Spinal Cord Injury, SCI, Traumatic — Hemodynamic, Respiratory, Neurologic Stability, DVT Prophylaxis — Clinical Pathway: Emergency and Inpatient

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

Hemodynamic, Respiratory and Neurologic Stability during Stabilization and Recovery

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
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.
DVT Prophylaxis
  • Inpatient VTE Risk Assessment and Prophylaxis
  • Note: Pharmacological DVT prophylaxis may be contraindicated secondary to concurrent injuries — Safety/appropriateness to be determined following discussion with primary/consulting services.
Respiratory Stability GOAL:
  • SpO2 > 92% and < 98%
  • EtCO2: 30-34mmHg
  • Supplemental oxygen, ventilatory support as clinically indicated
  • Note: Avoid Succinylcholine in SCI > 48 hours due to upregulation of acetylcholine receptors on denervated muscle and risk of hyperkalemia

Tracheostomy/ETT

  • Determined by PICU, Trauma, ENT based on SCI level/need for ongoing ventilator support
  • Cough assist, chest physiotherapy
  • Assess appropriateness for inline Passy Muir Valve (PMV) — tracheostomy only

Natural airway

  • Evaluation of baseline pulmonary function
  • Incentive spirometry, cough assist, chest physiotherapy, manually assisted coughing (“quad coughing”)
  • Abdominal binder when sitting up
  • Early mobilization (if spine stabilized)

Technique for manually assisted coughing (“quad coughing”):

  • Patient to be positioned supine in bed or sitting up in bed/wheelchair
  • Face the patient and place your hands in one of two positions:
    • Heels of hands, one on top of the other, pressing just below sternum
    • Hands on either side of body, just below the ribcage
    • Caution: No pressure should be placed on the ribs or sternum
  • Ask the patient to take 3 deep breaths. On the third exhalation, while the patient coughs, the caregiver pushes inward and upward
  • Contraindications include:
    • Acute abdominal or chest wall injury
    • Pain
  • Rationale: Expiratory muscle weakness may result in an ineffective cough and secretion clearance
Neurological Stability Prevent Secondary Injury

Stabilization:

  • External and/or Internal stabilization — determined by Neurosurgery and/or Orthopedics

TLSO brace

  • Determined by Neurosurgery and/or Orthopedics
  • Contact Boston Orthotics & Prosthetics (O&P): 215-634-9399

Cervical immobilization

  • Determined by Trauma or Neurosurgery

ISNCSCI (International Standards for Neurological Classification of Spinal Cord Injury) Exam

  • Completed by PM&R attending/fellow within 72 hours of admission

ISNCSCI graphics  

Procedures:

  • Cervical spine immobilization device: application of the Aspen pediatric collar for patients < 25 kg -
    See procedure
  • Cervical spine immobilization device: application of the Vista collar by Aspen for patients > 25 kg -
    See procedure
  • Collar care: skin assessment, cleaning the skin, and changing the pads, See procedure