Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content ++ Spinal cord injury (SCI) is common (˜10,000–11,000 cases per year), occurring usually after traumaDegree of dysfunction is directly related to level of injury, especially severe if above T6Most common site of injury is lower cervical spine or upper lumbar region:Midthoracic injury less common due to rotational stabilization provided by the rib cage and intercostal musclesPathophysiology:Upregulation of acetylcholine receptors from immobilization causes resistance to nondepolarizing neuromuscular blockers and increased potassium release with depolarizing neuromuscular blockers (e.g., succinylcholine)Sympathetic hyperreflexia:Nociceptive afferent circuits rebranch below the lesion and anastomose with sympathetic efferents, especially between T5 and L2Hyperreflexia mostly if lesion above T6, but possible even around T12Higher risk with: Urological surgeryComplete cord sectionChronic painMaximal 1–6 months after injury, but can persist indefinitelySmall stimuli can evoke exaggerated, unopposed sympathetic response: Extreme HTN with reflex bradycardia and other dysrhythmiasHeadache, anxietySweatingFlushing or pallorPiloerectionComplications: Myocardial ischemiaCardiac arrestPulmonary edemaHemorrhagic CVAReduced lower limb blood flow, but increased arterial and venous pooling leads to increased risk of thromboembolic diseaseSpasticity: similar mechanism as hyperreflexiaNatural history of injury:Acute (<3 weeks from injury):Spinal shock: hypotension and bradycardiaLoss of thoracic sympathetic outflow, with vasodilatation and pooling of bloodRelative predominance of vagal stimulation to the heartRetention of urine/feces leading to diaphragm elevation, which may impair respirationHyperesthesia above the lesionReflexes and flaccid paralysis below the lesionIntermediate (3 days to 6 months): Hyperkalemic response to depolarizing NMBChronic (after 6 months):Return of muscle tonePositive Babinski signHyperreflexia syndrome ++Table Graphic Jump Location|Download (.pdf)|PrintSystemAssessmentTest/interventionAirwayCervical cord injuryEarly intubation with in-line stabilizationPulmonaryRespiratory muscle involvementDiaphragm involved at C5 or above SCIAtelectasis/pneumoniaImpaired handling of secretionsPulmonary function tests (FEV1/FVC)ABGChest x-rayCardiacMyocardial conduction abnormalitiesHypotension (orthostatic)Baseline BP may run lower than normalElectrocardiogramInvasive BP monitoringRenalStatus of renal functionUrinary tract infectionsIntravascular volume statusBladder functionBUN, CrElectrolytes/GIElectrolyte statusBowel functionFull stomach from GI atony (mostly if cervical lesion)Na+, K+RSINeurologicalMental statusDeficits (level of SCI)Autonomic hyperreflexiaReview imagingMusculoskeletalBone fracturesDecubitus ulcersPhysical examination++ NB: ++ Creatinine does not correlate with renal functionIntramuscular injections may have delayed absorption ++ Gentle induction for GA (potential for severe hypotension) or neuraxial/regional anesthesia where indicated (less hemodynamic lability, but difficult to assess level; monitor carefully as diagnosis of high/total spinal might be delayed)Avoid succinylcholine from 24 hours after injury due to risk of hyperkalemia. Response typically seen if drug is given from 1 week to 6 months after the injury but may be seen before or after that period:If laryngospasm occurs, the benefits of giving a small dose of succinylcholine (20 mg) may outweigh the riskCareful padding of pressure points/decubitus ulcersConsider ... Your Access profile is currently affiliated with '[InstitutionA]' and is in the process of switching affiliations to '[InstitutionB]'. Please click ‘Continue’ to continue the affiliation switch, otherwise click ‘Cancel’ to cancel signing in. Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Username Error: Please enter User Name Password Error: Please enter Password Forgot Password? Forgot Username? Sign in via OpenAthens Sign in via Shibboleth You already have access! Please proceed to your institution's subscription. Create a free a profile for additional features.