sign in sign up
<<
Home , Neurogenic shock, Posterior cord syndrome, Spinal cord injury, Spinal shock

Acute Management of

Dan Rutigliano, D.O Director of Inpatient Trauma Stony Brook No financial disclosures OVERVIEW

• Spinal anatomy/classification

• Evaluating a patient with suspected spinal injury

• Broad management principles of spinal injury

• Hypovolaemic vs neurogenic vs spinal : EPIDEMIOLOGY

In the United States, the of spinal cord injury in 2010 was approximately 40 per million persons per year, or approximately 12,400 annually • Causes in the United States are: - Motor vehicle accidents: 48 percent - Falls: 16 percent - Violence (especially gunshot wounds): 12 percent - Sports accidents: 10 percent - Other: 14 percent

Prior to 2000, the most frequent occurrence was a young male with a median age of 22. Since that time, the average age has increased to 37 years in 2010, presumably as a reflection of the aging population. Males continue to make up 77 to 80 percent of cases. Alcohol plays a role in at least 25 percent of TSCI ANATOMY

Location of Spinal 55% in cervical region (mobile and exposed)

15% in thoracic region (less mobile and protected)

15% in thoracolumbar region (fulcrum)

15% in lumbosacral region ANATOMY

• Upper cervical region is wide from foramen magnum to lower part C3 - 1/3 die at scene from apnea - those that survive are usually neurologically intact when they reach the hospital ANATOMY

• Below C3 the diameter of the spinal canal is smaller - injuries are more likely to produce spinal cord injuries • Most thoracic spine fractures are wedge compression fractures without spinal cord injury - high association with a complete spinal cord injury because of narrow thoracic canal • Thoracolumbar junction is where the inflexible thoracic spine meets the strong spine making it an area vulnerable to injury ANATOMY

• Multiple ascending and descending tracts in the spinal cord • 3 clinically relevant ones - lateral corticospinal tract - Controls motor functions on SAME side - spinothalamic tract - transmits and temp sensations from the OPPOSITE side - dorsal columns - transmits and vibration senses from the SAME side ANATOMY

Dermatome- area of skin supplied by a single spinal or cord segment - the muscle/s supplied by a single or cord segment SPINAL CORD INJURY: CLASSIFICATION

• Injuries to the spinal cord can be categorized in numerous ways - Incomplete (incomplete thoracic injury) - Incomplete quadriplegia (incomplete cervical injury) - Complete paraplegia - Complete quadriplegia SPINAL CORD INJURY: CLASSIFICATION

Injuries may have complete or incomplete neurological symptoms • Complete injury patients demonstrate total and flaccid , total anesthesia/analgesia, and no tendon reflexes • Incomplete injury will demonstrate partial paralysis w/ altered sensation and preserved sacral function (sacral sparing) SPINAL CORD INJURY: CLASSIFICATIONS

Different patterns of injury can result in various “syndromes” • • Anterior Cord Syndrome • • Brown-Sequard Syndrome • Syndrome SPINAL CORD INJURY: CLASSIFICATION

Spinal injuries can also be described as: • Fractures • Fracture-dislocations • Penetrating injury • Spinal Cord Injury without Radiographic Abnormalities (SCIWRA) SPINAL CORD INJURY: EVALUATION

Signs and Symptoms: • Pain • Tingling, numbness and weakness in periphery • Loss of sensation or paralysis below the level of injury • Respiratory distress • Incontinence • SPINAL CORD INJURY: EVALUATION

Evaluation and care starts with the ABCs of trauma • A=airway - Need to establish an airway while maintaining c- spine immobilization - Place a definitive airway early if respiratory compromise is suspected- typically with high cervical injury (C3/4/5) SPINAL CORD INJURY: EVALUATION

Evaluation and care starts with the ABCs of trauma • B=breathing - evaluate for any associated symptoms to indicate underlying pulmonary trauma - monitor for accessory muscle use to indicate impending respiratory collapse - use supplemental oxygen to prevent SPINAL CORD INJURY: EVALUATION

Evaluation and care starts with the ABCs of trauma • C=circulation - identify and control any from injuries - Maintain a normal to prevent secondary spinal injury - ? - aggressive fluid , pressers may be required SPINAL CORD INJURY: EVALUATION

Evaluation and care starts with the ABCs of trauma • D=disability - Check patient’s GCS status - exam for equal and reactive pupils - evaluate all 4 extremities for signs of weakness or loss of sensation - perform a rectal exam to evaluate for sphincter tone - evaluate for priapism, bulbocavernosus reflex SPINAL CORD INJURY: EVALUATION

