Spinal Cord Injury

Posted bythespinebookPosted inTopics, Trauma

Background 

  • Injury to spinal cord resulting in temporary or permanent change to sensory, motor or autonomic function 
  • Bimodal 
    • Young – high energy 
    • Elderly – minor trauma + degenerative narrowing of canal 
    • M:F 4:1 
    • Race 
      • Caucasian > Black > Hispanic 
  • Types 
    • Incomplete tetraplegia (34%) – Central Cord 
    • Complete paraplegia (25%) 
    • Complete tetraplegia (24%) 
    • Incomplete paraplegia (17%) 
  • Mechanism 
    • MVA (50%) 
    • Improper immobilization iatrogenic (25%) 
  • Associated injuries 
    • Closed head 
    • Non contiguous spinal fracture 
    • Vertebral artery injury 
  • Prognosis 
    • 1% complete recovery at time of hospital diagnosis 
      • 90% return home and regain independence 
    • Complete SCI 5% chance recovery 
      • If still complete paralysis at 72h – no chance of recovery 
    • Incomplete SCI 50% chance walking 
    • Cause of death 
      • Pneumonia 
      • Heart disease 
      • Subsequent trauma 
      • septicemia 

Acute Management of SCI 

Short form 

  • ATLS for acute stabilization  
  • Admit to monitored bed 
  • Stabilize/ decoompressiono <24h 
  • MAP >85 
  • Mutldisicplinary care team including PT OT 

Full Form (see Trauma schpeal ATLS) 

  • Activate Trauma Team 
    • 3 RN 
    • Anesthesia 
    • Gen Surgery 
  • 2 Large Bore IVs 
    • Trauma BW 
      • CBC, Lytes, INR PTT, Type and Cross x4, 
      • BUN/Cr, glu, tox screen, beta HCG, cap gases, lactate, myoglobin 
      • Notify blood bank 
  • Monitors 
    • Telemetry 
    • Oximetry 
  • Primary Survey 
    • Airway and C Spine Collar 
      • GCS 
      • Mouth, dentition, bleeding, obstructions 
    • Breathing 
      • Air entry 
      • Saturation 
      • Apply face mask with 100% O2 
    • Circulation 
      • BP 
      • HR 
      • Abdomen 
        • Exam 
        • FAST 
      • Pelvic Stability 
        • Exam 
        • XR 
      • Resuscitation if needed 
        • 2L NS warmed 
        • 2units O -ve uncrossmatched blood 
        • MTP 
          • 1:1:1 ratio of PRBC:Plt:FFP 
    • Disability 
      • GCS 
        • EVM 
        • Eyes 4 spontaneous, 3 speech, 2 pain, 1 non 
        • Verbal 5 spontaenous 4 confused 3 inappropriate 2 incomprehensible 1 none 
        • Motor 6 spontaneous 5 localize 4 withdraw 3 flex 2 extend 1 none 
      • Pupils 
    • Exposure 
      • Long bones 
      • Log Roll spine palpation and DRE 
  • Secondary 
    • Head to toe MSK exam looking for any orthopaedic injuries 
    • Neurologic exam as per ASIA standards 
  • Admit to monitored bed in ICU capable of vasopressor therapy 
  • Hemodynamic monitoring 
    • MAP >85mmHG 
    • T6 and above – dopamine (alpha nand beta) 
      • Need HR and PVR 
    • T6 and below – phenylepherine 
      • PVR only 
  • No evidence for any other medications 
  • Surgery 
    • Timing <24h improves motor conversion 
    • Anesthesia concerns 
      • Bradycardia and hypotension and hypotension in tetraplegic 
      • No succinylcholine in first 48h (hyperkalemia) 
  • Hospital care 
    • Pressure sore prophylaxis 
    • Anticoagulation 
      • Pneumatic compression 
      • LMWH 
    • Respiratory 
      • Monitory 
      • Early trach for tetraplegics 
    • df