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INTRODUCTION

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Spinal cord injury is an insult to the spinal cord, resulting in either temporary or permanent dysfunction of the cord's motor, sensory, or autonomic function. In the United States, trauma remains the number one cause of spinal cord injury. The most common cause of traumatic spinal cord injury is motor vehicle collisions, followed by falls, violence (primarily gunshot wounds), and sport injuries.

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Direct mechanical injury from a traumatic insult leads to hemorrhage, edema, and ischemia. Pathophysiology reveals a release of inflammatory mediators, membrane-destabilizing enzymes, disruption of electrophysiological pathways, and eventual tissue degeneration.

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INITIAL MANAGEMENT

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Blunt trauma, especially those involving head injury, requires spinal stabilization. The spine should be immobilized on a board and cervical collar in order to prevent further injury. The patient should be assessed according to Advanced Trauma Life Support (ATLS) protocols. Patients who are alert with normal neurologic status and in no pain can have collars removed.

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Circulation

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Although spinal injury may be responsible for hypotension in the setting of trauma, hypovolemia remains more common. Initial management of hypotension should be targeted at volume replacement. Management includes invasive hemodynamic monitoring (with arterial line and central venous line) and support with isotonic crystalloid and/or blood products and vasopressors, titrated to maintain an adequate hemodynamic profile.

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Once hypovolemia has been ruled out through appropriate examination, imaging, and laboratory studies, neurogenic shock should be considered. Injury to the spinal cord at the level of the cervical or thoracic vertebrae causing sudden loss of underlying sympathetic stimulation of blood vessels is known as neurogenic shock. Physiologically, the body experiences decreased systemic vascular resistance and blood pressure and bradycardia due to unopposed vagal activity.

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The management goal in cases of neurogenic shock is to maintain adequate perfusion. Fluid resuscitation of at least 2 L of warmed crystalloid along with a vasopressor should be administered, as needed.

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Airway

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The need for intubation should be assessed. Rapid sequence intubation (RSI) is the most efficient way of achieving intubation in patients with respiratory compromise. For patients undergoing RSI, cricoid pressure can be maintained with an assistant utilizing one hand to support the back of the neck, and the other hand to apply firm pressure on the cricoid cartilage. Awake tracheostomy is reserved for patients with facial fractures or other, severe anomalies of airway anatomy that make safely securing the airway difficult and unsafe. Succinylcholine should be avoided in cases of neurogenic shock as it can increase the risk for extreme bradycardia. Atropine should be administered prior if succinylcholine must be used.

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Breathing

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Breathing is best managed by mechanical ventilation, with ventilation for SPO2 > 95% and ETCO2 = 35 mmHg. Spinal cord injuries involving C4 and cranial result in interruption of the descending bulbospinal respiratory pathways, resulting in respiratory ...

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