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RCoAPHEM&MotorsportDayDisability:SpinalCord&BrainInjury

Ma<WilesConsultantNeuroanaesthesia/CriBcalCare,Sheffield

Editor,Anaesthesiah<p://sthjournalclub.wordpress.com/

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ObjecBves

1.  Anatomyofspinalcordinjury2.  Evidencefor“protecBon”ofthespinalcord

a.  Cervicalcollarsb.  Manualin-linestabilisaBonc.  TrachealintubaBond.  ExtricaBondevices

3.  Diagnosisandmanagementofconcussion

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NICESpinalInjuryGuidelines2016

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Winningheartsandminds…Newman.JEmergMed2007;50:476-77

SemmelweissReflex“Thereflex-liketendencytorejectnewevidenceofknowledgebecauseitcontradictsestablishednorms,beliefsorparadigms”

Pseudoaxioms“FalseprinciplesorruleshandeddownthroughgeneraBonsofmedicalprovidersandacceptedwithoutseriouschallengeorinvesBgaBon”

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EpidemiologyofSCIThompsonetal.JSpinalCordMed2015;38:214-223•  813paBentsinCanada•  13yearincreaseinmeanagefrom2002-2010•  >60%paBentsaged>55years–  80%tetraplegia–  Increaseincentralcordsyndrome

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AsymptomaBccervicalspinediseaseBrinjikjietal.AmJNeuroradiol2015;36:811-16

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CervicalCollars&SpinalBoards“Thebestplaceforcervicalcollarsisinthebin”DrPerKrisBanHyldmo

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TheArgumentforCervicalImmobilisaBon

•  PaBentmayhaveanunstablespinalinjury•  Furthermovementofthecervicalspinemayfurtherdamagethespinalcord

•  CervicalimmobilisaBonisaharmlessintervenBon•  Collarspreventmovementofthecervicalspine

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EpidemiologyofSCIHasleretal.JTrauma2012;72:975-981

0"5"10"15"20"25"30"35"40"45"50"

RTC" Fall">"2m" Fall"<"2m" Sports" Other"

All"Injuries" Cord"Injuries"

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EpidemiologyofSCIHasleretal.JTrauma2012;72:975-981

•  Medianage47.2years•  66%male•  3.5%hadcervicalspineinjuries– 10.3%inthosewithGCS3to8– only23%hadneurologicalsymptoms[0.8%oftotal]

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EpidemiologyofSCIHasleretal.JTrauma2012;72:975-981

•  Medianage47.2years•  66%male•  3.5%hadcervicalspineinjuries– 10.3%inthosewithGCS3to8– only23%hadneurologicalsymptoms[0.8%oftotal]– 25%hadinjuriestootherregions

•  16%head•  16%extremiBes•  14%chest

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DistracBngInjuriesRoseetal.JTrauma2012;73:498-502

•  SensiBvity99%•  Specificity99%

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EfficacyofImmobilisaBonTechniquesHorodyskietal.JEmerMed2011;41:513-519

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ExtricaBonTechniquesEngsbergetal.JEmerMed2013;44:122-127

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CervicalCollars&SpinalBoardsSundstrømetal.JNeurotrauma2014;31:531-40

Bednar.CanJSurg2004;47:251-6

•  Mostspinalinjuriesarestable;thosethatareunstablehavealreadycausedirreversibledamage

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CervicalCollars&SpinalBoardsSundstrømetal.JNeurotrauma2014;31:531-40

Bednar.CanJSurg2004;47:251-6

•  Mostspinalinjuriesarestable;thosethatareunstablehavealreadycausedirreversibledamage

•  ExaggeratedrateofsecondarySCIwithoutcollars•  NumerousassociatedcomplicaBons:–  Pressuresores/sepsis(6-67%)–  AirwaymanagementdifficulBes–  IncreasedICP–  AgitaBon&discomfort–  DifficulBeswithinvenBons/carebundles

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CervicalCollars&SpinalBoardsFa<ahetal.ScandJTraumaResuscEmergMed2011;19:45

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CervicalImmobilisaBonOteiretal.InjuryIntJCareInjured2015;46:528–535

•  SystemaBcreviewofpre-hospitalimmobilisaBon•  4studiesfrom1471citaBons(noRCTs)–  IncreasedmortalityinpenetraBngtrauma(OR2.77)–  Increasedriskofneurologicalinjury(AOR2.03)–  SceneBmedoubled–  LongerICUstay(7.5vs.2.3days)“..lackofhigh-levelevidenceontheeffectofpre-hospitalcervicalspineimmobilisaBononpaBentoutcomes”

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ManualIn-lineStabilisaBonManoach&Paladino.AnnEmergMed2007;50:236-45•  Originuncertain–ATLSguidance1984•  Datafromcadavericstudies,healthyvolunteersandcaseseries(n=96)

