Spinal cord injuries require special care

Early ED interventions are key

Patients with acute spinal cord injury are at risk for spinal shock and or neurogenic shock, and hypotension and bradycardia are major concerns, says Jean M. Marso, RN, BSN, trauma coordinator at University of Colorado Hospital in Denver.

"In addition, there may be respiratory impairment, depending on the level of the cord injury," she adds.

Spinal cord injury patients present many challenges to ED nurses, says Marso. "Patients with suspected or known spinal cord injury need 1:1 monitoring, so that ties up at least one nurse," she says. "Early interventions are key, because these patients cannot be kept in the ED for long periods of time. Rapid surgical intervention, if needed, is imperative."

To improve care of acute spinal cord patients, do the following:

• Make sure patients are adequately resuscitated.

A well-resuscitated patient is more likely to have a favorable outcome than one that is underresuscitated, says Timothy J. Murphy, nursing director of trauma and injury prevention at Robert Wood Johnson University Hospital in New Brunswick, NJ. "We used to advocate limiting fluids with patients suffering [central nervous system] injury to limit expansion of any lesion," he explains.

However, patients who maintain their blood pressure and mean arterial pressure are less likely to suffer ischemia and hypoxia, which tends to contribute to secondary injury, says Murphy. "So adequate fluid administration, blood component use and vasopressors should be considered for the spinal cord injured patient," he says.

However, usually hypotension in a spinal cord patient is due to vasodilatation and not volume loss, unless there is another reason such as hemorrhagic trauma or a burn, says Marso. Therefore, if it is not volume loss, hypotension in a spinal cord injury patient would be treated with pressor agents instead of volume replacement, she says. "It is imperative that these patients not be volume overloaded due to erroneously suspecting volume loss as the cause of hypotension when it is not," stresses Marso.

If patients are volume overloaded, acute respiratory distress syndrome is likely to occur, says Marso. "If this occurs, the patient would most likely require ventilatory support, which then puts the patient at increased risk for ventilatory dependence and infection," she adds.

• Know current research on steroids.

According to a new study, steroids continue to be given to patients with acute spinal cord injury mainly out of fear of litigation.

"Although steroids are given to spinal cord injury patients in many EDs, there is no proven benefit to this," says John R. Hurlbert, MD, PhD, FRCSC, FACS, the study's lead author and associate professor in the division of neurosurgery at the University of Calgary in Canada.1 "Everyone involved in the administration of medications to patients should know the reason they are giving them, what they should expect from them, and what the possible side effects are."

At Robert Wood Johnson's ED, a methylprednisolone 24-hour protocol is used if the patient has a neurologic deficit from blunt trauma and presents within eight hours from the time of injury, says Murphy. "Just as the article points out, the major reason that most practitioners continue to use this regimen is because of medical-legal concerns of not initiating therapy," he notes.

• Do an early assessment of motor and sensory function.

Use the classification from the American Spinal Injury Association as a standardized way to assess progression of neurologic deficits, advises Murphy. "Serial examinations will help the clinician identify a worsening situation, which should be reported promptly to the attending physician," he says.

Both motor and sensory function are measured independently on the right and left side of the body. A maximum motor score of 50 on each side for a total of 100 may be obtained, says Murphy.

Likewise, sensory dermatomes are monitored both right and left to pinprick and light touch, for a maximum score of 112 each, says Murphy. A decrease in any of the numeric scores should be reported to the spine surgeon, who may alter the treatment plan based on your findings, he adds.

"We have had patients whose score showed a sudden decline," Murphy says. "The spine surgeon elected to take the patient to surgery emergently to stabilize the spine in hopes of preserving function."

• Maintain immobilization.

Immobilization is key if a neurologic deficit is identified or an injury is suspected, says Murphy. "This targets prevention of secondary injury," he says.

At the same time, be aware of the potential for development of complications such as respiratory compromise, pressure sores, deep vein thrombosis, and pulmonary embolism, adds Murphy.

Skin protection in spinal cord patients is of concern as these patients usually are on a backboard or other firm surface, says Marso. Spine-injured patients who are very young, elderly, or have concomitant burn injuries are at higher risk for skin breakdown, she says.

"The No. 1 preventative measure is early removal of the backboard if they are on one," says Marso. "This means getting X-rays and [computerized tomography scan] stat to determine if there is a spinal cord injury and whether early intervention, transfer, or admission are needed for stabilization of the injury."

Reference

  1. Hurlbert JR. Strategies of medical intervention in the management of acute spinal cord injury — epidemiology of spinal cord injury and early management. Spine 2006; 31(11S):S16-S21.

Sources/Resource

For more information about treatment of acute spinal cord injury in the ED, contact:

  • John R. Hurlbert, MD, PhD, FRCSC, FACS, Department of Clinical Neurosciences, Foothills Hospital and Medical Centre, 1403 29th St. N.W., Calgary, Alberta T2N 2T9, Canada. E-mail: jhurlber@ucalgary.ca.
  • Jean M. Marso, RN, BSN, Trauma Coordinator, University of Colorado Hospital, Department of Trauma Services, 4200 E. Ninth Ave., Mail Stop A021-630, Denver, CO 80262. Telephone: (303) 372-8905. Fax: (303) 372-0267. E-mail: jean.marso@uch.edu.
  • Timothy J. Murphy, Nursing Director, Trauma & Injury Prevention, Robert Wood Johnson University Hospital, One Robert Wood Johnson Place, New Brunswick, NJ 08903. Telephone: (732) 418-8095. Fax: (732) 418-8097. E-mail: timothy.murphy@rwjuh.edu.

The American Spinal Injury Association (ASIA) offers a Standards Teaching Package, which includes a classification standards booklet, two video tapes illustrating the neurological assessments recommended in the booklet, and a manual that provides support and training materials referred to in the videotapes. The cost is $150, including shipping and handling. To order, contact ASIA, 2020 Peachtree Road N.W., Atlanta, GA 30309. Telephone: (404) 355-9772. Fax: (404) 355-1826.