Airway Management.

• Early intubation for ^{[1] [2]}:
  • Injuries above C5 (diaphragm at risk)
  • Quadriplegia
  • Respiratory distress
  • Decreased LOC

Assess for complete vs. incomplete spinal cord injury (SCI).

For trauma patients with multiple injuries, spinal immobilization is adequate until other life-threatening conditions addressed ^[3].

Complete Spinal Cord Injury

• Signs/Symptoms:
  • Complete bilateral loss of innervation below level of injury ^[3].
  • No sensory or motor function is preserved in the sacral segments S4-5 ^[4].
• Mechanism ^[5]:
  • Trauma
  • Vertebral disc herniation
  • Transverse myelitis
  • Neoplasm / abscess

Incomplete Spinal Cord Syndromes 

Figure 1. Spinal Cord Syndromes (https://commons.wikimedia.org/wiki/File:Kabir_Spinal_Cord_Lesions_and_Syndromes.jpg)

Clinical Examination ^[1] [2]:

• Trauma assessment.
• Neurological assessment with focus on:
  • Highest level of motor and sensory function.
  • Complete vs. incomplete patterns of SCI.
  • Sacral nerve involvement, perineal sensation, anal tone, bulbocavernosus reflex (BCR).
  • Identify presence of cord syndromes (as above).

Spinal Immobilization precautions ^{[1] [9]}.

Imaging:

• All require spinal imaging ^[1][2].
• Follow Canadian C-Spine Rule for alert and stable trauma patients^[9].
• Follow BC PHSA Specialist Trauma Advisory Network (STAN) clinical practice guidelines for spine trauma imaging ^[10].

Neurogenic Shock ^{[1] [11]}:

• Hypotension (SBP ≤ 100 mm Hg) not attributed to other injuries.
• Bradycardia (HR ≤ 80/min) with hypotension not attributed to other injuries.
• Judicious volume resuscitation (if needed) to avoid pulmonary or spinal cord edema.

Spinal Shock ^[3]:

• Refers only to neurological state.
• Loss of sacral reflexes and bulbocavernosus reflex (BCR).

• Airway and ventilation support as required ^{[3] [1]}.
• Assess and treat shock ^[1].
• Treat neurogenic shock, including bradycardia ^[3][1].
  • Restore intravascular perfusion.
  • Administer vasopressor (recommendations)^[12]:
    • Norepinephrine (first line) 0.05-1 mcg/kg/min.
    • Epinephrine 0.05-0.5 mcg/kg/min.
  • Administer vasopressin to augment effects of other vasopressors (if required) at dose 0.03-0.04 units/min^[12].
  • Do not use phenylephrine, can result in reflex bradycardia^[12].
• Maintain mean arterial pressure > 85 mmHg (Reverse Trendelenburg position recommended) ^[3].
• NPO if surgical intervention required.
• Place indwelling urinary catheter unless contraindicated ^[1].
• Place patient on pressure reducing mattress^[1].
• Log-roll (with spinal precautions) every 2 hours to avoid pressure sores ^[3][1].
• Assess areas at risk of pressure sores or skin breakdown ^[1].

• All suspected SCI patients should be admitted by the hospitals spinal service.

• Transfer SCI patients to regional trauma center with neurosurgical service as soon as possible.
• Patient to be transported with full cervical and spinal immobilization protocols, consult with EMS transport team.

• Consult Neurosurgery (or orthopedic spine service) for all suspected SCI patients.

• Discharge to be done by admitting service.

1. ASIA-ISCOS-Worksheet_10.2019_PRINT-Page-1-2.pdf (asia-spinalinjury.org)

   Recognizing key spinal cord syndromes – YouTube

   Life in the Fastlane: Acute Traumatic Spinal Cord Injury • LITFL • CCC Trauma

   Canadian C-Spine Rule: Canadian C-Spine Rule – MDCalc

   STAN Clinical Practice Imaging Guidelines: Spine (phsa.ca)

   
   

1. Consortium for Spinal Cord Medicine. Early acute management in adults with spinal cord injury: a clinical practice guideline for health-care professionals. Journal of Spinal Cord Medicine 2008, 31(4): 403-479. doi:10.1043/1079-0268-31.4.408.

   
   

2. Nickson.Spinal Cord Syndromes. Life in the Fastlane 2020. https://litfl.com/spinal-cord-syndromes/.

   
   

3. Eckert & Martin. Trauma: Spinal Cord Injury. The Surgical Clinics of North America 2017, 97(5): 1031-1045. Accessed 05 07, 2023. doi:10.1016/j.suc.2017.06.008

   
   

4. American Spinal Injury Association. International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). American Spinal Injury Association 2019. https://www.asia-spinalinjury.org/wp-content/uploads/2019/10/ASIA-ISCOS-Worksheet_10.2019_PRINT-Page-1-2.pdf.

   
   

5. Bennett et al. Spinal Cord Injuries. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing 2022. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560721/

   
   

6. Ameer et al. Central Cord Syndrome. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing 2023. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441932/

   
   

7. Knipe et al. Artery of Adamkiewicz. Reference article, Radiopaedia.org (Accessed on 10 May 2023) https://doi.org/10.53347/rID-26389

   
   

8. Shams & Arain. Brown Sequard Syndrome. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing 2022. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538135/

   
   

9. Stiell et al. The Canadian C-spine Rule for Radiography in Alert and Stable Trauma Patients. Journal of the American Medical Association 2001, 286(15): 1841-1848. doi:10.1001/jama.286.15.1841.

   
   

10. Specialist Trauma Advisory Network (STAN). STAN Clinical Practice Guidelines Spine 2023. http://www.phsa.ca/health-professionals/clinical-resources/stan-clinical-practice-guidelines/spine

    
    

11. Taylor et al. Presentation of Neurogenic Shock Within the Emergency Department. Emergency Medicine Journal 2017, 34(3): 157-162. doi:10.1136/emermed-2016-205780.

    
    

12. Shah et al. Vasopressor and Inotrope Usage in Shock, Department of Surgical Education, Orlando Regional Medical Center. Surgical Critical Care Website 2019.