Presentation and buzz words:
Sensory level
Bladder/bowel symptoms - retention or incontinence
Respiratory involvement, "tetra breathing"
One liner:
When presenting the one liner, note the day of trauma, and what that makes today. Note ASIA grade and whether it was "non-op" or which surgery was done.
Example: "Trauma was 10/5. Today is post-trauma day 3, ASIA grade C, treating non op with MAP augmentation."
Diagnose etiology:
What was the mechanism of injury?
Does it need a cardiac or infectious work up?
What is the spinal cord level?
Above C5 is called "high cervical" with risk of respiratory failure.
Recognize central cord syndrome: loss of cervical sensorimotor function with relative sparing of lower extremities
Caused by cord contusion from buckling of the ligamentum flavum during neck hyperextension.
Recognize Brown-Séquard syndrome: ipsilateral loss of proprioception and motor function; contralateral loss of pain and temperature.
Caused by hemisection of the spinal cord.
Know the innervations and dermatomes relevant to your patient's injury level.
What does imaging demonstrate?
X-ray: initial imaging to evaluate for spinal fractures or dislocations.
CT scan: preferred imaging to provide detailed images of bony structures.
MRI: best to asses ligamentous injuries and determining the level and extent of cord compression and injury.
If patient surgical candidate, early surgical intervention has been shown to improve outcomes.
SCI ICU Course / Possible Complications:
Early hypoxia and respiratory failure
Cord swelling after trauma peaks around 3 to 6 days
Neurogenic shock: refractory hypotension and bradycardia secondary to unopposed vagal activity
"Spinal shock" is transient dysfunction that temporarily exaggerates the severity of impairment.
Areflexic flaccid paralysis and distal anesthesia
Develops within the first hours, lasts days to weeks
Autonomic dysreflexia may be a delayed complication (weeks to months later) that can provoke sudden severe hypertension / wide swings in blood pressure
Seen most commonly in injuries above T6
Severity scores:
Document the American Spinal Injury Association (ASIA) score to assess the severity of spinal cord injury.
Five grades (A to E): A is most severe, E is normal.
For prognostication, most appropriate to calculate at the end of initial hospitalization since spinal shock and/or edema can worsen the neurologic exam.
#SCI Plan Guidance
Note ASIA score and type of spinal cord injury
If C-collar in place, why? What is the plan for clearing?
If injury warrants surgery, what was done, when was it done?
Read the Neurosurgery post-op detailed note for details - way to find out details that are sometimes missed!
q1h neuro checks in the acute settings, then think about sleep holiday for delirium precautions once subacute.
If intubated and high injury, ensure respiratory hygiene in place
Often we aim for MAP goal >85.
The theory is to increase perfusion to the cord for 5-7 days. Sometimes we need to use pressors to do so.
Look out for high urine output! We are supra-physiologically perfusing the kidneys, which makes them work harder. If we're not on top of having a total body balance goal of euvolemia, we may find our patient getting hypovolemic, making pressor requirements go up, and at risk of causing AKI.
Pressure ulcer prevention
DVT prophylaxis
Ensure bowel movements
Try discontinuing foley and make sure patient does not have urinary retention. If so, they might need a foley long-term.
Medications:
High-dose steroids (ie, methylprednisolone) are not advisable in traumatic SCI due to adverse effect profile.