APPROPRIATE HEALTH CARE:
* Transportation
. A carefully applied rigid collar supplemented by sand bags on either side of the head on a rigid backboard
is probably the safest method
. Oxygen should be given to all patients with injury to the spinal cord. (Patients with high cord lesions die of
asphyxiation so assisted ventilation may be needed).
. 50% of serious cervical injuries will have associated head, chest, abdominal or major extremity injuries in
association. Give fi rst aid to these patients maintaining the ΒgABCΒh principle of airway, breathing, and
circulation.
. Military antishock garment (MASG) can be used in cases of shock
. Start an intravenous line if it can be done rapidly. Otherwise, this should not be done as valuable time
may be wasted. The principle of load and go in cases of ambulance or swoop and scoop in the case of helicopters is a good one if an acute care center is close at hand.
* Hospital
. Prior to dealing with the cervical injury, attention should be directed towards the ABCs (airway, breathing, circulation)
. Arterial oxygen should be measured immediately since oxygenation of an injured spinal cord helps prevent further damage and aids in recovery. If the oxygen partial pressure (pO2) is less than 70 mm of mercury, or the cervical lesion is above C5, intubation is indicated. If the patient is breathing, blind nasal intubation can be tried; otherwise the oral approach with a laryngoscope is necessary. Both require careful technique with avoidance of neck extension. If this cannot be done with ease or if there are severe facial injuries, a cricothyroidotomy should be done.
. A nasogastric (NG) tube should always be inserted to prevent vomiting, aspiration. It also prevents gastric
dilatation with lung compression and diffi cult breathing.
. In most cases, volume replacement is best accomplished through the femoral route. The subclavian approach risks pneumothorax and further oxygenation problems.
. If a pneumothorax is present, a chest tube should always be inserted (fi rst confi rmed by x-ray). Needle
aspiration is indicated only as a temporary measure to relieve symptoms in a tension pneumothorax prior
to insertion of the tube.
. In all cord injuries, abdominal and chest CT scan should be done to rule out a severe intra-abdominal injury. This procedure is highly accurate while all physical fi ndings and symptoms are unreliable. (The NG tube and an indwelling Foley catheter should be done prior to the scans.)
GENERAL MEASURES:
β’ Spinal shock occurs in 25-40% of spinal cord injuries. It is characterized by systolic hypotension and bradycardia. The cause is loss of distal sympathetic tone.
β’ Head injuries alone do not cause hypotension but can cause hypertension
β’ Because patients with cervical trauma may sustain other signifi cant injuries, systolic hypotension may be from blood loss and/or spinal shock. Remember that several liters of blood can be lost from a head or perineal wound.
β’ Shock other than from volume loss or spinal shock can come from pericardial tamponade, tension pneumothorax, or cardiac contusion
SURGICAL MEASURES: Surgical management as needed for type of injury
DRUG(S) OF CHOICE:
. Methylprednisolone
. If given within 8 hours after the injury, has been shown to not only minimize further injury, but to improve both motor function and sensation for up to six months. This steroid apparently prevents lipid hydrolysis and subsequent destruction of the cell membrane.
. Initial dose: 30 mg/kg over a 15 minute period. Then 45 minutes later, 5.4 mg/kg/hr for the next 23 hours.
ALTERNATIVE DRUGS:
β’ Naloxone, nimodipine and thyrotropin releasing hormones have been tried with equivocal results. Tests are underway using chemotherapeutic drugs, but these await the outcome of several studies.
β’ Other H2 receptor antagonists
PATIENT MONITORING : Critical care facilities must be available initially and later physical and occupational therapy units with special skills in spinal cord injuries
POSSIBLE COMPLICATIONS:
β’ Paresthesia
β’ Muscle weakness
β’ Reflex loss
β’ Sensory loss
β’ Radiculopathy
EXPECTED COURSE/PROGNOSIS:
In cases of signifi cant cord injuries, the prognosis is guarded. Development of newer orthopedic devices can stabilize the spine and allow early mobilization, but do not help to reverse neurological damage if present.