Acute Traumatic Spinal Cord Injury
Under revision 25/07/24.
PEARLS
Resuscitation per EMST/ATLS, rule out other causes of shock before ruling in neurogenic shock
Neck immobilisation change rigid collar to hard collar (e.g. Miami J) ASAP and off spinal board
Early referral to spinal centre
Determine: Neurological Level of Injury (NLOI) w/ ISNCSCI worksheet early
Surgical timing: <8h ideally (although in critically ill polytrauma, may need to delay)
MAP target: 85-90 for 5-7 days
Steroids: Remain controversial, currently evidence leans towards more harm than good
Novel therapies: Lots in the pipeline…
OVERVIEW
- patient requires synchronous resuscitation, evaluation, treatment and early transfer to a spinal unit following initial stabilisation
- ATLS/EMST protocol applies
- spinal shock is physiological response to spinal cord injury resulting in temporary loss or depression to most spinal reflex activity below the level of the injury (‘spinal cord concussion’)
- neurogenic shock is loss of sympathetic outflow resulting in a bradycardic, vasoplegic hypotensive state (a true shock state)
RESUSCITATION
Airway
- assess need for intubation
-> tetraplegia
-> VC < 10mL/kg and/or TV < 3.5mL/kg
-> respiratory distress (weak cough and shallow rapid breathing are early signs)
-> adequate gas exchange
-> diaphragmatic impairment
-> LOC
- if required: full neurological assessment prior, in-line stabilisation, may be difficult (AFOI), ETCO2
Breathing
- O2
- once intubated employ a protective lung ventilation strategy (VT 6mL/kg PBW and Pplat <30)
Circulation
- large bore IV access and fluid resuscitation
- rule out haemorrhage as a cause of possible hypotension
- optimize spinal cord perfusion
Disability
- neurological examination (see below)
Exposure
- keep warm
EVALUATION
History
- mechanism
- other injuries
- events
- AMPLE
Examination
- head to toe examination
- motor level (highest myotome level of grade > 3/5)
- sensory level (high sensory dermatome with normal sensation)
- back: step, deformity, haematoma, open # (when logged rolled)
- perineal: anal sensation and tone (active and passive), bulbocavernosus reflex
- injury complete or incomplete
- if incomplete define the zone of partial preservation
- priapism
- presence of a cord syndrome (central, anterior, Brown-Sequard, conus, cauda equina)
- American Spinal Injury Association classification (ASIA) (A-E)
- pressure areas
Investigations
- trauma x-ray series
- trauma bloods
- CT whole spine
- MRI
TREATMENT
- invasive monitoring (usually subclavian due to collar)
- once haemorrhage ruled out -> begin noradrenaline and aim for MAP >70 for spinal cord perfusion
- log roll 2 hourly
- analgesia
- replace hard collar with a more comfortable stabilizing collar (Philadelphia, Miami J)
- IDC
DISPOSITION
- early liaison with spinal centre and spinal surgeon
ASIA IMPAIRMENT SCALE
- The American Spinal Injury Association (ASIA) Standard Neurological Classification of Spinal Cord Injury is a standard method of assessing the neurological status of a person who has sustained a spinal cord injury.
- Scale assessments can be carried out using this ASIA Impairment Scale worksheet (PDF).
- The neurological level of injury is the most caudal segment of the cord with intact sensation and antigravity (3 or more) muscle function strength, provided that there is normal (intact) sensory and motor function rostrally respectively.
| Category | Description |
|---|---|
| A = Complete | No motor or sensory function is preserved in the sacral segments S4-S5 |
| B = Incomplete | Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-S5 |
| C = Incomplete | Motor function is preserved below the neurological level, and more than half of key muscles below the neurological level have a muscle grade of less than 3 |
| D = Incomplete | Motor function is preserved below the neurological level, and at least half of the key muscles below the neurological level have a muscle grade of 3 or more |
| E = Normal | Motor and sensory function are normal |
- Loss of motor function’ means a person has no voluntary control of their muscles.
- ‘Loss of sensory function’ means a person has no sense of touch and cannot feel hot or cold, pain, or pressure. They also have no sense of where in space their limbs are (proprioception).
