Acute Traumatic Spinal Cord Injury (SCI) Care Guidelines Emergency Department Management GOAL First 24 Hours of Injury Inclusion Criteria: Acute Spinal Cord Injury Patients (up through the first week of injury  Stabilize vital signs  Volume resuscitate and support airway and breathing Assessment: Mechanism of injury, vital signs, place TRIAGE ESI Level 2  Monitor for unidentified injuries, patient in c-spine, neuro exam, assess and support airway,  LABS: serial CBCs and coags q breathing and circulation. Assess any additional injuries Spinal Immobilization at 6 hours and ABGs q 6 hrs Laboratory: Type and Cross, CBC, PT, PTT 1st contact Radiology: Appropriate images to be determined by trauma team

Recommendations/ Patients presenting to the ED with Considerations Neurosurgery should be consulted suspected SCI with complete or  Loss of thoracic sympathetic immediately incomplete injury will undergo acute innervation (T1-T5) may inhibit trauma evaluation by the trauma surgeon. tachycardia and vasoconstriction as signs of hypovolemia and thus ED Nursing Assessment and disguise hemorrhagic injuries  During the resuscitation and ED Physician Management Management critical care phases, analgesic agents and sedatives are  Assess and support airway, breathing, typically required circulation  Perform Trauma Nursing Process (1° & 2°  The use of steroids is not  Perform serial neurological exams (to Assessment) proven as a standard of care. include pre and post resuscitation exam)  Establish 2 large bore IVs, insert Foley catheter and Evidence of the drug’s  Document the level of injury NG tube efficacy and impact is  Consult neurosurgery for spine stabilization  Monitor neurologic status (motor function, sensation, controversial and priorities and reflexes), vital signs, respiratory, GCS and administration is at the  Perform a full neurological survey as a hemodynamic status as indicated discretion of the baseline for comparison with future exams  Notify physician of any changes in neurologic neurosurgeon.  Optimize perfusion functional status, hemodynamic status, or respiratory  Closely monitor respiratory -Maintain age appropriate median MAP or status status and intubate early, as greater  GOAL: Maintain age appropriate MAP (per MD order) indicated. For patient with -First administer crystalloid or colloid IV to optimize perfusion uncleared c-spine, collaborate and consider the use of dopamine and/or  Maintain normothermia with neurosurgery/anesthesia norepiephrine  Assess patient’s pain, as necessary to assure proper  Administer clotting components to correct  Assess and monitor for other unidentified injuries or alignment during intubation any coagulopathy internal bleeding  Monitor for autonomic  Assess and monitor for other unidentified  Keep HOB flat and move patient using sliding sheets dysreflexia injuries and log roll to turn patient with adequate number of  Order appropriate specialty bed for spine personnel while maintaining spinal alignment. immobilization (Rotorest bed) and/or othotics per request of neurosurgery (i.e. halo or tongs)

Spinal Immobilization Autonomic Dysreflexia Respiratory Assessment (AD)  Respiratory involvement depends on the level MEDICAL EMERGENCY  Immobilize spine with c-collar and maintain until of injury: that most commonly occurs in cleared by Trauma Services. Refer to CHOC  C1-C4: Paralysis of diaphragm- will need patients with SCI above T6. Pediatric Trauma C-Spine Clearance Guidelines mechanical ventilation Characterized by remarkably high  Keep patient on back board until an order is  C5-T6: Paralysis of intercostals, diaphragm OK- BP, intense HA, sweating, flushing received from neurosurgeon to remove board. may need some form of respiratory support of skin above lesion. Most Maintain neutral spinal alignment for small children.  T6-T12: Abdominal muscles paralyzed- may commonly caused by full bladder or Assess skin frequently. Goal to get the patient off have some decreased function bowel. the backboard within hour (prior to transport to : Notify PICU) unless otherwise directed by Management of AD  Monitor respiratory status including: pattern, neurosurgery. Set-up cervical traction and/or the physician if suspected, treat the effort, ability to cough, ausculated chest, monitor immobilization devices for cervical spine fractures BP and the causative factor (noxious SpO2, ETCO2, blood gas, intubate as soon as  Assist physician in immobilization and postural stimulus, i.e. bladder distention, clinically indicated reduction of spinal fractures stool impaction, skin issue), loosen  Optimize respiratory status: decompress  Prepare for operative intervention based on tight clothing, sit patient upright (if abdomen via salem sump, perform CPT, incentive physician recommendations previously cleared to do so), check spirometry, assisted coughing per MD orders for sources of pain

Approved by Care Guidelines Committee 7/15/15 Reassess the appropriateness of Care Guidelines as condition changes and 24 hours after admission. This guideline is a tool to aid clinical decision making. It is not a standard of care. The physician should deviate ©2018 Children’s Hospital of Reviewed 9/19/18 from the guideline when clinical judgment so indicates. Orange County Acute Traumatic Spinal Cord Injury (SCI) Management Inpatient PICU Nursing Assessment and Management

