Patients with TSCI require intensive medical care and continuous monitoring of vital signs, cardiac rhythm, arterial oxygenation, and neurologic signs in the intensive care unit (ICU). 100,101 Many systemic, as well as, neurologic complications are common in the first days and weeks after TSCI, contribute substantively to prognosis, and are potentially avoidable or ameliorated with early intervention.101
The management of medical issues specific to spinal cord injury include the following:
Head Injuries and Neurologic Evaluation
Associated head injury occurs in about 25% of patients with spinal cord injury. A careful neurologic assessment for associated head injury is compulsory.
- The presence of amnesia
- External signs of head injury or basilar skull fracture
- Focal neurologic deficits
- Associated alcohol intoxication or drug abuse
- A history of loss of consciousness
Neurogenic shock refers to hypotension, usually with bradycardia, attributed to interruption of autonomic pathways in the spinal cord causing decreased vascular resistance.
Patients with TSCI may also suffer from hemodynamic shock related to blood loss and other complications. An adequate blood pressure is believed to be critical in maintaining adequate perfusion to the injured spinal cord and thereby limiting secondary ischemic injury.
Guidelines currently recommend maintaining mean arterial pressures of at least 85 to 90 mmHg, using intravenous fluids, transfusion, and pharmacologic vasopressors as needed.101-104 Maintenance of blood pressure intraoperatively is also important.
Patients with multiple injuries often receive large amounts of intravenous fluids usually an isotonic crystalloid solution to a maximum of 2 L for various reasons. Excess fluids cause further cord swelling and increased damage and places the patient at increased risk for acute respiratory distress syndrome (ARDS).
Interventions include monitoring of:
- Fluid administration/blood administration
- Urinary output
- Electrolyte levels
Bradycardia may require external pacing or administration of atropine. This complication usually occurs in severe, high cervical (C1 through C5) lesions in the first two weeks after TSCI. 105,106
Autonomic dysreflexia is usually a later complication of TSCI, but may appear in the hospital setting, requiring acute management.107 This phenomenon is characterized by episodic paroxysmal hypertension with headache, bradycardia, flushing, and sweating.
Aspiration and Pulmonary Complications
Aspiration and pulmonary complications are the most frequent category of complications during acute hospitalization after TSCI which contribute substantively to early morbidity and mortality and both are related to the level of neurologic injury. 89,101,108-110 Respiratory complications include:
- Pulmonary edema
- Pulmonary embolism
The incidence of these pulmonary complications is highest with higher cervical lesions (up to 84%), but they are also common with thoracic lesions (65%).
Weakness of the diaphragm and chest wall muscles leads to impaired clearance of secretions, ineffective cough, atelectasis, and hypoventilation.
Signs of impending respiratory failure, such as increased respiratory rate, declining forced vital capacity, rising pCO2, or falling pO2, indicate urgent intubation and ventilation with positive pressure support. 89,110,111
Rapid-sequence intubation with in-line spinal immobilization is the preferred method of intubation when an airway is urgently required.
If time is not an issue, intubation over a flexible fiberoptic scope may be a safer, effective option. Tracheostomy is performed within 7 to 10 days, unless extubation is imminent.
For patients with concomitant pneumothorax and/or hemothorax chest tube thoracostomy may be performed.
With a goal of preventing atelectasis and pneumonia, interventions include:
- Chest physiotherapy
- Frequent airway suctioning
Venous Thromboembolism and Pulmonary Embolism
Deep venous thrombosis (DVT) is a common complication of TSCI, occurring in 50 to 100% of untreated patients, with the greatest incidence between 72 hours and 14 days. 112,113
The level and severity of TSCI does not clearly have an impact on the risk for DVT. All patients should receive prophylactic treatment.
Low-molecular-weight (LMW) heparin (considered the treatment of choice for patients with TSCI). 101,114-116 Combining LMW heparin with pneumatic compression stockings may provide additional benefits, but this has not been studied.
Use of either low-dose unfractionated heparin therapy or pneumatic compression stockings as monotherapy is considered inadequate protection117, but combination therapy with these two approaches may be considered an alternative to LMW heparin.
Inferior vena cava filters should be inserted for patients for whom anticoagulation is contraindicated.101
When using opiates with potential sedating properties, the need for pain control must be balanced with the need for ongoing clinical assessment, particularly in patients with concomitant head injury. Pain is often reduced by realignment and stabilization of the cervical fracture by surgery or external orthosis.
Pressure sores are most common on the buttocks and heels and can develop quickly (within hours) in immobilized patients.101
- Pad all extensor surfaces
- Undress the patient to remove belts and back pocket keys or wallets
- Backboards should be used only to transport patients with potentially unstable spinal injury and discontinued as soon as possible.
- After spinal stabilization, the patient should be turned side to side (log-rolled) everyone to two hours to avoid pressure sores.
- Rotating beds designed for the patient with spinal cord injury should be used in the interim, if available.
Initially, an indwelling urinary catheter must be placed to avoid bladder distension, to monitor urine output and to decompress the neurogenic bladder. Urine output should be more than 30 mL/h.
Rarely, inotropic support with dopamine or norepinephrine is required and should be reserved for patients who have decreased urinary output despite adequate fluid resuscitation. Usually, low doses of dopamine in the 2 to 5 mcg/kg/min range are sufficient.
Three or four days after injury, intermittent catheterization should be substituted, as this reduces the incidence of bladder infections.101
Urologic evaluation with regular follow-up is recommended for all patients after SCI.118
Gastrointestinal stress ulceration
Patients with TSCIs, particularly those that affect the cervical cord, are at high risk for stress ulceration.119 Prophylaxis with proton pump inhibitors is recommended upon admission for four weeks.109
Bowel motility may be silent for a few days to weeks after TSCI. Placement of a nasogastric (NG) tube is essential to prevent aspiration. Aspiration pneumonitis is a serious complication in the patient with a spinal cord injury with compromised respiratory function. Antiemetics should be used aggressively.
Patients should be monitored for bowel sounds and bowel emptying and should not ingest food or liquid until motility is restored.120
Prevent hypothermia. Patients with a cervical spinal cord injury may lack vasomotor control and cannot sweat below the lesion. Their temperature may vary with the environment and needs to be maintained.
Interventions may include:
- Place the patient in a warm ambient room
- Administer warmed IV fluids
- Cover the patient with warm blankets
- Occupational and physiotherapy should be started as soon as possible. Psychological counseling is also best offered to patients and relatives as early as possible.
- Enteral or parenteral feeding should be provided within a few days after TSCI.101