ACUTE MANAGEMENT

Published: March 28, 2004
324

The emergency medical care system is the patient’s point of entry into the medical care system. The goal during this period is for the SCI patient is to immobilize the spine to prevent further damage to the spinal cord prior to reaching the emergency room. Maintenance of an adequate airway, cardiopulmonary resuscitation, and fluid management are required to ensure survival and limit secondary damage.

The acute management of traumatic spinal cord injury is unique and requires specialized medical training. Among the issues addressed are spinal stabilization, pulmonary Rehabilitation, gastrointestinal and urinary function, hemodynamics and thermodynamics. Although this discussion will focus on these medical issues, it should be remembered that SCI is associated with psychosocial adjustment, and oftentimes substance abuse withdrawal and head injury.

In acute spinal cord injury, it is considered standard of care to implement high doses of intravenous (IV) steroids (methylprednisolone), which has been scientifically shown to decrease the swelling in the spinal cord after a traumatic insult. The protocol is administered within the first eight hours of the injury and is completed within 24 hours. There has been no documented medical benefit supporting the administration of methylprednisolone after the initial eight-hour period. In spinal cord injury research and development, there are nerve regenerating medications as well as surgeries that are being investigated throughout the country. Most notable is the Gm-1 Ganglioside (Sygen). The intended purpose of this medication is to improve the patient’’s neurologic function when administered within 72 hours of injury. The results of the multi-center investigation are slated to be available February 1998.

As stated above, spinal cord injury is most often associated with skeletal instability. This can occur at the Cervical, Thoracic or Lumbar level. Patients are optimally managed in a rotokinetic bed, but may be “log-rolled” by trained staff every two hours. The rotokinetic bed acts as a body cast to stabilize the spine until surgical fusion. Cervical injuries, in addition, usually require weighted traction via a halo ring or tongs. After cervical fusion, depending on the type of surgical stabilization, continued external immobilization via a halo vest or a cervical orthotic (Philadelphia collar) is required for a period of time defined by the surgeon. Although spinal stabilization is necessary to correct fractures and dislocations, it must be remembered that it rarely improves the neurologic function of the patient. In the majority of cases, therefore, the neurologic level that the patient has at the time of injury is the level of function that the patient has to work with during rehabilitation and live with for a lifetime.

In the acute trauma setting, patients with spinal cord injury are routinely hypotensive. This is manifest by low blood pressure that is most often corrected by intravenous fluids. However, this type of hypotension is a result of neurogenic shock or “Spinal Shock,” which is secondary to Autonomic Nervous System dysfunction. Until the patient is determined to be spinal cord injured, high volumes of IV fluids are introduced which puts the patient at a hemodynamic disadvantage, and places the respiratory status at risk for pulmonary Edema. Once the patient is known to be spinal cord injured above the level of T9, IV fluids are gingerly administered and the pulmonary status must be monitored very closely. Blood gases are ordered. The patient typically receives oxygen via nasal canula and begins respiratory therapy exercises. There is a low threshold for intubation especially in patients with cervical injury and a history of smoking or asthma. In the acute spinal cord setting, the two most common causes of death are infection and respiratory complications. The patient’s pulmonary status is aggressively monitored and treated.

In addition to neurogenic shock, other organ systems also slow down. An ileus develops (bowel functions slows or ceases) in the gastrointestinal system, and the risk for associated stress gastritis is present. The patient is treated with bowel rest and IV administration of an H2 blocker. Occasionally, with severe gastritis, blood transfusions are necessary. The bladder is also affected by these autonomic changes, becoming hypotonic and non-contractile. Treatment is with indwelling (Foley) catheterization.

Finally, during spinal shock, patients have difficulty maintaining a stable core body temperature. They tend to take on the room temperature; if it is hot, they are hot, and conversely if it is cold, they will be cold. Patients commonly arrive at the acute care setting with Hypothermia or hyperthermia, and must be managed by someone skilled in the rehabilitation of acute spinal cord injury.

Preventing pressure sores is an ongoing challenge during the acute care phase. In the supine position, the back of the head, the sacrum and heels are at particularly risk. Special mattresses are available as well as seating cushions. While in bed, a regular turning schedule is emphasized. Non-blanching erythema (redness) is considered a grade I ulcer and a precursor to skin ulceration.

Joint contractures should be prevented by frequent Range of Motion and orthotics may be needed as well. The individual in bed with a spinal cord injury is at significant risk for a deep venous thrombosis and prophylaxis (up to twelve weeks) should be started early with a short-acting anti-coagulant (such as low molecular weight heparin) which can be supplemented with support stocking and intermittent compression boots.