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

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

Ongoing Resuscitation

Hemodynamic Stability GOAL: MAP appropriate for age
  • Hypotension may be hemorrhagic and/or neurogenic in nature
  • Must consider additional injuries/hemorrhage as sources of hypotension
Adequate MAP
  • Maintenance fluids with NSS
Inadequate MAPs
  • NS 20 mL/kg boluses
  • Blood products for documented blood loss or coagulopathy
  • Consider vasoactive infusion if poor response to fluid/blood products (40-60 mL/kg)
Vasoactive Infusions
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
Neurological Stability/Prevent Secondary Injury
  • No methylprednisolone unless specifically directed by Neurosurgery
    • Note: Available medical evidence does not support a significant clinical benefit from the administration of methylprednisolone for 24-48 hours, instead suggesting harmful side effects.
Pain Management
Nutrition
  • GI prophylaxis —
    • Famotidine I.V.:
      • < 3 months: 0.25 mg/kg/dose once daily, up to 0.5 mg/kg/dose once daily
      • ≥ 3 months: 0.25 – 0.5 mg/kg/dose every 12 hours; maximum: 40 mg/day or
    • Pantoprazole: 0.5 - 1 mg/kg/dose IV every 24 hours (max 40 mg/dose)
  • Consider TPN/IL vs enteral tube feedings
    • Enteral is preferred method
    • Barriers to Enteral Nutrition:
      • Absence of bowel motility
        • Bowel motility may be silent for a few days to weeks — monitor for bowel sounds and/or flatus before considering enteral feeds
      • Persistent hemodynamic instability
      • Concurrent intra-abdominal injury
      • Planned NPO time > 72 hours (Including need for multiple surgical procedures)
    • Consult General Surgery/Trauma Dietician for recommendations
Skin Care
  • Daily skin exam
  • Specialty mattress/bed
Job Aids:
Patient / Family Education
  • Education about pathophysiology of injury
  • Orientation to hospital environment, overall plan of care
  • Verify patient’s insurance benefits