm. So along with that, because if you're gonna put somebody in a collar in spinal motion restriction, then you should be doing something about it, and if you're not gonna do anything about it, you don't do it, so imaging and spinal motion restriction actually should be block-stepped together. This goes back much longer. You can see back in 2000, 23 years ago, there was a publication in the New England Journal of Medicine, pretty highly respected journal, after a huge group of patients were looked at to see what's the criteria to actually image the cervical spine, which really should go along with who you need to worry about in the pre-hospital environment and put for spinal motion restriction. These are pretty similar, as you would expect, so the nexus criteria for imaging really is close to the recommendations you saw before, focal neurologic deficit, midline spine tenderness, alteration of consciousness, intoxicants, and a distracting injury, or a distracting injury. If you have one of those, then the patient should get imaging, and again, that should go along with who you would put into spinal motion restriction. So all of this just to say that spinal motion restriction is not a benign intervention, and it really should, if you see somebody come in with a collar in a system where everyone agrees in what you're doing, that all of those patients would essentially get imaging, and you won't have the situation where a patient comes in after somebody took a great deal of time and effort to put them for spinal motion restriction, and the doctor just walks in and takes everything off. It's a lot of waste of time for people. It's very uncomfortable for patients. It can distract you from other injuries, and it can lead to frustration between caregivers. So people could spend an entire session talking about this, but I wanted to make sure I touched on it, because it is important in relationship to the care of the patients we are talking about, who, again, spinal cord injury patients do need spinal motion restriction. So some more imaging. This is, again, you know, multiple parts of this talk could be an entire hour, an entire day of themselves. Imaging is clearly one of those things. So in 2023, plane radiology, crane x-rays probably don't have a big role in the ultimate diagnosis of spinal cord injury for these patients. So, and in fact, there are places where if you are a C-spine x-ray, somebody's gonna call you and say, doc, do you really do that? Do you really want that? Don't you want a CAT scan? Because CT scan, CAT scanning is the recommended first line to evaluate the spine. It is available at essentially every trauma center. It's very high quality, and it's fast. Now, what it does not show you very well at all is the spinal cord itself. That's where you need an MRI scanning. And the MRI scan can see actually the cord within the spinal canal much better and delineate what is putting the pressure on the cord if there is pressure. So plane radiology has no role really. CT scan is the go-to to start with. MRI is gonna give you your ultimate diagnosis most of the time. Downside to MRI, takes a long time, takes a still patient. Other people have to go to MRI with you, and you have to have availability of the scanner, which everyone does not have. And then finally, just to mention it, although it's old technology, but it certainly works, is myelography. And that is really only necessary if you don't have MRI. And I would say if you're at a center where you don't have MRI, you probably don't have the other expertise to take care of the patient. And it would make more sense to send that patient to a dedicated center. All right. And then again, some limitations. The cord can appear normal on non-MRI modalities. You also can have, and these are some old terms because of now that we use MRI so much, but for a long time, we talked about SCIWORA, spinal cord injury without radiographic abnormality, primarily in the pediatric population where they are so flexible. You can have a lot of movement with the bones and the ligaments without injury, but the cord itself is damaged. So you could have a neurologic deficit without any imaging abnormalities. And then a newer, a little bit different term, which I can't even say, SCIWOTEC, is spinal cord injury without CT evidence of trauma. The other thing to keep in mind is sometimes imaging is not diagnostic right away just because these injuries do, they don't happen immediately all of the time. You can have ongoing ischemia and inflammation that increases the amount of deficits. And then when you do follow-up scanning, which you'll see done very appropriately, you can see the injuries, which are worsened. The natural history of some of these injuries is likely the reason that we have some of the anecdotes where we moved patients and they got, they came into the emergency department, they had worked, or they looked like an incomplete injury. Later in the ICU, they looked like a complete injury or a worsened injury. And it's like, oh my God, it's when we moved them. Well, it probably wasn't that. It was probably the natural history of the disease because just like any injury, just like you sprain your ankle, you sprain it and later in the day, the next day it's big and swollen, same thing happens. All right. And next, we are