Managing spinal cord injury
In this video, we look at the factors that lead to worsening neurological deficits, what to do when your patient responds poorly to fluid resuscitation, and commonly used medications that can actually make the situation worse.
Over-resuscitation in a spinal cord patient can lead to accidental death. So how do you strike the right balance? In this video, we look at the factors that lead to worsening neurological deficits, what to do when your patient responds poorly to fluid resuscitation, and commonly used medications that can actually make the situation worse.
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When addressing a patient with a suspected spinal cord injury, attend first to the ABCs. Hypotension and hypoxia are mortal enemies of the injured spinal cord. It turns out though that spinal cord injured patients often do present with hypotension and bradycardia. This will need to be addressed because it can lead to worsening neurological deficits. Therefore, resuscitate the patient with appropriate fluids and run IVs at maintenance rates.
Note though, that patients have been killed through over resuscitation. This is because the hypotension of spinal cord injury is often caused by neurogenic loss of peripheral vascular tone. High volume resuscitation under these circumstances can lead to high output, cardiac failure and pulmonary edema. Therefore, do not keep adding IV fluids if there is no corresponding increase in blood pressure to one to two liters of resuscitation ration IV fluid.
Instead, if there is a poor response to fluid resuscitation, implement vasopressors to maintain a mean arterial pressure of over 90 millimeters of mercury. Dopamine is the vasopressor of choice because it has a long history of good efficacy, has some renal preservation characteristics and its dosing is very well understood.
Avoid phenylephrine as it may increase vagal tone and worsen bradycardia. In patients with spinal cord injury, a mean arterial pressure of greater than 90 millimeters of mercury should be maintained for the first seven days after the injury. Atropine can be used in cases of profound bradycardia.
During the initial evaluation, keep the patient immobilized in a cervical collar and on a spine board until after the initial CT scans. Make sure you monitor respiration and oxygenation in high spinal cord injury patients as they are prone to respiratory failure. Notify spinal surgeons early that you have a patient with a spinal cord injury even before imaging, they will want to be intimately involved in the patient's care to include ordering supplemental imaging, initiating traction and or bringing the patient emergently or urgently to surgery.
As the patient is being evaluated, maintain spinal precautions at all times. The patient's bed should be placed in reverse trendelenburg up to 30 degrees, particularly if they have associated head injuries, but only if mean arterial pressure can be sustained over 90 millimeters of mercury and no other contraindications have been identified by you or your trauma team. Make sure you remember to take the patient off the spine board after imaging but keep them on spinal precautions.
As time elapses, the patient will need to be turned from side to side regularly for pulmonary, toilet and skincare by log rolling. Neurological deficits can progress so make sure frequent neurological exams are performed. Consider using a nasogastric tube for patients with severe spinal cord injury where gastroparesis, vomiting, and aspiration are common. Do not give steroids. Their use was in favor for quite some time but now they're thought to be contraindicated. There are many potential side effects to their use, and no proven benefits.
Other spinal cord injury medications are currently investigational. Initiate compression hosiery as spinal cord injury patients are prone to DVTs or deep vein thrombosis. Initiate low molecular weight heparin injections within the first 24 to 48 hours, this may be held if surgery is intended. Also consider special rotating beds for patients with high spinal cord injuries.
These may help with pulmonary toilet and skin breakdown. In patients with cervical fracture dislocations spinal cord surgeons will often initiate traction to realign the spinal column. In line traction helps pull displace bone fragments and vertebrae back into more normal alignment, helping take pressure off the injured spinal cord.
Tongs or a halo Ring are attached to the head by a metal pins embedded into the patient's skull, a rope is tied to the top of the device and hung off the bed, weights are tied to the end of the rope affecting traction along the longitudinal axis of the patient. Such a device may need to be incorporated into the patient's bed with special adaptive equipment.
If not in traction, the patient will likely be placed in some form of rigid brace, whether they're going to surgery or not. Urgent surgery is often initiated if a patient with a spinal cord injury has definitive persistent spinal cord compression on CT and or MRI, or they are declining in their neurological exam. To be eligible for urgent surgery, the patient must be stable with respect to vital functions and other major injuries.
Most patients with spinal cord injuries will eventually require surgery to stabilize their spine and prevent secondary injury before they can be fully mobilized. After surgery, most patients will be placed in some form of restrictive brace or even a halo device when they are mobilized. Bracing will remain in place for three to six months.
Monthly upright x rays will be obtained to assure the spine is maintaining its alignment. The X rays don't actually show that the fractures are healing per se, but that the spine is holding together. Recognize that rehabilitation is a critical component of the care of spinal cord injured patients. Spinal cord injury patients should be mobilized and should undergo rehabilitative therapy as early as possible after their spines are deemed safe for such activities.