If you don’t follow recent guidelines, a patient may come into your ED with a spinal cord injury and leave paralyzed. "Patients with cervical spine fractures could cause more damage to their spinal cord if not appropriately immobilized," underscores Kelli Vaughn, RN, BSN, CEN, trauma nurse coordinator at John D. Archbold Memorial Hospital in Thomasville, GA. "This could lead to more paralysis and greater complications."
New guidelines for acute cervical spine and spinal cord injuries were developed by the Rolling Meadows, IL-based American Association of Neurological Surgeons and the Schaumburg, IL-based Congress of Neurological Surgeons. Use these key points from the guidelines to ensure you don’t injure a patient with potential spinal cord injuries:
• Make sure the patient is immobilized adequately.
Since approximately 20% of spinal cord injuries involve noncontinuous vertebral levels, the complete spine should be immobilized until injury has been ruled out, advises Michael Frakes, BSN, CFRN, CCRN, EMTP, flight nurse at Lifestar/Hartford (CT) Hospital. Adequate immobilization consists of a rigid cervical collar with supportive blocks on a rigid backboard with straps, he says.
You must make sure that adequate precautions are taken for all patients who present with a possible spinal cord injury, stresses Frakes. "This includes ensuring the adequacy of spinal restriction placed by EMS [emergency medical services] and also placing appropriate equipment on patients who do not arrive by EMS," he says.
According to the Des Plaines, IL-based Emergency Nurses Association’s Trauma Nurse Core Course, spinal immobilization is required for "any patient whose mechanism of injury, symptoms, or physical findings suggest a spinal injury," notes Frakes.
The following areas are associated with potential spinal injury, he says:
- Mechanism of injury: Motor vehicle crash, fall, diving injury, near-drowning, direct force to spine or head, penetrating trauma to spine, or ejection from motor vehicle.
- Symptoms: Spinal pain or tenderness, paresthesias, and paralysis.
- Physical findings: Head injury or altered level of consciousness after trauma.
• Don’t remove immobilization until adequate imaging is completed.
No single film can adequately rule out injury in symptomatic or obtunded patients, says Frakes. These patients should have a three-view series of plain films supplemented by computerized tomography or magnetic resonance imaging, he explains. "You should ensure that immobilization remains in place until adequate imaging is completed and the studies read," says Frakes. It’s a mistake to think you can clear a neck injury with only a lateral cervical spine view, says Frakes. "If there is an injury to the anterior aspects of the cervical spine that are only visible on the odontoid view, particularly high cord injuries, that would be missed," he says.
• Perform a thorough respiratory assessment.
Patients with spinal cord injuries are at high risk for airway compromise and pulmonary dysfunction, says Frakes. "The ED nurse should complete a careful initial respiratory assessment and provide close ongoing monitoring for ventilatory compromise," he says. Supplement frequent examinations and vital signs measures with pulse oximetry and capnography, recommends Frakes.
• Monitor blood pressure carefully.
A single episode of hypotension is potentially harmful, warns Frakes. "You should carefully monitor the patient’s blood pressure and advocate for blood pressure support as necessary," he says.
• Arrange for transport if necessary.
Patients with acute spinal cord injuries should be monitored in an intensive care unit (ICU) at a center with spinal cord injury expertise, says Frakes. "If transport for a specialty ICU is required, transport should be arranged early," he says. "The patient should be transported by a team with trained flight nurses."
• Consider risks of methylprednisolone.
Methylprednisolone therapy may not be appropriate for everyone, says Frakes. "The risks and benefits of therapy should be carefully weighed for each patient," he says.
Methylprednisolone is a steroid therapy, and for spinal cord injuries, the therapy is a high dosage and continuous for 24 hours, explains Vaughn. "So, you want to consider side effects of steroids, including decreased immune response stomach ulcers, and fluid retention," she says. Methylprednisolone is used to decrease the secondary injury to the spinal cord, says Vaughn. The primary injury is the event causing the spinal cord injury, such as a motor vehicle accident or fall, Vaughn explains. "The secondary injury is the swelling, inflammation that occurs from the primary injury," she says.
Research has shown that the drug works best if given as soon as possible following the injury, says Vaughn. "That does not mean that it should not be given if treatment has been delayed, but results may not be as effective," she says.
• Perform frequent serial neurological assessments.
You carefully must monitor spinal cord injury patients for changes, as you would in any critically injured patient, says Vaughn. "These changes need to be documented and the physician notified as appropriate," she says. "For example, a thoracic fracture may not initially affect respiratory status, but as swelling of spinal cord occurs, respiratory status can become an issue."
For more information on the treatment of spinal cord injuries in the ED, contact:
• Michael Frakes, BSN, CFRN, CCRN, EMTP, Flight Nurse, Lifestar/Hartford Hospital, P.O. Box 5037, Hartford, CT 06102-5037. Telephone: (860) 545-4369. Fax: (860) 545-5491. E-mail: Mfrakes@harthosp.org.
• Kelli Vaughn, RN, BSN, CEN, Trauma Nurse Coordinator, John D. Archbold Memorial Hospital, P.O. Box 1018, Thomasville, Georgia, 31799-1018. E-mail: KVaughn@archbold.org.
Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries were published in a supplement to the March 2002 issue of Neurosurgery. The guidelines can be ordered on-line at www.neurosurgery-online.com/home2.html. Scroll down to "Guidelines for management of acute cervical spinal injuries," and click on "Full text print." The cost to download the guidelines is $20 per chapter. Or single copies of the supplement issue (which contains the complete text of the guidelines in 22 chapters) are available for $61, including shipping. To order, contact Lippincott, Williams & Wilkins, P.O. Box 1600, Hagerstown, MD 21740-1600. Telephone: (301) 223-2300. Fax: (301) 223-2400. E-mail: email@example.com. Web: www.lww.com.