Spine and spinal cord are vital and complex organs. therefore there initial evaluation is also complex and involves a multitude of signs and tests. Spinal examination cannot be straightforward examination. Rather it needs to be modified as more information about the patient becomes available.
Each subsequent event in the patient’s evaluation is influenced by the findings of the initial evaluation, both for diagnosis and management of the spinal injury and for management of other potential injuries.
Severe injuries require continuous or serial examinations to monitor and diagnose conditions because some conditions may not readily apparent early.
Examination At Arrival
When the patient arrives in hospital a brief over must be taken from the prehospital care team. This helps to get an idea about the scene of injury and circumstances in which patient had been. Also relevant information about treatment along the way must be sought.
There are lot of possibilities in this scenario. In some countries, the prehospital care is excellent and by the time patient arrives in hospital, all the relevant information had been passed by prehospital care team over radio or phone and the hospital is ready to receive the patients.
On the other extreme patient might be brought to the hospital by police van or some good Samaritan and the physician is first person to look at the patient.
Sometimes there is no information available about the circumstances of the injury as the patient was found roadside and brought to the hospital.
In either case, initial evaluation of the patient must include spinal injury evaluation which might go concurrent with resuscitative measures.
Initial evaluation at the hospital arrival must include
- Gross neurological assessment with movement and sensation in all extremities [This might have been done already if prehospital care was extended]
- Assessment of gross neurological function. This again might be based on by report from field personnel, direct observation, or initial examination
- Direct examination to get a a clinical idea of level of injuries
- Cervical spine x-ray, anteroposterior chest x-ray and xray of any other injured part
- Analysis of hemodynamic parameters
Any condition which needs immediate treatment should be part of the side by side ongoing resuscitation.
Hypotension, bradycardia, warm extremities in presence of normal urine output must raise the suspicion of neurogeninc shock and it needs to be differentiated from haemorrhagic shock as the tretment is different. Treatment of neurogenic shock is pharmacologic intervention to augment peripheral vascular tone and may be essential for effective resuscitation. Fluid overload from excessive fluid volume administration, as appropriate for hemorrhagic shock, can result in pulmonary edema in the setting of neurogenic shock.
Spinal cord injury also increases the risk of multiple organ system failure in polytrauma patients. The presence of severe hemodynamic parameter abnormalities in the initial phases of resuscitation is associated with a poor prognosis for neurologic recovery but normal hemodynamics, however, do not predict neurologic recovery.
After the patient has been resuscitated, a detailed examination of the patient follows. We would cover that in next article.