SCI: The First 72 Hours
Which major issues should medical personnel be aware of during early care?
In the Introduction to his 1982 text Early Management of Acute Spinal Cord Injury, Charles Tator writes, “The early management of a patient with an acute spinal cord injury is one of the most difficult tasks in trauma cases. During the first few days after an acute cord injury, every physician, nurse, or paramedical person coming in contact with a cord-injured patient bears a major responsibility.” He later adds that the final outcome of a spinal-cord injury (SCI) may be affected by the accuracy, adequacy, and speed of first aid management, diagnosis, and treatment within the first few hours.
SCI prevention efforts have borne only modest success, and the condition remains as much a threat to life and health as ever. However, the medical community’s understanding of the physiology after SCI is improving, and research evidence is slowly accumulating to guide us in our management decisions. Where possible, we would like to base treatment on science rather than tradition or opinion, but is the evidence sufficient to support us in our care of a newly-cord-injured person?
A clinical practice guideline (CPG) provides evidence-based recommendations for care that are likely to be applicable in most cases of a particular diagnosis. There are two distinct components of guidelines for clinical practice: (1) the summary of the evidence from which to draw recommendations and (2) the detailed instructions or recommendations for applying that evidence to patients. Best practice requires that the quality of the evidence is graded independently, a task United Biosource Corporation of Cambridge, Mass., undertook on behalf of the Consortium for Spinal Cord Medicine.
Preparation of “Early Acute Management in Adults with Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Providers,” the tenth guideline in the series, followed the protocols developed by the consortium. The panel reviewed the evidence pertaining to care of the patient with a new SCI, focusing on the first 72 hours after injury. This care is in the hands of many people, from the paramedics first on the scene to the spine surgeon providing definitive care and the physiatrist initiating rehabilitation (which should begin in the intensive care unit).
Along the way the team may include emergency physicians, radiologists, respiratory specialists and intensivists, and many other clinical personnel who spend varying percentages of their work week with people with new spinal cord-injuries. This team needs to know the specific issues—and evidence—relevant to this injury group. We hope all those involved in the early care stage will find this guideline a helpful reference.
The Consortium for Spinal Cord Medicine spans many disciplines and for this guideline has addressed the need to have on the expert panel professionals who work in the acute-care portion of the rehabilitation process. Particular mention must be made of the Society for Critical Care Medicine, many of whose members provide care to cord-injured people and with whom we have worked in developing this guideline, which is the better for their input.
Throughout, the CPG uses the terminology of the International Standards for Neurological Classification of Spinal Cord Injury. Thus, tetraplegia (not quadriplegia) is the preferred term for a spinal-cord deficit affecting the upper and lower extremities, and paraplegia for that affecting only the lower part of the body, excluding the upper extremities.
While you will need to read the entire guideline if you are a health professional caring for a newly-injured person with SCI, the following information outlines a number of the panel’s recommendations.
Where Should Someone with a New SCI Go?
Over the last 20 years or so, trauma care has made great advances. The “scoop and run” approach is intended to get the injured person into a specialized trauma center as rapidly as possible, thereby improving the chances of survival. Our first recommendation, therefore, is that every patient with SCI should go to a regional trauma center staffed and equipped to provide rapid resuscitation, with quickly-available imaging and other services. Evidence exists that patients with SCI will do better if admitted to a specialized spinal-injury center as soon as medically stable. There is less likelihood then of developing contractures and pressure ulcers. Early contact should be made among the trauma surgeon, the intensivist, and the SCI service.
ABCs and Resuscitation Concerns
Trauma protocols provide a quick list of what must be done in an emergency; these are the “ABCs” of trauma care and are taught by the Advanced Trauma Life Support program of the American College of Surgeons. Emergency physicians are trained to respond quickly when a seriously injured person comes into the emergency department/room (ER).
Airway and breathing come first. People with high-level SCI need quick attention to any breathing difficulty and may urgently require a breathing tube on a temporary or more permanent basis. Insertion of the tube must be done with caution because of the possibility of a neck injury.
A person with a new SCI also may have a low blood pressure, which in turn could reduce the flow of blood through the injured cord. This might lead to further loss of function of the cord, but no research has yet shown whether treatment to increase the blood pressure at this stage can improve outcome.
In addition, individuals with tetraplegia often have a slow heart rate that may require careful medical treatment. Some physicians might not be familiar with the abnormal physiology following SCI.