gonna talk a little bit about the different cord syndromes. I will tell you that in part one, Dr. Scribnik did a wonderful job of this. By the way, that picture in the corner there, that's not him, that's Nick Nolte. The picture on the other corner is him. But this is how you say his name, Dr. Scribnik. I think he did a wonderful job, much better job than I could do of looking at these cord syndromes and showing you the anatomy. So I'm referring you back to part one for some of this. And I'm gonna talk about the clinical aspects of cord injury. So the big question, of course, always is, somebody comes in, do they have complete loss of all motor function below the injury or is it an incomplete injury? Incomplete injuries can be very confusing. And a lot of times we have to pause our own disbelief when we take care of patients. For some reason with neurologic problems and injuries, a lot of times we almost don't wanna, quote, believe the patient. When they say they can't move, somehow it's, oh, patient won't move. Well, the burden is on us to prove that they, quote, are faking. But unfortunately we see this. We're not so much with trauma but with the medical reasons for paralysis. So complete injury, just what it says. You cannot feel or move below the level of the injury. Much easier to diagnose. Unfortunately, tends to be overwhelmingly permanent with very little we can do. Incomplete injuries can look very different depending on the part of the cord that's injured and what level the cord is injured at. And that's where you go back to the detailed neurologic exam that Gabe was talking about. That's why that is so important to help you decide what kind of an injury this is. So here's a few examples of some cord injuries. So central cord injury, central cord syndrome, I'm sorry, is the most common incomplete spinal cord injury. It actually can happen with pretty mild trauma than the classic patient. And I'll apologize a little bit for saying it this way. The classic patient is the old drunk guy that slips and falls. But it is more common in older patients. It can be a pretty, like, you know, they literally slipped, fell. They hyperextend their neck and that pinches the central part of the spinal cord. And what that does is it gives you more weakness, like you can't see on the screen that well, more weakness in the upper extremities than the lower extremities. So this patient could actually walk in but not be able to move their upper extremities very well. Or they can be, they're definitely weaker in their upper extremities than at the lower extremities. So it's the same thing. We can't just say he's making it up. This is real. This is something that really exists. So your knowledge that this can exist helps us in taking care of the patient. The good thing is this can be treated in some cases and it can get better. Now here's another incomplete cord syndrome, the anterior cord syndrome. This tends to be more with direct trauma to the anterior part of the cord and you have motor and sensation deficits. You have loss of pain and temperature but you can still touch some and you can tell where your extremities are. So urinary incontinence is also usually present but it's the same thing. Patients come in and it doesn't seem to make anatomic sense but when you know that there's part of the cord that can be injured, not the whole cord, then it makes more sense. And again, you have to try to figure this out through doing your neurologic assessment. And then finally is one that is much more uncommon. It's called Brown's card syndrome. It's almost always due to penetrating injury, either gunshot wounds or stab wounds. And I don't wanna have a pointer here but if you look down at the picture of the spinal cord, basically draw a line right through the middle and take out half the cord. And what that does, and again, that's hard to do but take out half the cord, just slice through it. And because the nerve fibers cross as they go down through the body, you get different deficits on each side of the body. So on one side of the body, the side that's injured, you can't move or you have decreased motion. You can't feel vibration and you can't tell where somebody puts your arm, that's proprioception or your leg. And on the other side, you can't feel pain or temperature. So you do a physical exam, it's like, wow, that doesn't make sense. But actually again, it does. And being aware of these partial or incomplete injuries is very important in the care of these patients to know that yes, that can be an incomplete cord syndrome. And it's on us to now provide spinal motion restriction to do the diagnostic studies, do CAT scans, do MRIs and refer for appropriate care. And I believe that's my part so far. I'm gonna turn it back over to you, Gay. And we're gonna talk just real quickly about the care that we're gonna provide this patient in the emergency room. Once we do know there is a spinal cord injury and we're waiting to get this patient where they need to be, whether it's transferred to another facility or transferred up to a neuro ICU or wherever they need to go. Some of the considerations for nursing and providers to help order and ensure that it's happening is the serial neurologic assessments. We need to continue doing our neurological assessments at least minimum every