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Management of Cervical Spine Injuries-Scenario 1: Cardiorespiratory Compromise

Life-threatening alteration of cardiopulmonary function is a rare event in the collision sport athlete. Respiratory distress from obstruction of the airway can result by a foreign body, facial fractures, or direct injury to the trachea or larynx. The ability to maintain airway patency also can be lost secondary to a depressed level of consciousness.

In the absence of upper airway compromise, problems with respiration may develop in association with an upper cervical spinal cord injury as a result of paralysis of the diaphragm and accessory breathing muscles. Other possible causes of altered pulmonary function include pneumothorax, asthma, and anaphylaxis.

If not rapidly recognized and treated, any of these conditions may progress to frank respiratory failure with the potential to degenerate into cardiac arrest. Circulatory collapse from a primary cardiac event is distinctly uncommon in this setting.

Regardless of the etiology of respiratory compromise, the primary objective is to rapidly identify hypoxia and then intervene by providing proper ventilation of the injured player. This must be accomplished without causing any further injury to the spinal or neurological structures.

In this regard, any athlete with a life-threatening condition is assumed to have a catastrophic cervical spine injury until proven otherwise. Protection of the cervical spine is an important underlying principle.

When airway obstruction is identified during the primary survey, immediate steps to reestablish patency of the upper respiratory tract are taken. While maintaining manual stabilization of the neck in a neutral position, the mouthpiece is extracted.

The athlete who is lying prone on the playing surface must be carefully log-rolled into a supine position (see Protocol for Positioning and Helmet Removal). Once supine, the face mask is rapidly removed. A chin-lift, jaw-thrust maneuver is performed to move the tongue away from the back of the throat, thereby opening the airway; the head-tilt technique should be avoided because of potential alteration of cervical spine alignment.

In the player who is unresponsive or has altered mental status, an oral airway may need to be inserted to prevent occlusion of the oropharynx. Removal of the helmet is not routinely indicated unless it interferes with resuscitation of the patient.

Once the airway has been opened and protected, the next priority is to maintain adequate ventilation and perfusion. Patency of the airway does not assure adequate alveolar gas exchange, however, and ventilation also is dependent on appropriate function of the diaphragm, chest wall musculature, and lungs.

The initial assessment of respiratory function involves observation of chest excursions along with feeling and listening for air movement at the mouth or nares. Auscultation of breath sounds with a stethoscope should be performed early during the evaluation process.

Assisted ventilation is required if breathing is of insufficient depth or rate. In general, on-field ventilatory support involves use of a bag-valve device and a face mask. Indications for definitive airway control by endotracheal intubation include apnea, inability to maintain oxygenation with face mask supplementation, protection from aspiration, and severe closed head injury.

Circulation is the third issue to consider during the primary survey. The peripheral and central pulses should be evaluated in terms of quality, rate, and rhythm. Diminished amplitude of the peripheral pulses in combination with bradycardia often signifies neurogenic shock as a result of cervical spinal cord injury.

A rapid, thready pulse of normal rhythm is consistent with hypovolemic shock; this unusual finding in the collision sport athlete can be related to rapid internal blood loss, such as with a splenic injury. An irregular pulse rhythm should raise suspicion of potential cardiac dysfunction.

Inability to palpate the femoral or carotid pulses indicates the need to initiate cardiopulmonary resuscitation. In most cases, the front of the shoulder pads can be opened to allow chest compressions and, when necessary, defibrillation.

If the helmet has been removed, however, the shoulder pads also should be removed to maintain the neutral alignment of the cervical spine.

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