Always suspect spine injury in significant trauma, even if no initial neurologic sign
DO NOT WORSEN LESIONS: immobilize, treat as unstable spine until cleared.
Beware of secondary SCI due to mechanical trauma (spine lesions) and/or ischemia
Spinal cord injury above C4 will block the diaphragm; high thoracic lesion will block abdominal and thoracic accessory muscles and weaken cough.
Conscious patient: motor or sensory deficit often obvious.
Comatose patient: diagnosis more difficult. Treat as unstable spine until cleared (CT-scan). Additional suspicion if hypotension without tachycardia.
Be thorough. Do not miss other lesions.
- Spine immobilization by cervical collar and spinal board systematically
- Only exception: alert, normal neurologic status, AND no pain: no imaging needed, remove collar
- 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
- Ventilation for SpO2 > 95% and ETCO2 = 35 mm Hg
- Gastric atony and distention: decompress stomach to facilitate ventilation
- 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
- 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
Figure 114-1. ASIA Spinal Cord Injury Scoring Sheet
|Within 3 h of trauma||30 mg/kg, followed by 5.4 mg/kg/h for 24 h|
|3 to 8 h after trauma||30 mg/kg, followed by 5.4 mg/kg/h for 48 h|
|8 h or more after trauma||No benefit|
- Risk of spine instability and spinal cord compression depends on intensity and mechanism of trauma