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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

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Methylprednisolone Dosage
Within 3 h of trauma30 mg/kg, followed by 5.4 mg/kg/h for 24 h
3 to 8 h after trauma30 mg/kg, followed by 5.4 mg/kg/h for 48 h
8 h or more after traumaNo benefit

Surgical indication

  • Risk of spine instability and spinal cord compression depends on intensity and mechanism of trauma

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