The most informative test of the injured spinal cord remains a careful neurological examination. However, because many patients with one spinal fracture also have another in the same or a different region, imaging the whole spine is important after SCI—often with CT scanning, although x-ray dosage may be a concern with the use of multiple x-rays or CTs.
The rapidly evolving sophistication of imaging techniques makes it difficult to confidently recommend expensive MRI for every patient. While MRI offers no radiation, it is much slower than CT, and it is difficult to provide intensive nursing care during the time the patient is in the scanner. Individuals who already have an arthritic or stiff spine also need particular attention to imaging to ensure important fractures are not overlooked.
Protecting the Spinal Column and the Skin
During the first few hours, care is needed not only to minimize excess motion of the spinal column but also to ensure the skin is protected by turning the patient frequently. If this is not done, the scene is set for development of pressure ulcers that may not become apparent for a week or two.
Neuroprotection and Preparing for Translational Research
In the 1990s, a number of research studies suggested that function after SCI is improved following a 24–48-hour course of high-dose methylprednisolone. Subsequent reanalyses of the data have shown the benefit is not as great as was hoped, and our panel could not strongly recommend any of the currently available approaches, including steroids or cord cooling. However, a number of drug treatments are under investigation, and we may in the future have to reconsider the use of medications.
A clear and accurate diagnosis of SCI can be difficult in a person who has just been injured, and head injury can make examination very difficult. Many people with SCI also have a traumatic brain injury (TBI), and it is important to carefully assess any change in memory or personality that may relate to brain injury, which can impair a person’s ability to benefit from rehabilitation. The tertiary trauma screen, usually undertaken within a day or two after admission, should minimize the risk of overlooked SCI as well as brain or other injuries or fractures.
- Arterial injury. Major arterial injuries can occur in association with high-energy ones at any level, but vertebral arteries are especially vulnerable in their course alongside the spinal column in the neck, leading to a risk of stroke. We recommend angiographic screening for arterial injury in patients with risk factors present.
- Glucose levels and insulin. Critically ill patients may benefit from careful control of blood glucose through the use of insulin in the intensive care unit. The role of this treatment in someone with SCI is yet to be determined.
Ventilation and Weaning
People with SCI in the cervical spine may require the support of a ventilator for a number of days or longer. Ventilator-associated pneumonia is a serious problem prolonging an ICU (intensive care unit) stay and is less likely with the use of recently developed treatment protocols.
Research has shown the volume of air delivered by the ventilator with each breath may influence the development of and recovery from lung collapse, and also the time for weaning from the ventilator. This is one of the many areas requiring further research.
In spinal-injury centers, we like to see early involvement of rehabilitation therapists: respiratory, physios, and occupational. However, we cannot say which treatments must begin when, nor do we have any evidence to say how much—if any—physiotherapy time is needed on a regular basis. Clearly, more research is needed here.
We recommend an early assessment of mental health and emotional state, and note the need to constantly foster independence. While many of us who work with people with SCI are aware of the potential for rehabilitation to help spinal-injured people return to a high level of satisfaction with life, workers in the ER or ICU may be less aware. When newly-injured people with higher levels of tetraplegia (and their families) question whether they wish to continue life, such concerns must be taken seriously. It is then that it becomes very important for the care team to have help from experienced SCI specialists and psychologists.
Less Usual Causes of SCI
Rarely, SCI may result from other forms of insult such as high-voltage electric shock or decompression sickness. While these are not often seen, we recommend the emergency team be aware of this possibility.
Lastly (and not infrequently) we note the ways in which “functional paralysis” can present—the paralysis that can result as part of an emotional rather than a physical response, that usually recovers well over a short time.
We have carefully considered the best evidence available in making recommendations for clinical care. These recommendations will stand for a while, until our understanding evolves based on new evidence. This evolution is part of the excitement of medicine and rehabilitation science. It remains for readers to take our recommendations into consideration with newer evidence that will become available.
We may also see great changes over the next few years, as translational research suggests the careful deployment of interventions shown to be of value in the lab that must be responsibly evaluated in humans in a controlled setting before being widely used.
Paralyzed Veterans of America continues to sponsor this CPG series and is a vital coordinator of the process. This acute-care guideline owes much to the experienced hands and minds of J. Paul Thomas, Thomas Stripling, Kim Nalle, and Caryn Cohen, and I thank them.
Visit the PVA Web site, www.pva.org, to download the guideline and other publications.
Contact: KimN@pva.org or CarynC@ pva.org.
SCI: The First 72 Hours
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