Evaluation and care starts with the ABCs of trauma • E=exposure - remove all clothes to fully evaluate for injuries - carefully log roll the pt to palpate the spine and paraspinal regions ‣ identify all areas of pain with palpation - patients with high spinal injuries may be vasodilated and unable to regulate temperature ‣ Cover patients with warm blankets SPINAL INJURY: EVALUATION

Adjuncts to primary survey • Done after completion of ABCs • Patient should be on continuous of vitals • CXR and pelvic x-rays typically performed • FAST exam- bedside ultrasound to evaluate for bleeding in the as a source of • Placement of Foley catheter, OGT • Obtain a full medical history- important to ask about use of ! SPINAL CORD INJURY: EVALUATION

Spinal Imaging • X-rays- not done as first line, provided limited information, can be difficult to obtain needed views • CT scan- gold standard for defining bony injuries, typically done as 1st line imaging as part of the trauma “pan scan” • MRI- useful to identify ligamentous injury or contusions/compression of the spinal cord

SPINAL CORD INJURY: EVALUATION

Identify the level of spinal cord injury • Make note of both sensory and motor deficit levels ANATOMY

Dermatome- area of skin supplied by a single spinal nerve or cord segment Myotome- the muscle/s supplied by a single spinal nerve or cord segment SPINAL CORD INJURY: EVALUATION

Identify the level of spinal cord injury • Make note of both sensory and motor deficit levels SPINAL CORD INJURY: EVALUATION

American Spinal Injury Association (ASIA) Classification • Allows for standardized classification of spinal cord • Based on • severity of neurological deficit- A=complete to E=normal • the neurological level- identify the most caudal segment with normal function SPINAL CORD INJURY: EVALUATION SPINAL CORD INJURY: MANAGEMENT

Phases of injury • Primary spinal cord injury- injury to spinal cord directly related to fractures, dislocations, compression, bleeding • Secondary spinal injury- resulting from prolong mechanical instability or subsequent episodes of hypotension, hypoxia, SPINAL CORD INJURY: MANAGEMENT

Management principles: Stabilize the primary source of injury; prevent any secondary injury from occurring • Immobilization • IV fluid resuscitation • Medications • SPINAL CORD INJURY: MANAGEMENT

Strict immobilization • 5% of patients with existing injury experience a worsening or new onset of symptoms after arriving to the ED- poor immobilization techniques • use a • if a pt needs intubation must maintain inline cervical stabilization • These are potentially difficult intubations • maintain patients flat and on bedrest until appropriate bracing is in place if appropriate SPINAL CORD INJURY: MANAGEMENT SPINAL CORD INJURY: MANAGEMENT

IV fluid resuscitation • maintain SBP > 90mm Hg • Normal saline bolus • If blood pressure is refractory to fluid resuscitation consider SPINAL CORD INJURY: MANAGEMENT

Hypovolemic Shock vs Neurogenic SPINAL CORD INJURY: MANAGEMENT

Neurogenic Shock: • Mechanism- impairment of descending sympathetic pathways in the cervical or upper thorax (usually above T6) - Leads to a loss of vascular sympathetic motor tone ‣ Results in peripheral , pooling of blood and hypotension - Loss of sympathetic stimulus to the heart (injury above T1) ‣ Results in and lack of reflexive response to hypotension SPINAL CORD INJURY: MANAGEMENT

Neurogenic Shock vs Spinal shock SPINAL CORD INJURY: MANAGEMENT

Spinal Shock: • Mechanism- transient loss of voluntary and reflexive neurologic function below the level of injury - Spinal cord dysfunction maybe transient but can last days to months - flaccid paralysis, bowel and bladder incontinence, priapism - first reflexes to return are bulbocavernosus and babinski SPINAL CORD INJURY: MANAGEMENT

Neurogenic Shock • Management - Hypotension: ‣ Bolus of crystalloid fluids- may require large amounts but beware of fluid overload and pulmonary ‣ Vasopressors- typically a pure alpha-blocking agent such as ‣ Goal is to maintain end organ - warm extremities, MAP >65mm Hg, UO >0.5cc/kr/hr - Bradycardia: treatment only needed if persistent hypotension ‣ given for therapy ‣ Pacemaker can be needed rarely in refractory cases ‣ Avoid over-zealous vagal stimulation such as NT suctioning, ETT manipulation, carotid massage SPINAL CORD INJURY: MANAGEMENT