hour, at least for the next few hours. Hopefully they will not be with us in the ER for days. We prefer that to not happen. But we need to make sure that they're not decompensating, they're not getting worse. Depending on the type of injury, they can decompensate over about a six to 12 hour period of time. And so we wanna be watching very closely as well as the vital signs, making sure we're watching that as well as treating for any kind of oxygen issues, hypoxia, and then reassessing for shock. The patient can go into shock hours after it may not happen immediately. So we have to be aware and be monitoring for that. And then again, the MAP goals are a little bit different. So the MAP goal, don't be surprised that the provider wants you to keep the MAP between 85 to 90. That is not uncommon in the spinal cord injuries. So pain control, this is always interesting and it's always an interesting topic, hot topic between the nurse's provider and the patient. Patients hurting, we know we need to do neuroassessments. It's hard to do when the patients have tended. But then again, you also don't want them in pain and tense and moving. So that's also not good. So just trying to figure out what you can give, it may be different. And there may come a point where they do just go ahead and give them something, whether it's like a little bit of Ativan to kind of calm, relax, or whether it's gonna be actual fentanyl or something for pain. But I haven't personally used IV Tylenol, but I've heard lots of people come from facilities where they did use IV Tylenol and said it works really great. My understanding is it's super expensive. It's not on formulary for everybody. And so if your hospital has it, that's great. Maybe this would be an option for you. Some other things to consider is just stabilizing the injuries. Sometimes that feels better, just less movement, getting them in alignment as much as possible, as much as you can. Distraction, these patients are probably going to be immobile for a long time. So figuring out some sort of distraction that's not just for the ER, that's gonna be for ICU as well or wherever the patient's gonna go. Figuring out something for them to do on a stretcher or on a bed for a long time. So keep that in mind. Moving them out of your trauma room into a room that has a TV or something to calm them if possible or indicated. And then urinary cath, generally the providers are gonna want you to put in a Foley catheter and monitor urine output as well as just... It helps, especially if they have a neurogenic bladder or something so that we can kind of help control that part of the care. And then back to Dr. Greenberg. Thanks, is the audio better now? It is. Yep, Zoom changed my microphone to my laptop. My apologies, I didn't know it had done that. So it's fixed now. I wanna add on to what Gay was just saying though about pain control. Oh my God, give these people pain medicine. You know, you're not gonna get them addicted while they're in the midst of their trauma. And one of the downsides of our concerns about opioid use is under treating pain. Treat their pain. I'm not saying you gotta snow them, but give them pain medicine, my goodness. All right, let's do some more about caveats of care. All right, so general care considerations. And again, this is in the setting of someone with a known or suspected spinal cord injury. We've kind of already gotten to that point. So let's talk about the general care. Unfortunately, because there's very little we can do in the emergency department to treat their spinal cord injury, the ABCs is the most important part. Don't forget to treat and look for other injuries. We tend to, we can get distracted when we have a very severe injury or very gruesome looking injury, a mangled extremity, sometimes we get really focused on those and we forget about the other potential life threats to the chest, to the belly, to the brain. If a patient is hypotensive, do not just assume that they are hypotensive secondary to neurogenic shock like Gabe was talking about earlier. Make sure that you continue to look for the other causes of hypotension if hypotension is present. I put on here that glucocorticoids are not recommended. Why did I put that? Almost like as long as I've been practicing, for 30 years, steroids have been studied and sometimes recommended for the treatment of spinal cord injuries. It does not appear that they work. Actually, the literature really is pretty good that they do not work, they do not help. So they are not recommended for treatment of the spinal cord but you may hear that from some of the caregivers around, why aren't we given steroids? We want to do something to help people but the downside to steroids are significant. And this is something we also tend to forget too when you have a patient who's paralyzed, especially if they're a quad or a high quad, we sometimes think that they're not awake, that they may be awake. And I mean, if they're paraplegic, if it's just their lower extremities, they're not intubated, they are awake. So remember to think about that as you're taking care of the patients. These are devastating, life-changing injuries and these patients are awake. So we have to be careful about what we say and what we do and how we say and do things. So what about intubation and