The initial management of people with actual or suspected spinal cord injury in high dependency and intensive care units by Paul Harrison, RGN, ONC, ENB 371, MAEd Paul Harrison, RGN, ONC, ENB 371, MAEd L The initial management of people with actual or suspected spinal cord injury in high dependency and intensive care units Information for acute care sector staff The Spinal Injuries Association would like to thank Coloplast, the sponsors of this reprint. Published by the Spinal Injuries Association Supported by 76 St James’s Lane London N10 3DF Tel: 020 8444 2121 Website: www.spinal.co.uk Published by June 2000 Financial support provided by the Department of Health from the Section 64 grant scheme and the National Lottery Charities Board Illustrations executed by Louise E. Hunt and Claire Macdonald from the North East Wales School of Art and Design, NEWI (thanks Yadzia). Illustrations undertaken with the kind assistance of nursing staff from the Princess Royal Spinal Injuries Unit, Sheffield and National Rehabilitation Hospital, Dunlaoghaire. Artwork for page make-up originated by Sammy Frimpong and Khadine Sinclair students on the HND Typographic Design Course at the London College of Printing (thanks Dave D.) Front Cover by James Shearman Medical Proof reader was Michelle Clarke Index was compiled by Dr Laurence H. Errington Edited by Dominic Joyeux (SIA) Printed by designyprint solutions ltd Copyright of text remains with Paul Harrison and SIA Copyright of illustrations is retained by L.E. Hunt, C. Macdonald and SIA 2000 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, without prior written permission of the publisher. ISBN 0-9531237-8-2 For more copies of this booklet contact the Spinal Injuries Association on 020 8444 2121 ext 222. This publication is available in other formats upon request. The Spinal Injuries Association website is at www.spinal.co.uk L 2 L Dedication This book is dedicated to all those healthcare professionals currently working in Intensive or High Dependency Care Units and Spinal Injuries Units who, along with the Spinal Injuries Association, have committed themselves towards improving the collaborative management of people with actual or suspected spinal cord lesions. Without their expressed interest and support this book would not have been possible. The first book in this series is also available from the Spinal Injuries Association. Spinal Injury: The First 48 Hours The initial management of people with actual or suspected spinal cord injury from scene of accident to A&E Department by Paul Harrison, RGN, ONC, ENB 371, MAEd Information for acute care sector staff Published by the Spinal Injuries Association L 3 L Contents chapter page Foreword L 7 1 Introduction Incidence and Prevalence of Spinal Cord Injury L 9 Management of Spinal Cord Injury in District General Hospitals 2 Initial Management The First 48 Hours L 11 of Spinal Cord Injury Spinal Injuries Units in the UK and Eire 3 Aetiology of Spinal Causation of Traumatic SCI L 13 Cord Injury Spinal Cord Injury Resulting from Low Falls 4 Pathophysiology of Process of Lesion Formation L 18 Spinal Cord Injury Spinal Shock Presentation of Spinal Cord Injury Management of Spinal Shock Incomplete Spinal Cord Lesions 5 Guidelines for the Initial Basic Principles L 23 Management of Spinal Initial Airway Management Cord Injury During Cardiovascular Effects of Spinal Shock Admission Initial Orthopaedic Management Moving and Handling 6 Guidelines for the Initial The Three Main Scenarios L 26 Management of Spinal Clinical Examination Cord Injury in the High Conducting the Clinical Survey Dependency or Intensive Difficulties in Diagnosis Care Unit 7 Radiological Examination Plain Radiography L 32 SCIWORA and SCIWORET Computed Tomography and Magnetic Resonance Imaging The Risks Associated with CT and MRI Scanning in the Presence of SCI Moving and Positioning Patients with SCI for Diagnostic Imaging Moving and Positioning Patients with SCI for CT Scanning Moving and Positioning Patients with SCI for MRI Scanning L 4 8 Moving and Handling Basic Principles L 38 Patients with Spinal Cord Guidelines for Using Spinal Boards Injuries Positioning and Securing a Patient on a Spineboard Using Spinal Boards in Flat Surface Transfers Procedure for Removing a Patient from a Spinal Board Procedure for Placing a Patient upon a Spinal Board Scoop Stretchers 9 Use of Cervical Collars Guidelines for Using Cervical Collars L 44 Applying a Cervical Hard Collar Justification for the Removal of a Cervical Hard Collar Managing Cervical Collars for the Unconscious or Ventilated Patient Removing the Collar Safely 10 Systemic Effects of Reduction and Stabilisation L 51 Spinal Cord Injury: Prevention