Medical therapy: • - Aimed at reducing the extent of secondary spinal damage - Most trials have used high dose ‣ to be given within 8 hrs from time of injury ‣ bolus first given followed by IV infusion for 24-48hrs - Insufficient evidence to routinely recommend ‣ Early studies (NASCIS I&II) showed no increased complications or mortality, however larger and later studies have raised significant concerns related to and mortality ‣ In 2013, based upon the available evidence, the American Association of Neurological Surgeons and Congress of Neurological Surgeons stated that the use of glucocorticoids in acute spinal cord injury is not recommended ‣ Position statements from the Canadian Association of Emergency Physicians, endorsed by the American Academy of Emergency Medicine, concur that treatment with glucocorticoids is a treatment option and not a treatment standard. SPINAL CORD INJURY: MANAGEMENT

Management of co-morbidities of the injury • Respiratory compromise- Pulmonary complications, including , , , and pulmonary , are the most frequent category of complications after injury - early intubation and ventilator support as needed - Tracheostomy is performed within 7-10 days unless extubation is imminent

• Venous - Deep venous thrombosis (DVT) is a common complication of spinal injury, occurring in 50 to 100 percent of untreated patients, with the greatest incidence between 72 hours and 14 days - All spinal cord injury patients should receive DVT prophylaxis as soon as possible - Early consideration for placement of an IVC Filter if pt is quadriplegic SPINAL CORD INJURY: MANAGEMENT

Management of co-morbidities of the injury • Pain control. After spinal injuries, patients usually require pain relief. • Pressure sores. Pressure sores are most common on the buttocks and heels and can develop quickly (within hours) in immobilized patients. - Backboards should be used only to transport patients with potentially unstable spinal injury and discontinued as soon as possible. - After spinal stabilization, the patient should be turned side to side (log-rolled) every two to three hours to avoid pressure sores. - Check for pressure sores under cervical collars • . Typically an indwelling urinary catheter is used to avoid bladder distention. - Three or four days after injury, intermittent catheterization should be substituted, as this reduces the incidence of bladder infections SPINAL CORD INJURY: MANAGEMENT

Management of co-morbidities of the injury • Gastrointestinal stress ulceration. Patients with spinal injury, particularly those that affect the cervical cord, are at high risk for stress ulceration. Prophylaxis with proton pump inhibitors is recommended upon admission for four weeks • Paralytic ileus. Bowel motility may be silent for a few days to weeks after injury. Patients should be monitored for bowel sounds and bowel emptying, and should not ingest food or liquid until motility is restored • Temperature control. Patients with a cervical spinal cord injury may lack vasomotor control and cannot sweat below the lesion. Their temperature may vary with the environment and need to be maintained. • Functional recovery. Occupational and physiotherapy should be started as soon as possible. Psychological counseling is also best offered to patients and relatives as early as possible. • Nutrition- nutritional support should be provided early after injury- ideally within the first 24hrs if patient is stable - Enteral or PO feeding is the prefer route. SPINAL CORD INJURY: MANAGEMENT

Surgical Fixation • Cervical Traction - Gardner-Wells tongs ‣ Provides temporary stability of the cervical spine ‣ Contraindicated in unstable hyperextension injuries ‣ Weight depends on the level (usually 5lb/level, start with 3lb/level, do not exceed 10lb/level) ‣ Cervical collar can be removed while patient is in traction ‣ Pin care: clean q shift with appropriate solution, then apply povidone- iodine ointment ‣ Take XRays at regular intervals and after every move from bed SPINAL CORD INJURY: MANAGEMENT SPINAL CORD INJURY: MANAGEMENT SPINAL CORD INJURY: MANAGEMENT SPINAL CORD INJURY:MANAGEMENT SPINAL CORD INJURY : CONCLUSIONS

Take Home Messages: • Over 1/2 of spinal cord injuries occur in the cervical spine • C-spine immobilization is critically early in patients with suspected injury to prevent further damage • Consider early intubation and ventilation for patients with evidence of high cervical injuries before they show signs of respiratory distress • The principles of ATLS “ABCs” still apply to fully evaluate the patient and treat any associated injuries SPINAL CORD INJURY: CONCLUSIONS

Take Home Messages: • Neurogenic shock is a triad of hypotension, bradycardia, and peripheral vasodilation • In trauma patients, neurogenic shock is a diagnosis of exclusion • Avoid over-zealous fluid resuscitation- consider vasopressors if blood pressure is refractory to treatment • Early consultation with a spinal specialist for surgical fixation Questions?

Thank you!