•  SeveralstudiessuggestMILShasnoeffectoncervicalsegmentmovement

Study Method Grade1 GradeII GradeIII GradeIV

Nolan&Wilson.Anaesthesia1993;48:630-33

OpBmalposiBon 129 26 2 -

MILS 75 48 34 -

Heath.Anaesthesia1994;49:843-45

OpBmalposiBon 46 4

MILS 12 27 11

Collar/tape/sandbags 2 16 25 7

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AnatomyofSpinalCordInjuryCrosby.Anesth2006;104:1293-318

Spaceavailableforspinalcord(SAC):1/3odontoid;1/3cord;1/3space

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•  10casereportsofworseningSCIaterintubaBon–  Li<letoimplicatelaryngoscopyascause

•  ClosedClaimsAnalysis:–  1970-2007(n=7740)–  48casesidenBfied(0.9%ofGAclaims)– Majority(>75%)hadstablec-spinespriortoprocedure–  Ninehadunstablecervicalspines

•  Twocasesofcordinjurywithdirectlaryngoscopyimplicated•  TwocasesoccurreddespiteAFOI

RiskofLaryngoscopyHindmanetal.Anesth2011;114:782-795

McLeod&Calder.BrJAnaes2000;84:705-9

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CervicalSpine&AirwayManoeuvresDonaldsonetal.Spine1997;22:1215-18Donaldsonetal.Spine1993;18:1220-23

•  CadaverswithunstableC1-2– MILS–  Gloucviewachievednotstated–  Spaceavailableforcordassessed

•  Jawthrust>chinlit>laryngoscopy•  CadaverswithunstableC5-6–  NoMILS–  Gloucviewachievednotstated–  CervicalspinemoBonassessed

•  Chinlit/jawthrust≈cricoidpressure≈laryngoscopy

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CervicalSpine&BVMVenBlaBonHauswaldetal.AmJEmergMed1991;9:535-8

•  Cadaversstudiedwithin40minofdeath–  Collar,spinalboard,tape–  Gloucviewachievednotstated–  Neckmaintainedinneutral

•  MaskvenBlaBon>>trachealintubaBon[P=0.00004]

0

1

2

3

4

5

MaskA MaskB Miller3 MacIntosh3

FOIOral FOINasal

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CervicalSpine&DirectLaryngoscopyMcCahonetal.Anaesthesia2015;70:452-61

•  Odontoidpegfractureincadavers

•  Minimalgloucexposure•  MILS•  Assessed“spaceavailableforspinalcord”

•  Airtraq,McCoy&Mac3–  nosignificantdifference

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CervicalSpine&OtherAirwayTechniques•  LMA[Kilicetal.AmJEmergMed2013;31:1034-36]–  Doneincervicalcollars–  LMA&iLMAsimilartoMacintosh

•  GlideScope[Robitailleetal.AnesthAnalg2008;106:935-41]– MILS–  NodifferencebetweenMacintoshandGlideScope

•  FibreopBcintubaBon[Sahinetal.EJA2004;21:819-23]–  NoMILS–  Bestpossiblegloucviewachieved–  FOIsignificantlylessmovementatC1/2(8°)butnotC2/3comparedtodirectlaryngoscopy

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ChronicTraumaBcEncephalopathy

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Whydon’twoodpeckersgetTBI?

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ConcussioninMotorsportFernandesetal.JEngMed2015;229:592-608

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ConcussioninMotorsportDowdetal.Trauma2013;15:265-270

Minoyamaetal.BrJSportsMed2004;38:613-616

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ImpactBrainApnoeaAtkinson.MayoClinProc2000;75:37-47

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ConcussionDiagnosis1.  AmericanMedicalSocietyforSportsMedicine

posiBonstatement:Concussioninsport(ClinJSportMed2013;23:1-18)

2.  AmericanAcademyofNeurologysummaryofevidence-basedguidelineupdate:EvaluaBonandmanagementofconcussioninsports(Neurology2013;80:2250-2257)

3.  Consensusstatementonconcussioninsport:The4thInternaBonalConferenceonConcussioninSportheldinZurich,November2012(BrJSportsMed2012;47:250-258)

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ConcussioninMotorsportAuto-CycleUnionHandbook2016

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Summary•  MaximalinsulttothespinalcordoccursattheBmeofinjury

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Summary•  MaximalinsulttothespinalcordoccursattheBmeofinjury

•  Hypotension&hypoxiawillworsenspinalcordinjurytoagreaterextentthananymovement

•  Don’tdelaylife-savingtreatment(s)toadheretonon-evidencedbasedguidelines

•  Impactbrainapnoeaismorecommonthanisthoughtandiseasilytreated