Inclusion Criteria: Acute Spinal Cord Injury Patient (up through the first week of injury)

First 24 Hours of Injury 24-72 Hours Post Injury 72 Hours – 1 Week Post Injury  Stabilize vital signs  Ongoing stabilization and Monitoring/  Rehabilitation and continued support  Volume resuscitate and support airway and breathing Prevention of complications associated with  Determining extent of injury/prognosis  Monitor for unidentified injuries, SCI  Transitioning patient and family into  LABS: serial CBCs and coags q 6 hours, and ABGs q  Monitor for unidentified injuries chronic phase of injury 6 hrs

Vital Signs and Autonomic Control Respiratory Neurologic Activity/  Place CVP and A-line upon arrival to Assessment Assessment Rehabilitation PICU (consider removing after 48 hours)  Ensure that rehabilitation  Respiratory involvement  Neurological assessment and  Monitor VS continuously while in the services (PT/OT/Speech) are depends on the level of injury: documentation should be PICU st consulted within 24 hours of  C1-C4: Paralysis of diaphragm- performed hourly for 1 24  Goal: Maintain age appropriate MAP admission will need mechanical ventilation hours then per unit standard of (per MD order) to optimize  Consult Hematology to  C5-T6: Paralysis of intercostals, care (if condition stabilizes): perfusion collaborate on VTE prevention diaphragm OK-may need some  Sensory level  First administer crystalloid or colloid IV within 24 hours of admission form of respiratory support  Motor function to maintain CVP 4-8 mm Hg then (patient is at high risk)  T6-T12: Abdominal muscles  Glasgow coma scale consider the use of dopamine and/or  C-Spine precautions (with c- paralyzed- may have some  Pupil response (with norepinephrine collar) until cleared by Trauma decreased function pupillometer) Services. Refer to CHOC Assess for complications Pediatric Trauma C-Spine  Monitor respiratory status Clearance Guidelines including: including: pattern, effort, ability  Place patient on specialty bed  Other unidentified injuries to cough, auscultated chest, (i.e. Roto Rest bed) per  Loss of autonomic control, particularly monitor SpO2, ETCO2, blood gas, provider order in cervical or high thoracic injuries intubate as soon as clinically  Keep patient HOB flat until  Bradycardia with ETT or trach indicated suctioning due to unopposed vagal Additional otherwise ordered by neurosurgery activity (thoracic sympathetic input may  Optimize respiratory status: Recommendations/  Log roll with adequate have been damaged) decompress abdomen via salem Considerations personnel to turn patient while  Neurogenic shock: loss of autonomic sump, perform CPT, incentive maintaining spinal alignment control/vasomotor tone. Patient may spirometry, assisted coughing per The use of steroids is  Move patient using sliding be vasodilated, hypotensive, with a MD orders not proven as a widened pulse pressure. Can last standard of care. sheets with adequate number of personnel maintaining spinal several weeks. Avoid hypotension as Evidence of the drug’s this can result in poor perfusion to the alignment efficacy and impact is  Apply sequential compression spine. controversial and  Loss of temperature control devices while in bed (for VTE administration is at the prevention) discretion of the  Once patient is cleared by Autonomic Dysreflexia neurosurgeon. neurosurgeon to sit up: (AD)  -Consult rehab for specialty cushion for sitting upright MEDICAL EMERGENCY that  -Perform pressure relief (for most commonly occurs in patients with 30 seconds every 30 minutes) SCI above T6. Characterized by while patient is in the sitting remarkably high BP, intense HA, position sweating, flushing of skin above lesion. Most commonly caused by full bladder or bowel. Management of AD: Notify the Optimal management requires physician if suspected, treat the BP and the comprehensive expertise of the causative factor (noxious stimulus, i.e. the inter professional team. The bladder distention, stool impaction, skin goal of treatment is to maximize issue), loosen tight clothing, sit patient function and provide the upright (if previously cleared to do so), necessary family education to check for sources of pain allow optimal home management. Occupational therapy and physical therapy interventions should be provided Continued throughout the continuum of care Reassess the appropriateness of Care Guidelines as condition changes and 24 hours after admission. This guideline is a tool to aid clinical on page 2 decision making. It is not a standard of care. The physician should deviate from the guideline when clinical judgment so indicates. Continued from Acute Traumatic Spinal Cord Injury (SCI) Management page 1 PICU Inpatient PICU Management Nursing Assessment and Management

Bowel Management Bladder Management Skin Assessment and (Neurogenic Bowel) (Neurogenic Bladder) Management