airway support? So a lot of these patients do need to be intubated for different reasons that I'll talk about. But once you've intubated them, you lose the ability to now get from them their history, if they can talk and give you history about what happened, their past medical history, allergies, all those things that are important in their care. You need to document what their mental status was prior to intubation and what their neurologic exam was prior to intubation. Because once we intubate them and sedate them, then you're gonna lose the ability to do those exams. They may require airway suctioning or intubation or both, but sometimes you could just simply suction the airway rather than having to intubate a patient. And if we can do that, that's better. You should have some expectations that some patients will need to be intubated. The higher the core injury is, the more likely it is that a patient is gonna have respiratory compromise due to lack of intubation to the diaphragm and thoracic muscles. One third of patients with cervical injuries require intubations within the first 24 hours. We also may need to intubate somebody because we're sending them to MRI or for other procedures where one won't be as close to critical care and also because they have to be still and they have to be still for a long time, especially for an MRI. The recommended way to intubate somebody is rapid sequence intubation with inline stabilization. You can, if you have the ability, you're sending somebody to the OR, you have the equipment, you can consider flexible fibro optic laryngoscopy. But truthfully, and it's a whole different talk, the likelihood that you're gonna make somebody worse during the intubation procedure is very, very low. And we should not let somebody die from a lack of an airway because we're afraid we're gonna make their spinal cord injury worse. Hypotension and neurogenic shock. So again, spinal cord injury is the cause of hypotension, should be a diagnosis of exclusion. Make sure we look for the other injuries. Unfortunately, we'd like to talk about patients as their injury, but lots of patients have lots of injuries. So volume replacement should only occur as indicated for the other injuries, not for the spinal cord injury, not if you have neurogenic shock, not if you have hypotension and bradycardia. The treatment for neurogenic shock, which is still somewhat, not that it's controversial what to use, not that you should treat it, because hypotension is definitely bad for spinal cord injuries. But the current recommendation is for upper spinal cord injuries, you use norepinephrine. And for lower spinal cord injuries, you use phenylephrine. But again, it is still somewhat controversial. We may hear different recommendations from your center. And this is one of those things that you should have a guideline on for how you're gonna treat. Most importantly, the AANS recommends keeping your map between 85 and 90 for a week to try to keep that cord confused. And again, hypotension and hypoxia are both associated with poor outcomes with any kind of neurologic injury. And then what about neurosurgical consultation? We asked to talk about this, but I gotta say, if you've got a spinal cord injury, you need a neurosurgeon. Again, these are devastating, life-changing injuries. This is where a neurosurgeon needs to be involved in their care very early to help direct appropriate imaging, so diagnosis and consideration for treatment, understanding that sometimes, especially for the complete cord injuries, emergent treatment really is not indicated, won't help. For the incomplete cord injuries, it certainly has a role, although that's still somewhat controversial, but the most recent literature I've seen says that treatment of incomplete injuries within 24 hours definitely has better outcomes than after 24 hours. And there really are two different surgeries that are done. One is the decompression of the cord itself to take the pressure off the cord, whether it be from bone fragments or hematoma or something else impinging on the cord. And then there is stabilization where you actually go in and operate on the bones, the structure around the cord to make it more stable around the cord. Unfortunately, that in and of itself does not improve neurologic outcome, but it is important in the recovery process. And then finally, what do we do with these patients? So if you have the capability to keep them at your center, you have the neurosurgical capability and ultimately the rehab, you keep them where you're at, they should be admitted to the ICU at least for the first 24 hours. But if you're gonna transfer them out, again, these patients have very significant injuries. They may have multiple injuries. So if you're transferring them out because you don't have the neurosurgical capability, remember to stabilize their other immediate life threats first within your capability. You don't want to send somebody for neurosurgical care, but they get there and quite frankly die or do worse because you didn't take care of the things you could. And sometimes you'll transfer these patients because of the other injuries, not necessarily for the spinal cord injury. Would highly recommend you consider a trauma center with neuroscience ICU or specialized cater capabilities. And then there