Spinal Injury Patient Hot Case

GENERAL APPROACH

• Phase of injury
  — Acute: ileus, cardiovascular, ventilation
  — Sub-acute: recurrent atelectasis and segmental collapse
  — Chronic: pain, psychological issues, infection (uro, resp, pressure areas), autonomic dysreflexia, spasm.
• Stability of spine
• Tracheostomy
• Other injuries

INTRODUCTION

CUBICLE

• Edgerton spinal bed until spine stabilized
• long/short stay
• pressure area prevention bed (Nimbus mattress) after spine stabilised
• equipment for moving patient (Jordan frame, poles with canvas)

INFUSIONS

• methylprednisolone if an acute, blunt traumatic injury (in some centers)
• low dose vasopressor/inotrope for bradycardia and hypotension management

VENTILATOR

• mode: mandatory breathing early -> weaning with time (strategy)
• tracheostomy
• level of oxygenation: FiO2, PEEP (high with aspiration, nosocomial pneumonia, ARDS)
• devices to assist speech: Passy-Muir valves, various type of tracheostomies

MONITOR

• acute phase: mild hypotension and bradycardia
• chronic phase: autonomic dysreflexia

EQUIPMENT

• spinal immobilisation devices: skull tongs with traction, cervical collars (hard or Philadelphia), halo brace with thoracic jacket, sandbags
• splints to prevent contractures
• DVT prophylaxis (SCDs, TEDs)
• pacing wires to manage bradycardia/asystole in high cervical cord injuries
• NJ tubes for persistent gastroparesis

QUESTION SPECIFIC EXAMINATION

• neurological:

-> scars, surgical wounds, drains
-> motor level: myotomes, spinal reflexes, limbs and abdominal muscles, return of bulbocaveronsus reflex (resolution of spinal shock)
-> sensory level: dermatomes, sensory tracts (dorsal columns, spinothalamic tracts)
-> paradoxical, diaphragmatic breathing
-> priapism during spinal shock
-> central cord assessement: perineal sensation, anal tone, bulbocavernosus reflex

• hands/arms -> head -> chest -> abdo -> legs/feet -> back (secondary survey)

-> general:
-> cardiovascular:
-> respiratory:
-> abdominal:

• attempt to delineate cord syndromes
• pressure sores
• other injuries

RELEVANT INVESTIGATIONS

• imaging of the level of injury (xrays, CT, MRI)

OPENING STATEMENT

• “The patient has an acute cervical spine injury with complete C6 neurology / central cord syndrome. This is supported by the following clinical findings… The c-spine injury is complicated by… Other associated injuries include…
• Stage of Illness
• ASIA Classification
  • A – Complete: No sensory or motor function is preserved in sacral segments S4-S5.
  • B – Incomplete: Sensory, but not motor, function is preserved below the neurologic level and extends through sacral segments S4-S5.
  • C – Incomplete: Motor function is preserved below the neurologic level, and most key muscles below the neurologic level have muscle grade less than 3.
  • D – Incomplete: Motor function is preserved below the neurologic level, and most key muscles below the neurologic level have muscle grade greater than or equal to 3.
  • E – Normal: Sensory and motor functions are normal.
• Cord syndrome presentation
  • Complete transection: bilateral and symmetrical loss
  • Brown-Sequard syndrome: hemicord transection
  • Central cord lesion: weakness of UL and relative sparing of LL
  • Posterolateral column:
  • Posterior columns
  • Anterior horn cell
  • Combined anterior horn cell-pyramidal tract syndrome
  • Anterior spinal artery occlusion
• Issues

DISCUSSION

• Weaning from Mechanical Ventilation
• neurogenic shock versus spinal shock (see Q7)
• Spinal cord syndromes
• approach to acute traumatic spinal cord injury
• Cervical Spine Assessment and Clearance
• Airway in Neck Trauma

References and Links

• CCC — Acute Traumatic Spinal Cord Injury
• Trauma! Spinal Injury