 In the early acute phase of injury (< 3 days),  Bowel may be affected by damage to the nerves that control its function. Constipation Patients with SCI are high risk for altered an indwelling catheter is indicated skin integrity due to loss of sensation  Once the patient has stabilized and on can trigger complications such as autonomic dysreflexia. Maintain oral/nasal gastric tube to of pain, pressure, temperature, and reduced opioids, consider changing to motor function intermittent catheter every 4-6 hours. If low continuous suction until GI function returns  Consult dietitian to assist with bowel bladder volumes consistently exceeds  Place patient on specialty (Rotorest) bed expected capacity, increase frequency of management plan  H2 blocker or PPI for gastric ulcer prevention as ordered intermittent catheterization and/or consider  High risk for pressure ulcers-initiate care alternative bladder management method  Administer pro-motility medications as prescribed plan  Consider Mepilex border on bony Estimated pediatric bladder capacity  Establish nutrition per PICU Enteral Feeding Guidelines and guidance of dietitian prominences (i.e. scapula, sacrum, heels, (2 x age (years) + 2) x 30 = capacity (mL) for elbows) to prevent pressure ulcers, children less than 2 years old discuss with PT Upon initiation of enteral nutrition,  Reposition patient at least every 2 hours (age (years) divided by 2 + 6) x 30 = capacity choose one of the following:  Remove c-collar to clean skin underneath (mL) for those 2 years old or older with a normal Docusate sodium (Colace®) PO BID, or every day (manually immobilize head adult capacity of approximately 500 mL Polyethylene glycol (Miralax™) PO at bedtime while collar is off) IF ON OPIATES, add senna (Senokot®) PO at  Assess and document full skin  Long term bladder management may bedtime or may substitute Peri-Colace® (fixed dose assessment (including under c-collar) at include: use of suprapubic catheter, condom combination of docusate sodium and senna) PO least once per shift cath, continued intermittent caths, and/or BID medications to reduce bladder spasm -If NO stool after 48 hrs on enteral Once patient is cleared by neurosurgeon nutrition, choose one of the following: to sit up: Potential Complications: recurrent UTI, -Increase Miralax™ to BID, or  Consult rehab for specialty cushion for renal and bladder calculi, vesico-ureteric reflux, -Consider glycerin suppository or sitting upright and autonomic dysreflexia, Priapism may occur bisacodyl suppository once daily  Perform pressure relief (for 30 seconds in boys and is usually self-limiting and not a -If NO stool after 24 hrs of increasing every 30 minutes) while patient is in the contraindication to catheterization. Consult Miralax™ or adding suppository, choose one of sitting position urology if priapism is prolonged (>1 hour). the following: -Start Senokot (stimulant) PO daily or BID Prevention of Complications: Maintain (if not already started) -Consider phosphate enema adequate patient hydration, good hand hygiene; provide perineal care once a shift and after bowel For impaction: Contact stimulant or osmotic movements (Refer to infection Prevention laxative, lubricant and assisted evacuation only Policy #337: CAUTI-Prevention Strategies). if necessary For diarrhea: Adjust diet, reduce aperients, stool specimen, abdominal X-ray if impaction suspected, consider probiotics

Reassess the appropriateness of Care Guidelines as condition changes and 24 hours after admission. This guideline is a tool to aid clinical decision making. It is not a standard of care. The physician should deviate from the guideline when clinical judgment so indicates. References

Acute Traumatic Spinal Cord Injury Care Guideline

Hickey J. 2009. The Clinical Practice of Neurological and Neurosurgical Nursing. Philadelphia: Wolters Kluwer AANS/CNS. 2013 (March Supplement). Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injury. Chapters 1-26. Neurosurgery 72 (3):Pages 1-259. Kaefer M, Zurakowski D, Bauer S.B., Retik A.B., Peters C.A., Atala, A., Treves S.T. (1997) Estimating Normal Bladder Capacity in Children. Journal of Urology, 158(6):2261-4. Merenda, L. A., & Hickey, K. (2005). Key elements of bladder and Bowel management for children with spinal cord injuries. SCI Nursing: A Publication Of The American Association Of Spinal Cord Injury Nurses, 22(1), 8-14. McIllvoy L, Meyer K & Mahanes D, Sachse S, McQuillan K. (2010). Traumatic Spine Injuries. In M.K. Bader & LR Littlejohns (Eds.), AANN Core curriculum for neuroscience nursing (5th ed., pp. 349-416). Glenview, IL: AANN. Powell, A., & Davidson, L. (2015). Pediatric spinal cord injury: a review by organ system. Physical Medicine & Rehabilitation Clinics Of North America, 26(1), 109-132. doi:10.1016/j.pmr.2014.09.002 Stahel PF, VanderHeiden T and Finn MA. 2012. Management strategies for acute spinal cord injury: current options and future perspectives. Curr Opin Crit Care 18:651-660. Vale F.L., Burns J., Jackson A.B., & Hadley M.N. (1997). Combined medical and surgical treatment after acute spinal cord injury: Results of a prospective pilot study to assess the merits of aggressive medical resuscitation and blood pressure management. Journal of Neurosurgery 87: 239-246

Authors: Jennifer Hayakawa, RN, MSN, CNS, CCRN, DNP, Kent Lee, RN, MSN, CPEN, William Loudon, MD, Paul Lubinsky, MD, Michael Muhonen, MD, Allison Breig

Reviewed 9/19/18