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Always suspect spine injury in significant trauma, even if no initial neurologic sign
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DO NOT WORSEN LESIONS: immobilize, treat as unstable spine until cleared.
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Beware of secondary SCI due to mechanical trauma (spine lesions) and/or ischemia
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Spinal cord injury above C4 will block the diaphragm; high thoracic lesion will block abdominal and thoracic accessory muscles and weaken cough.
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Conscious patient: motor or sensory deficit often obvious.
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Comatose patient: diagnosis more difficult. Treat as unstable spine until cleared (CT-scan). Additional suspicion if hypotension without tachycardia.
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Be thorough. Do not miss other lesions.
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- Spine immobilization by cervical collar and spinal board systematically
- Only exception: alert, normal neurologic status, AND no pain: no imaging needed, remove collar
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- Assess need for intubation: in-line stabilization with RSI. FOB or video laryngoscope if available
- Consider retrograde intubation if facial trauma
- No nasal intubation in trauma patient
- Avoid succinylcholine, especially if neurogenic shock (risk of extreme bradycardia); if necessary, administer atropine prior to succinylcholine
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- Ventilation for SpO2 > 95% and ETCO2 = 35 mm Hg
- Gastric atony and distention: decompress stomach to facilitate ventilation
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- Insert A-line and CVL
- MAP > 80 mm Hg with isotonic crystalloids (fluid will not increase ICP in a hypotensive TBI patient)
- If needed, initiate norepinephrine infusion through a CVL
- Transfuse as needed for Hb > 8 g/dL
- If severe hemorrhage due to other lesions, emergent surgical hemostasis might be needed
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- Thorough clinical examination to document neurologic deficit, including assessment of anal sphincter tone and contraction
- Level of lesion? (Not always the same on both sides)
- Complete or incomplete lesion? (Any sensory/motor preservation below lesion, and/or anal sphincter tone maintained = incomplete lesion)
- ASIA score (see scoring sheet = Figure 114-1)
- 30% spinal cord injuries are at multiples levels
- Assess for traumatic brain injury (see Chapter 113): GCS, neurological exam
- Whole body (vertex to pelvis) CT scan to diagnose associated lesions
- Transfer the patient to a specialized center as soon as possible
- Methylprednisolone probably not helpful, but still widely used as there is no effective therapy
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- Risk of spine instability and spinal cord compression depends on intensity and mechanism of trauma
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