References and Links
CCC Neurocritical Care Series
Emergencies: Brain Herniation, Eclampsia, Elevated ICP, Status Epilepticus, Status Epilepticus in Paeds
DDx: Acute Non-Traumatic Weakness, Bulbar Dysfunction, Coma, Coma-like Syndromes, Delayed Awakening, Hearing Loss in ICU, ICU acquired Weakness, Post-Op Confusion, Pseudocoma, Pupillary Abnormalities
Neurology: Anti-NMDA Encephalitis, Basilar Artery Occlusion, Central Diabetes Insipidus, Cerebral Oedema, Cerebral Venous Sinus Thrombosis, Cervical (Carotid / Vertebral) Artery Dissections, Delirium, GBS vs CIP, GBS vs MG vs MND, Guillain-Barre Syndrome, Horner’s Syndrome, Hypoxic Brain Injury, Intracerebral Haemorrhage (ICH), Myasthenia Gravis, Non-convulsive Status Epilepticus, Post-Hypoxic Myoclonus, PRES, Stroke Thrombolysis, Transverse Myelitis, Watershed Infarcts, Wernicke’s Encephalopathy
Neurosurgery: Cerebral Salt Wasting, Decompressive Craniectomy, Decompressive Craniectomy for Malignant MCA Syndrome, Intracerebral Haemorrhage (ICH)
— SCI: Anatomy and Syndromes, Acute Traumatic Spinal Cord Injury, C-Spine Assessment, C-Spine Fractures, Spinal Cord Infarction, Syndomes,
— SAH: Acute management, Coiling vs Clipping, Complications, Grading Systems, Literature Summaries, ICU Management, Monitoring, Overview, Prognostication, Vasospasm
— TBI: Assessment, Base of skull fracture, Brain Impact Apnoea, Cerebral Perfusion Pressure (CPP), DI in TBI, Elevated ICP, Limitations of CT, Lund Concept, Management, Moderate Head Injury, Monitoring, Overview, Paediatric TBI, Polyuria incl. CSW, Prognosis, Seizures, Temperature
ID in NeuroCrit. Care: Aseptic Meningitis, Bacterial Meningitis, Botulism, Cryptococcosis, Encephalitis, HSV Encephalitis, Meningococcaemia, Spinal Epidural Abscess
Equipment/Investigations: BIS Monitoring, Codman ICP Monitor, Continuous EEG, CSF Analysis, CT Head, CT Head Interpretation, EEG, Extradural ICP Monitors, External Ventricular Drain (EVD), Evoked Potentials, Jugular Bulb Oxygen Saturation, MRI Head, MRI and the Critically Ill, Train of Four (TOF), Transcranial Doppler
Pharmacology: Desmopressin, Hypertonic Saline, Levetiracetam (Keppra), Mannitol, Midazolam, Sedation in ICU, Thiopentone
MISC: Brainstem Rules of 4, Cognitive Impairment in Critically Ill, Eye Movements in Coma, Examination of the Unconscious Patient, Glasgow Coma Scale (GCS), Hiccoughs, Myopathy vs Neuropathy, Neurology Literature Summaries, NSx Literature Summaries, Occulocephalic and occulovestibular reflexes, Prognosis after Cardiac Arrest, SIADH vs Cerebral Salt Wasting, Sleep in ICU
LITFL
Journal articles
- Consortium for Spinal Cord Medicine. Early Acute Management in Adults with Spinal Cord Injury – A Clinical Practice Guideline for Health-Care Professionals. J Spinal Cord Med. 2008; 31(4): 408–479. PMC2582434
FOAM and web resources
- SCI Info Pages — Spinal Cord Injury Levels & Classification
- ENLS — Traumatic spine injury
- ICN — PODCAST #3: The acute management of spinal cord injury
- ICN — SMACC: FLOWER – TIME IS SPINE (2013)
- Resus.ME — Another reason to be skeptical about collars
- Resus.ME — Cervical spine guideline
- Resus.ME — Neck movement in spite of collar
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC
ICU Advanced Trainee BMedSci [UoN], BMed [UoN], MMed(CritCare) [USyd] from a broadacre farm who found himself in a quaternary metropolitan ICU. Always trying to make medical education more interesting and appropriately targeted; pre-hospital and retrieval curious; passionate about equitable access to healthcare; looking forward to a future life in regional Australia. Student of LITFL.