of Pressure Sores Musculoskeletal System Pressure Sore Prevention Turning and Positioning Patients with SCI The Multiple System Benefits of Regular Turning Cast Management with SCI Prevention of Contractures Management of Pain with SCI Upper Limb Positioning in Tetraplegia 11 Systemic Effects of Autonomic Effects of SCI L 62 Spinal Cord Injury: Management of Spinal Cord Oedema Neurological System Methylprednisolone: Dosing Details for Acute SCI The Initial Management of Spasm 12 Systemic Effects of Respiratory Muscle Paralysis L 66 Spinal Cord Injury: Measuring and Monitoring Respiratory Function Respiratory System Monitoring Blood Gases Assisted Coughing Hand Positions for Assisted Coughing Acute (Adult) Respiratory Distress Syndrome Use of Mini-Tracheostomy Associated Chest Injuries Pulmonary Embolism Mechanical Ventilation Anaesthesia in Acute SCI Patients Weaning Ventilator Dependency 13 Systemic Effects of Vasomotor Effects L 75 Spinal Cord Injury: Circulation Cardiovascular System Blood Loss Accompanying Spinal Cord Injury Deep Vein Thrombosis Thermoregulation Immune Response L 5 14 Systemic Effects of Paralytic Ileus L 79 Spinal Cord Injury: Acute Abdominal Complications Gastrointestinal System Bowel Management Bowel Management after SCI Bowel Management Problems Outside of Specialist Units 15 Systemic Effects of Effects on the Urinary Bladder L 86 Spinal Cord Injury: Reduced Urinary Output Genitourinary System Autonomic Dysreflexia 16 Psychological and Dealing with Fear and Anxiety L 89 Emotional Support 17 Spinal Cord Injury in Special Needs of ChildrenL 91 Children and Elderly and Elderly People People Children Incidence and Occurrence Pathophysiology Orthopaedic Management Respiratory Management Cardiovascular Management Gastrointestinal Management Genitourinary Management Parental Needs Elderly Incidence and Occurrence Presentation and Diagnosis Systems Management 18 Transferring the Patient Guidelines of the British Association L 96 to a Spinal Injuries Unit of Spinal Cord Injury Specialists for Transferring Patients to SIUs 19 Conclusion L 98 20 References L 99 21 Appendix: Spinal Injury Units in the UK and Eire L 106 22 Index L 107 L 6 L Foreword - by Paul Harrison In comparison to spinal column trauma, the actual incidence of spinal cord injury (SCI) is relatively low. In most instances, transfer of a patient to a specialist Spinal Injuries Unit (SIU) can be achieved direct from the Accident & Emergency (A&E) department or within a few days of the injury. However, a significant proportion of patients will also present with accompanying head injury or multi-system trauma occasioning actual or potential respiratory compromise, single or multi-organ failure. For these reasons, most SIUs now possess dedicated Intensive or High Dependency Care facilities within their infrastructure. This enables them to receive these patients as soon as possible after referral. Despite this, and recent improvements in the transportation of critically ill patients, transfer distances or the uncertain nature of the patient’s condition at the time may force a delay in transfer. In these cases, transfer to a local Spinal Injuries Unit can be delayed by several weeks until the patient’s condition improves sufficiently for the transfer journey to be undertaken. During this time the patient will need to be cared for appropriately within the acute and critical care areas of the admitting District General Hospital (DGH). The admission of a person with an actual or suspected traumatic spinal cord injury to the High Dependency Unit (HDU) or Intensive Care Unit (ICU) of a DGH is therefore a potentially real event.1 L Key point There is no better way to prepare for this eventuality than by liaising with your local SIU to establish a good rapport and effective channels of communication with your local specialist team. Spinal Cord Injury poses significant challenges and concerns for any healthcare professional currently working in critical care areas today. As well as saving lives, these particular healthcare professionals can also make an important contribution towards preventing further disability, thereby facilitating the process of rehabilitation that follows SCI. Complications that occur during the initial hospitalisation can have a detrimental effect on an individual’s anticipated outcomes for rehabilitation.2 This book is written to make critical care professionals aware of their role and contribution within the rehabilitation process: ‘Rehabilitation is a continuous process, beginning at the moment of injury, and is an integral part of critical care. If critical care and rehabilitative care are not combined, people with spinal cord injuries are subject