are some very, very specialized treatments that are needed for some injuries that not every place can do. And there may be only a few places in your state or in the country that can take care of the patient. So I think we're running out of time, but hey, look, we're at questions and discussion. Thank you, Dr. Greenberg and thank you, Gay. If you want to hop back on, we have one question from the audience and then I have a few that I'll ask as well. So somebody asked, Gay, during your presentation, ENA teaches a six person lift instead of the log roll for suspected spine and pelvic fractures with the implication that log rolling is unsafe. It gets a lot of eye rolls from rural nurses. Can you comment and have ever seen a spinal cord harmed by a log roll? Yes, so I have also seen that and heard that the six person lift, I've never actually seen anybody do it though. Most people log roll, that seems to be what we do, the standard that I guess everybody lives by because that's what we've always done. Should we move to the lift? Potentially, but again, in a rural area, you don't often have six people at the bedside to do this, the type of lift. And so, and I know, and Dr. Greenberg, you probably have something to say about log rolling and whether or not it's truly gonna injure the spinal cord and I'm gonna let you talk to that. Well, yeah, I mean, this is the whole topic of how much, I mean, we can clearly hurt patients. There's lots of ways we can hurt patients. We know that we should never do that. But I think, and again, you get neurosurgeons, trauma surgeons, ER docs in the room together, we can argue about this all day, but I'm the one that's on camera, so I can say what I want. But I think the likelihood that by being gentle and careful with somebody and moving them, that we're gonna somehow, I'll use the word, pith them, it's just not really that big of an issue. And in fact, Dr. Michael McGonigal, who y'all may know, he's very well-known in the trauma world, he did a, one of his recent web questions about, web questions about actually intubation and causing a worsening of spinal cord injury. There's not any reports out there. Of course, not many people have a report when they do something really bad, but we hear the anecdotes that, oh my, this patient came in not paralyzed, and the next day they were paralyzed, we must have done something, but it can be the natural course of disease. So I think, and the reason I think it's important is, we sometimes don't treat emergent problems, we don't treat patients well because of this paranoia that, oh my God, we might make them worse. And I think as long as you have to, as long as you're careful with them and moving them carefully, I'm not sure there's a big difference. So, and if you can't, waiting 20 minutes to get six people to move somebody would clearly not make sense, right? So you do what you can with what you have and just be careful about it. Perfect. If you guys have any more questions, please put them in the chat, otherwise I'll ask a couple more to keep us in this timeframe that we're in. You have a lot of people in the chat saying, thank you, great presentation. So we have patients come in that we think are faking and that they cannot move. How can we quickly figure out if it's real or not? I'll take that one. So that's basically caregiver denial and neurologic problems, patient is not much different than patients that come in with strokes. So patients that come in with strokes, we have to get over our own denial that what the patient is telling you is real. And they'll have an injury or a stroke and they can't move their arm, but they're talking to you. So somehow we think, well, that can't be possible. Well, it actually can be possible. And as I talked with the incomplete spinal cord injuries, especially when you get into the cervical region, you can have very unusual neurologic presentations that are not quote anatomic like we're used to because of the different parts of the core that are being compressed. So quite frankly, the burden is on us. Anytime we think a patient's not being truthful with us, the burden is on us to prove that that's not the case, which means you would work them up just like somebody else that came in that you quote know has a spinal cord injury. So even you can disbelieve it all you want, but you still do the same thing. You do the right thing. And remember, if you're at the limitations of your diagnostic studies, if all you have is CT, you don't have MRI available, you have not ruled out a cord injury. So the answer to that is it doesn't matter what you think. If it looks like they might have it or they say in their habit, the burden is on us to prove it and to diagnose and treat appropriately. Perfect, I agree, I agree. So another couple of questions, I'll roll these two I had in together. Talking about kind of coverage, maybe you have a level three or four center or a two center who doesn't have 24 seven MRI. If the patient's at a center that doesn't have any spinal neuro coverage, how much of a workup should you do there before you transfer? And then at what point at a facility that does have MRI, but MRI is not there, at what point do you call in those techs? You want me to do that one, Getty? Yeah. Okay, so when do you call in your tech? I think the answer is