Spinal Cord Injury (SCI) Clinical Pathway — Emergency Department and ICU

Emergency Department and PICU Clinical Pathway for Evaluation/Treatment of Children with Suspected Traumatic Spinal Cord Injury

Goals and Metrics
Patient Education
Provider Resources
Traumatic Spinal Cord Injury Suspected
Initial Assessment and Resuscitation
  • Goals
  • Avoid hypotension
  • Avoid hypoxia - Titrate supplemental O2 for
    SpO2 > 92% and < 98%
  • Maintain normothermia
  • Maintain safety
  • Adequate analgesia
Plain Radiograph, +/- Dedicated CT
Admission to PICU
Ongoing Resuscitation
24 - 48 hours
  • Goals
  • Avoid hypotension
  • Avoid hypoxia - Titrate supplemental O2
    for SpO2 > 92% and < 98%
  • Prevent secondary neurological injury
  • External/internal stabilization of spine, as indicated
  • Tertiary exam per ATLS Standard, treat
    additional injuries
Stabilization: Acute Inpatient Care Goals
  • Prevention of complications:
    • Infections
    • Skin breakdown
    • Severe constipation
  • Prepare child for ongoing management in acute rehab
  • Stabilization Complications
  • Spinal shock
  • Orthostatic hypotension
  • Respiratory insufficiency
  • Feeding Intolerance
  • Temperature instability
48 hours and on
  • Goals
  • External/internal stabilization of spine, as indicated (if not previously completed)
  • Characterizing the Injury
    • ASIA (ISNCSCI) exam
    • Interpreting ISNCSCI
    • Suspected Upper Motor Neuron vs. Suspected Lower Motor Neuron
  • Initiate/advance nutrition
  • Neurogenic bowel and bladder care
  • Adequate analgesia
  • Rehabilitation consults/advance in activity
  • Prevent/treat SCI-related complications
Recovery
  • Recovery Complications
  • Autonomic dysreflexia
  • Respiratory insufficiency
  • Neuropathic pain
  • Superior mesenteric artery syndrome
  • Hypercalcemia
  • Joint contracture
  • UTI/urosepsis
  • Vesicoureteral reflux
  • Muscle spasticity
  • Scoliosis
  • Osteopenia
  • Decubitus ulcer
  • Goals
  • Patient/family education and training
  • Discharge Planning
Discharge to Rehabilitation Facility
  • Discharge Criteria
    • Hemodynamically stable
    • Adequate enteral intake
    • Definitive airway, stable respiratory exam
    • Spine stabilized
    • Pain managed with enteral, topical medication
    • Bowel, bladder program initiated
    • Active skin care regimen
    • Tolerating increased activity, rehabilitative services
    • Other injuries addressed, treatment plan in place
    • Family, child knowledgeable of care plan, indications for inpatient rehabilitation
Resources
  • Contact PHL Wound Ostomy
    via Epic On-call Finder
  • Boston Orthotics & Prosthetics (O&P): 215-634-9399
  • Specialty Bed: Unit-based CNS or
    • Nursing Supervisor (off shifts)
Posted: August 2015
Revised: June 2023
Editors: Clinical Pathways Team