Spinal Cord Injury, SCI, Traumatic Clinical Pathway — Emergency and Inpatient

Clinical Pathways Home Emergency ICU Inpatient Outpatient Specialty Care Primary Care

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

Trauma Team Resuscitation
ATLS protocol
Spinal immobilization including cervical collar
Spinal Trauma Consult

Resuscitation Complications
Neurogenic shock
Spinal shock
Respiratory Failure
Temperature instability

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

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)
ISNCSCI (International Standards for Neurological Classification of Spinal Cord Injury) exam
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
Taking adequate calories enterally (PO and/or feeding tube)
Definitive airway with stable respiratory exam
Spine stabilized
Pain managed with enteral or topical medications
Bowel and Bladder Program initiated
Skin care regimen in place
Tolerating increased activity/rehabilitative services
Other injuries addressed/treatment plan in place
Family/patient knowledgeable about patient care and indications for inpatient rehabilitation

Resources Contact Info:

Trauma Fellow: 10258
On-call Trauma Nurse Practitioner:
See staff directory
On-call Neurosurgery: 10781
On-call Orthopedics: 11014
Pain Management: 10444
Wound Care APN: 16787
Boston Orthotics & Prosthetics (O&P): 215-634-9399
Specialty Bed: Unit-based CNS or
Nursing Supervisor (off shifts)
PM&R: 76303

Posted: August 2015
Revised: January 2017, January 2018, August 2018
Authors: J. Osipowicz, CRNP; M. Nance, MD; D. Mowery, MD; A. Weiss, MD

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.