you call in your tech if you think you need them. And one of the best ways to get them in is to have neurosurgery already involved in the patient's care. I wish they'd listen to me, but they want the neurosurgeon and that's fine because they can help to focus what kind of imaging they want and where they want it. But if you don't have rapid access to MRI, it's possibly probably because you don't have onsite or rapid neurosurgical capability, and you really should be considering transferring that patient out. And these are decisions and processes that you really should have set up ahead of time. So you should know that if you have a patient that comes into your center with a spinal cord injury, your obligation is to stabilize their acute life threats, chest, belly. And if you are gonna investigate them for a spinal cord injury, they need advanced care. You should know kind of upfront, this is a patient we will be transferring, or this is a patient we'll be taking care of at RED. And that is best done through a systems process. Across the country, systems are set up different ways, but almost everyone does have systems. And you know where you're gonna send somebody if they have a spinal cord injury. So that's better done, not that we like meetings, that's better done in a meeting than it is done at two o'clock in the morning. And I'll say coming from a level four rule access, critical access facility, if we can tell there's an injury right away, we know we're not gonna keep this patient. So we don't wait till the CAT scan for the diagnostics to go ahead and start the transport process. In fact, a lot of your helicopters and transports, they don't mind if you call them out and then have to call them off. They would rather go ahead and get to your facility to get the patient somewhere. So don't be afraid to go ahead and start the transfer process. Don't wait for diagnostics. We will generally, in the meantime, we will go to CAT scan, go ahead and do that because that's also part of the assessment and that we can also give to the transferring facility and the results of that, the CAT scan. But don't be afraid to go ahead and start that transfer process from the moment they walk in if you are not going to keep those patients and you can tell they're injured. Yeah, don't delay their transport and their ultimate care to do diagnostic studies that you can't act on. Right. Now, if you're waiting on transport, it may be reasonable to do those diagnostic studies if you have the right equipment, but I do not delay their transport and their care. The only caveat to that is there may be some areas where, and again, I wouldn't delay their transport, but getting their CT scan or even an MRI, if you could, I guess, and having that underway as the patient's being transported and if those studies can then be sent to the tertiary facility. Because if the surgeons can look at that imaging before the patient even gets there, a lot of times they already know their plan of care. But again, that all has to be set up ahead of time and that is the power of trauma systems is to have that coordination set up and ready to go before the patient shows up. Perfect, yeah, and going off of that, so one more quick question, because we're almost out of time, but coordinating things and having guidelines in place. You talked about the spinal motion restriction and having that set in place for all trauma patients that come in with a history of trauma, right? So how do you recommend, go ahead, sorry. Oh, I just said correct, yeah. Okay, how do you recommend the best way to implement this at centers that maybe don't have this in place? So it's like anything else that's been longstanding and firmly held in people's psyche that it's the right thing to do. You have to do both education and culture change. Education is easy, culture change is hard, but they have to go together. You can't just tell people, we're not doing that anymore, you have to tell them why. You have to educate them as to why you're not gonna do it anymore, why it's not the right thing to do. And then you have to stick with it and you have to continue to educate people and you have to change the culture. Otherwise, we always go back to kind of what we always did. And remember, depending on how long you've been doing this, when I started, it was absolutely beat into everybody's head that everybody had to have immobilization. You know, I even remember years ago, I went to a scene, I was an EMS medical director, I went to a scene and I had a volunteer firefighter holding somebody's neck up against the side of a truck. And this patient's awake, alert, you know, not even hurt. And I'm just like, what are you doing? I'm stabilizing her spine. It's like, I think if you leave her alone, it'll be pretty well stabilized. But it was just so ingrained. And we think we're doing the right things. That's what we wanna do is the right thing. We have to let people understand it's not the right thing. And understand these things were implemented without much study. It seemed like a good idea. So we did it. Great, great. I don't think there are any more questions. Thank you all for joining.

spinal cord injuries

care

spinal motion restriction

assessment

treatment

neurologic assessments

pain control

neurosurgeons

imaging studies

education