Spinal Cord Injury, SCI, Traumatic — Initial Assessment and Resuscitation — Clinical Pathway: Emergency and Inpatient

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

Initial Assessment and Resuscitation

Hemodynamic Stability

Obtain IV access — Initiate maintenance fluids with NSS

GOAL: Normal MAPs
Note: In adults, Class III evidence suggests that maintenance of MAP at 85 to 90 mm Hg after acute SCI for seven days is safe and may improve spinal cord perfusion and ultimately, neurological outcome.

Hemodynamic support as needed

  • Note: Hypotension may be hemorrhagic or neurogenic in nature — unexplained hypotension should raise the suspicion of a spinal cord injury

  • 2-3 20 mL/kg NS boluses as initial blood pressure support
  • Blood products for documented blood loss or coagulopathy
  • Consider vasoactive infusion if poor response to 40-60mL/kg of fluid/blood products
First Line: DOPAMINE — starting dose 5 mcg/kg/min, fellow/attending may select an alternate first-line agent
Hypotension AND Bradycardia Hypotension AND Tachycardia
If still hypotensive, titrate EPINEPHRINE, Starting dose 0.05 mcg/kg/min If still hypotensive, titrate NOREPINEPHRINE, Starting dose 0.05 mcg/kg/min
Caution: Phenylephrine often causes reflexive bradycardia possibly worsening bradycardia associated with T4 and above injuries
  • Arterial line, CVL, Foley should be placed for patients on vasoactive infusion for > 1 hour, if not already in place.
Respiratory Support
  • Rapid Sequence Intubation (RSI):
  • Goals:
    • SpO2 > 92% and < 98%
    •  
    • EtCO2:
      30-34 mmHg
  • Etomidate
    • Appropriate for patients with multiple-traumatic injuries or tenuous hemodynamics
    • Lasts for approximately 8 minutes – Consider the need for additional sedation but avoid hypotension
  • Propofol and thiopental may exacerbate hypotension resulting from hemorrhage and/or neurogenic shock
Maintain Safety/Activity Restrictions
  • Cervical immobilization
  • Bedrest with HOB flat
  • Logroll only
Temperature Instability
  • Temperature control, including ambient temperature and/or warmed IVF/blood products
Pain Management

GOAL: provide adequate pain control without worsening hypotension or impeding normal coagulation

  • Short-acting opioids (Fentanyl - 1 mcg/kg/dose IV) — Administer the minimal amount needed to avoid hypotension
  • Acetaminophen as first-line
  • Avoid NSAIDs during initial assessment/resuscitation