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Hypotension following trauma should be considered secondary to hemorrhage until proven otherwise, even in patients with early suspicion of spinal injury. Neurogenic shock and spinal shock are separate, important entities that must be understood.
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Hypoxia and hypotension should be aggressively corrected because they lead to secondary spinal cord injury, analogous to traumatic brain injury. Critical care support of multiple organ systems is frequently required early after injury.
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Early spinal
Trauma: Spinal Cord Injury
Section snippets
Key points
Assessment of spinal cord injuries
The critical step in early evaluation of patients with possible SCI is recognition of patients at risk and a focused, yet thorough neurologic examination. Too often the steps of physical examination are deferred to the all-knowing computed tomographic (CT) scanner. This delay can slow recognition of SCI and establishment of baseline function and delay consultation of appropriate specialists and the initiation of preventive measures avoiding further secondary injury. The performance of such an
Spinal shock versus neurogenic shock
The terms “spinal shock” and “neurogenic shock” are often both used inappropriately or incorrectly, or are confused for one another in the clinical setting. Neurogenic shock is the hemodynamic consequence of the SCI, classically characterized by hypotension due to vasodilation and increased perfusion of the lower extremities (also known as “warm shock”). In cases of higher SCI (cervical spine), hypotension may often be accompanied by paradoxical bradycardia. This pattern is a relatively unique
Management of acute spinal cord injury
The management of SCI begins with spine precautions (logrolling, cervical collar) and protection from further injury. Spinal immobilization precautions do not mean lying flat and motionless once the initial trauma evaluation has been completed. Reverse Trendelenburg position up to 30° will greatly benefit, and participatory pulmonary toilet should begin if they are not intubated. Ensure adequate pain control to maximize tidal volumes. Have a low threshold for nasogastric decompression because
Management of penetrating spine trauma
Penetrating SCI is most commonly secondary to gunshot wounds and typically results in complete SCI due to direct trauma to the cord and associated blast effect as well as secondary hemorrhage and ischemia.47 In civilian trauma centers, the thoracolumbar spine is the region most frequently injured. The management options for open spine trauma are not much different than those for closed spine trauma, even in patients with open vertebral column fractures. The wound must be managed with irrigation
Airway management
The need for appropriate airway management is of particular importance for patients with cervical SCIs. Most patients with high cervical SCIs will present with quadriplegia and respiratory distress or arrest and clearly require intubation. The difficult patient population is the lower cervical spine injury (C5-C7) and upper thoracic spine (T1-T6), who frequently present with no obvious respiratory distress due to the ability to continue shallow breathing. Be wary of these patients: previous
Spinal cord syndromes
Although simple complete traumatic SCI is relatively straightforward, with a dense and complete neurologic deficit below the level of injury, there are several spinal cord syndromes involving injuries to an isolated segment that have a much more varied and subtle presentation. These syndromes can be easily missed or misdiagnosed if a thorough neurologic examination and appropriate differential diagnosis are not performed. Table 3 reviews the cause, diagnosis, and management for the common
Venous thromboembolism after spinal cord injury
Venous thromboembolism (VTE) events and appropriate prophylaxis are major concerns in the acute and long-term management of SCI patients. A recent large population study of roughly 48,000 SCI patients found an approximately 2.5-fold increased risk of deep venous thrombosis (DVT) and 1.6-fold increased risk of pulmonary embolism compared with controls. The risks were greatest within the first 3 months following injury and with increasing age.61 Additional studies confirm the heightened risk in
Summary
The impact of a SCI in any trauma patient can range from a minor nuisance to devastating paralysis, and unfortunately, the full spectrum of these injuries is frequently seen after trauma. Although much of the damage is done at the time of presentation and irreversible immediately, adherence to comprehensive supportive care aimed at treating the injury and preventing secondary injury may make a significant difference in the patient’s ultimate functional outcome. Every physician should be able to
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