Spinal column & spinal cord injuries

• Refer to cervical spine assessment and imaging protocol 
• Refer to thoracolumbar spine assessment & imaging protocol
• MRI aids prognosis, identifies prolapsed discs, haematomas and ligamentous injuries
• Perform MRI urgently in SCI patients (emergent MRI may be required as per Neurosurgical guidance)

• ED trauma team leader ensures an ASIA Chart is completed
• ED trauma team leader confirms SCI and refers to Neurosurgical Registrar on call 

All patients with a traumatic spinal cord injury should be admitted to a critical care environment. Isolated SCI patients should be admitted under the care of neurosurgery, or transferred to the local MTC or ICU following advice from SIU and neurosurgeon. Polytrauma patients with spinal cord injury should remain at the RIE with neurological input.

Spinal shock

Total flaccid paralysis of all skeletal muscle and loss of all spinal reflexes below the level of the lesion. It may last several hours to weeks. The return of the bulbospongiosus reflex denotes its end.

Neurogenic shock

Body's response to sudden loss of sympathetic control in cervical and high thoracic lesions (above T6). Hypotension is from a lack of vasomotor control. Bradycardia from of an unopposed vagus nerve

Airway

Intubation can precipitate severe bradycardia and cardiac arrest in cervical/high thoracic spinal cord injuries. Atropine 0.3mg / 0.6mg may be required. 

Breathing

Patients with high cord lesions (C3/4/5) have a high risk of respiratory deterioration.

• Monitor SaO2, blood gases and vital capacity
• Use humidified oxygen
• Early, regular and frequent physiotherapy including assisted cough and incentive spirometry
• Hourly turns to optimise V/Q mismatch
• Elective ventilation may be needed
• Secure airway if vital capacity <1L
• Consider primary tracheostomy
• Pre-oxygenate with 100% oxygen before and after suctioning as bradycardia and hypoxia can occur 

Circulation

• Patients with acute spinal cord injury must be nursed flat
• Monitor BP usually via arterial line
• Maintain SBP >100mmHg. Initial MAP target 85mmHg. Consider maintaining these targets for 7 days
• Antihypertensives should be avoided/used with caution in spinal cord injury
• Maintain urine output of 30mls or above per hour
• Administer IV fluids - DO NOT over-infuse. This may precipitate cardiac failure and pulmonary oedema
• Vasoconstrictors via a central line may be required to maintain a stable BP
• Use atropine 0.5-1.0mg or glycopyrrolate 200-600mcg i.v. for bradycardia <40bpm or instability
•  Bradycardia usually resolves over a few days. Avoid pacemakers where possible 

Disability

• Ensure ASIA Chart is completed in full
•  Perform neurological examinations 2 hourly to identify and prevent any avoidable deterioration 

Other considerations

1. Do not give IV steroids
2. LMWH VTE prophylaxis should be started by day 3 and TEDs/flowtrons on admission
3. Give regular ranitidine/PPI
4. Prescribe nebulised saline, salbutamol 2.5mg and ipratropium 250mcg 4 hourly in all high cord injuries
5. Monitor for signs of alcohol withdrawal 

Skin

1. Heels should be supported clear of the bed with pillows
2. Pressure relief and minimum 30 degrees side to side turning should occur every 2 hours from admission

Bladder

1. All patients should be catheterised
2. If priapism is present, initially manage with urethral catheterisation where possible. May require a suprapubic catheter

Paralytic ileus

1. Nil-by-mouth
2. NG tube in all patients (may precipitate bradycardia)
3. If abdomen is distending due to build up of gas, undertake PR and decompression
4. Commence nutrition once bowel sounds have returned  

Bowel

1. Daily insertion of a glycerin or bisacodyl suppository 15-30 minutes before rectal examination and evacuation if rectum full 2. If BS present, passing flatus or moving bowels then start in ALL patients:
   1. Senna 15mg alternate evenings
   2. Lactulose 15ml bad
   3. OR if unsuccessful consider d) macrogol i sachet b.d.
   4. Bisacodyl 10mg alternate evenings

AND if T12 & above (reflex UMN bowel)

1. Daily PR
2. Daily anal digital stimulation to trigger reflex. CHECK digitally that emptying is complete

OR if L1 or below (flaccid LMN Bowel)

1. Daily PR
2. daily manual evacuation of faeces (essential in these patients).

DO NOT USE A FLEXISEAL unless diarrhoea caused by confirmed C.Diff. infection

Analgesia

1. Prescribe simple analgesia e.g. paracetamol
2. Opiates for fractures but caution in high cord injuries
3. Neuropathic analgesics e.g. gabapentin

Joint mobility

Daily passive limb movement, stretching and positioning with input from PT, OT and nurses from admission 

Other guidance

Further guidance on mobilisation, autonomic dysreflexia, weaning and other issues is available at www.spinalunit.scot.nhs.uk and www.spinalcordinjury.nhs.uk. Contact Edenhall for nursing advice on 0141 201 2533

Neurosurgical registrar refers to spinal injuries unit within 4 hours of diagnosis (please refer to the referral form). An early joint management plan must be formulated and recorded in the notes within 12 hours transfers to SIU do not usually occur direct from the ED (only at SIU discretion)

Patients accepted for transfer to SIU should be transferred with 24 hours of being stable and accepted for transfer spinal stabilisation for patients with a spinal cord injury may be chosen to be undertaken at the SIU in Glasgow. See spinal injury unit transfer checklist.

Spinal Cord Injury Pathway from Trauma Units