Triage

Process of prioritizing patient treatment during

multiple and mass-casualty events.
Principle of Triage
• Do the most good for the most patients using
available resources
• Make a decision
• Triage occurs at multiple levels
• Know and understand the rsources available
• Planning and rehearsal
• Determine triage category types
• Triage is continous (retriage)
 Primary Survey Secondary Survey
• A = airway (with cervical spinal • should be done after
protection) complete primary survey and
• B = breathing stabilize patients
• C = circulation (control • Head to toe examination,
hemorrhage) include history taking, physical
• D = disability examination , laboratory
• E = exposure studies and imaging studies

History Taking Physical Examination

• M = mechanism of injury Mental status
• I = injuries found and suspected • Eyes
• S = signs and symptoms • Head
• T = treatment initiated • Maxillo-facial
• Cervical vertebrate & neck
• A = allegy • Thorax
• M = medication • Abdomen
• P = past illnesses • Pelvic
• L = last meal • Musculoskeletal
• E = events
 Work Up

Laboratory Studies
• Arterial blood gas
• Pulse oxymetry
• Lactic acid concentration
• Blood group
• Complete blood count
Imaging Studies
• X-rays (thorax and pelvic)
• USG (abdomen)
• CT scans (head and cervical
vertebrate)
Additional Studies
• ECG
• Urethral catheterization
• NGT
SPINE AND SPINAL CORD TRAUMA

• Spine injury, with or without neurologic deficits,

must always be considered in patients with
multiple injuries
• Epid:
• 55%  cervical region
• 15%  thoracic region
• 15%  thoracolumbar junction,
• 15%  lumbosacral area

ATLS, students course manual, 9th ed. p. 175-205

Anatomy and Physiology of Spinal Cord

ATLS, students course

manual, 9th ed. p. 175-
205
Anatomy and Physiology of Spinal Cord (2)
• Complete spinal cord injury  when a patient has no
demonstrable sensory or motor function below a
certain level
• Incomplete spinal cord injury  is one in which any
degree of motor or sensory function remains; the
prognosis for recovery is significantly better
ATLS, students course
manual, 9th ed. p. 175-205
ATLS, students
course manual,
9th ed. p. 175-
205
Rosen’s emergency medicine, 8th ed. p. 382-420
 SPINE AND SPINAL CORD TRAUMA :
Sensory Examination
• DERMATOME
is the area of skin
innervated by the
sensory axons within a
particular segmental
nerve root.

ATLS, students course manual, 9th ed. p. 175-205

SPINE AND SPINAL CORD
TRAUMA :
Sensory Examination (2)
• MYOTOMES
Each segmental nerve
(root) innervates more
than one muscle, and most
muscles are innervated by
more than one root
(usually two).
 certain muscles or
muscle groups are
identified as representing a
single spinal nerve
segment.

ATLS, students course manual, 9th ed. p. 175-205

 NEUROGENIC SHOCK VS SPINAL SHOCK

Neurogenic shock Spinal shock

• results from impairment of the • refers to the flaccidity (loss
descending sympathetic pathways in the of muscle tone) and loss of
cervical or upper thoracic spinal cord. reflexes seen after spinal
• This condition results in the loss of vasomotor cord injury.
tone and in sympathetic innervation to the
heart. • The “shock” to the injured
cord may make it appear
• Neurogenic shock is rare in spinal cord completely nonfunctional,
injury below the level of T6. although the cord may not
• Loss of vasomotor tone causes necessarily be destroyed.
vasodilation of visceral and lower- The duration of this state is
extremity blood vessels, pooling of variable.
blood, and, consequently, hypotension.

ATLS, students course manual, 9th ed. p. 175-205

 SPINE AND SPINAL CORD TRAUMA :
Classifications of Spinal Cord Injuries
1. Level
2. Severity of neurologic deficit
3. Spinal cord syndromes
4. Morphology

ATLS, students course manual, 9th ed. p. 175-205

 Classifications of Spinal Cord Injuries :
1. Level
• The neurologic level  the
most caudal segment of the
spinal cord that has normal
sensory and motor function
on both sides of the body.
• Sensory level  the most
caudal segment of the spinal
cord with normal sensory
function
• Motor level  similarly with
respect to motor func tion as
the lowest key muscle that has
a grade of at east 3/5 (Table
7.3).
ATLS, students course manual, 9th ed. p. 175-205
2. Severity of Neurologic Deficit
• Spinal cord injury may be categorized as:
• Incomplete paraplegia (incomplete thoracic injury)
• Complete paraplegia (complete thoracic injury)
• Incomplete quadriplegia (incomplete cervical injury)
• Complete quadriplegia (complete cervical injury)

ATLS, students course manual, 9th ed. p. 175-205

 3. Spinal Cord Syndromes

• Central cord syndrome  characterized by a

disproportionately greater loss of motor strength in
the upper extremities than in the lower
extremities, with varying degrees of sensory loss
• Anterior cord syndrome  characterized by
paraplegia and a dissociated sensory loss with a
loss of pain and temperature sensation
• Brown-Séquard syndrome  results from
hemisection of the cord, usually as a result of a
penetrating trauma.

ATLS, students course manual, 9th ed. p. 175-205

 4. Morphology
• Spinal injuries can be described as:
• Fractures
• Fracture dislocations
• Spinal cord injury without radiographic bnormalities
(SCIWORA)
• Penetrating injuries
• These categories may be further described as stable
or unstable
• In the initial treatment, all patients with radiographic
evidence of injury and all those with neurologic
deficits should be considered to have an unstable
spinal injury.
ATLS, students course manual, 9th ed. p. 175-205
 SPINE AND SPINAL
CORD TRAUMA :
Classification of Spinal
Column Injuries

• Flexion
• Shear injury
• Flexion-Rotation
• Extension
• Vertical compression

Rosen’s emergency medicine, 8th ed. p. 382-420

 SPINE AND SPINAL CORD TRAUMA :
Classification of Spinal Cord Injuries
Primary Spinal Cord Injury Secondary Spinal Cord Injury
• The spinal cord may be • The maximum neurologic
injured in a number of deficit after blunt spinal cord
ways: trauma is often not seen
• penetrating trauma / immediately and may
massive blunt trauma with instead progress over many
disruption of the vertebral hours.
column
• when elderly patients • The histopathology of the
w/cervical osteoarthritis & so-called “secondary SCI”
spondylosis are subjected to
forcible cervical spine
extension
• Primary vascular damage to
the spinal cord (extradural
hematoma  patients who
have bleeding disorders)

Rosen’s emergency medicine, 8th ed. p. 382-420

 SPINE AND SPINAL CORD TRAUMA :
X-Ray Evaluation
1. Servical Spine
• Cervical spine radiography is indicated for all trauma
patients who have midline neck pain, tenderness on
palpation.
• CT scans may be used in lieu of plain images
• Under no circumstances should the patient’s neck be
forced into a position that elicits pain. All movements
must be voluntary.
2. Thoracic And Lumbar Spine
• The indications for screening radiography  same as
those for the cervical spine
ATLS, students course manual, 9th ed. p. 175-205
ATLS, students course
manual, 9th ed. p. 175-
205