Suspected Spinal Cord Injury

VBMC TRAUMA CARE SERVICES GUIDELINE

Suspected Spinal Cord Injury

Neurogenic Shock in Spinal Cord Injury (SCI)

Hemodynamic management of acute spinal cord injury

1. Patients with traumatic aSCI (cervical or thoracic ASIA A-D) and central cord syndrome

2. MAP ≥ 85 mmHg for 5 days

3. Vasopressor agent:

• Norepinephrine (most patients)

• Dopamine (pts w bradycardia)

• Phenylephrine (more potential for harm in patients with bradycardia or heart failure)

• Epinephrine/vasopressin (use in refractory response only)

4. Arterial line if indicated

Hemodynamic management of acute spinal cord injury

Statement of Need

Perfusion & oxygen delivery is integral to prevent worsening of acute spinal cord injuries (aSCI). Some patients with aSCI may exhibit hemodynamic instability due to damage to autonomic/sympathetic innervation pathways. The published literature is weak in this area, which may result in variations in therapy.

Background

A mean arterial pressure (MAP) target of 85-90mmHg is suggested by guidelines to ensure adequate spinal perfusion after aSCI.(1-3) Proactive hemodynamic management also reduces the risk of fluctuations in blood pressure, which may be deleterious after aSCI (particularly hypotension).(4) Isotonic fluid resuscitation and the use of vasopressors may be needed to meet the target blood pressure in some individual. Overall, the scientific support for the MAP target of >85mmHg is weak, consisting of under-powered, retrospective studies. However, there is some consistency in these studies in that patients who consistently have a MAP >85mmHg seem to have better neurologic outcomes.(5-8) Based on animal and human evidence, the level of evidence would be characterized as low to very low based on GRADE criteria.(9) The literature primarily pertains to patients with traumatic injuries, rather than exacerbations of chronic spinal problems, though some of the same perfusion concerns may be applicable in these situations.

Recommendations

1. Patients with traumatic aSCI

a. Acute cervical or thoracic

b. ASIA A-D

2. Patients who exhibit a MAP < 85mmHg may require fluid management and/or vasopressors for hemodynamic support

a. Isotonic fluids to ensure euvolemia should be initiated promptly (conditional recommendation, low level of evidence)

b. Vasopressors may be considered to maintain MAP >85mmHg (conditional recommendation, low level of evidence)

i. There is no literature to support a primary vasopressor of choice

ii. Norepinephrine is a reasonable option for most patients with aSCI (conditional recommendation, low level of evidence)

iii. Dopamine may be necessary in patients with bradycardia who need more chronotropic support (conditional recommendation, low level of evidence)

iv. Phenylephrine is also reasonable to use as a primary or adjunct agent (conditional recommendation, low level of evidence)

1. Phenylephrine has more potential for harm in patients with bradycardia or patients with heart failure

v. Epinephrine, vasopressin should be used in situations of refractory response only (conditional recommendation, very low level of evidence)

c. The duration of MAP targeting has commonly been described as 7 days (not to exceed) (conditional recommendation, low level of evidence)

3. Consider continuous arterial blood pressure monitoring, particularly in the acute phases of care (good practice statement)

References

1. Schroeder GD, Vaccaro AR, Welch WC. Best Practies Guidelines: Spine Injury: NEUROGENIC SHOCK AND SYSTEMIC PRESSURE-DIRECTED THERAPY. In: American College of Surgeons; 2022. p. 46-48.

2. Early acute management in adults with spinal cord injury: a clinical practice guideline for health-care professionals. 2008;31(4):403-479.

3. Cozzens JW, Prall JA, Holly L. The 2012 Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injury. 2013;72 Suppl 2:2-3.

4. Kong CY, Hosseini AM, Belanger LM, et al. A prospective evaluation of hemodynamic management in acute spinal cord injury patients. 2013;51(6):466-471.

5. Weinberg JA, Farber SH, Kalamchi LD, et al. Mean arterial pressure maintenance following spinal cord injury: Does meeting the target matter? 2021;90(1):97-106.

6. Vale FL, Burns J, Jackson AB, et al. Combined medical and surgical treatment after acute spinal cord injury: results of a prospective pilot study to assess the merits of aggressive medical resuscitation and blood pressure management. 1997;87(2):239-246.

7. Hawryluk G, Whetstone W, Saigal R, et al. Mean Arterial Blood Pressure Correlates with Neurological Recovery after Human Spinal Cord Injury: Analysis of High Frequency Physiologic Data. 2015;32(24):1958-1967.

8. Levi L, Wolf A, Belzberg H. Hemodynamic parameters in patients with acute cervical cord trauma: description, intervention, and prediction of outcome. 1993;33(6):1007-1016; discussion 1016-1007.

9. Andrews JC, Schunemann HJ, Oxman AD, et al. GRADE guidelines: 15. Going from evidence to recommendation-determinants of a recommendation's direction and strength. 2013;66(7):726-735.

Inpatient Care of Spinal Cord Injury Guideline

1. Transfer to specialized spinal cord injury center as soon as possible.

2. Involve clinical liaison (PMR) in ALL cases, EARLY after admission.

3. Pressure relief over bony prominences within 2 hours of injury (get off backboard, use sheepskin, turn patient every 2 hours and apply Mepilex.

4. Provide airway and ventilatory support early in high tetraplegia (C5 and above) by intubation and mechanical ventilation. If patient is intubated and not weaning trach. (This must be patient specific. If patient maintaining own airway given him/her a chance to maintain it.

5. If trying to avoid mechanical ventilation, evaluate baseline pulmonary function with TV, VC and NIF (bedside spirometry every hour with documentation of effort/level) and monitor/assess daily with chest films if needed and mucous production and clearance.

6. Treat hypotension (MAP>85 with fluid first, then Norepinephrine 0.05 mcg/kg/min-titrate to response) for a minimum of seven days

7. Do not use steroids unless indicated by spine service.

8. If surgery is performed, continue post-operative ventilatory support past PACU because intraoperative events may result in airway edema and respiratory compromise ie: prone positioning, residual anesthetic agents. Continue until patient meets separation requirements.

9. Pain control-morphine or fentanyl –intubated-fentanyl drip 50 mcg/hour (SAS 3-4) or morphine 2 mg/hour and nonintubated Morphine 1-5 mg IV q1 hr pain, Fentanyl 50-100 mcg IV q1 then transition to our pain protocol when extubated and eating and then start gabapentin [300 mg po daily and titrate up to bid and tid (max 3600 mg/day)] and pregabalin (75 mg po bid, increase to 150 BID within 1 week than increase to 300 po BID withing 2-3 weeks, Max 600 mg/day). Both drugs need to be tapered off.

10. SCD’s and low molecular wt heparin or unfractionated heparin- combination of both as there is evidence that SCD’s may enhance the efficacy of heparin or lovenox. IVC filter only in those patients with active bleeding expected to last more than 72 hours.

11. Tetraplegic patients should be admitted to ICU and considered for mechanical ventilation. The incidence of ventilatory failure following tetraplegia is as high as 74%. 95% of patients with injury at or above C5 may require mechanical ventilation. Evidence shows monitoring ABG early after injury may identify impending failure.

12. Trach early if expected to be ventilator dependent or a slow wean. Early trach is associated with reduced LOS in ICU. Additional indications for tracheostomy include advanced age, higher level of injury and preexisting medical conditions.

13. Use Manually Assisted coughing or Quad coughing, NT suctioning, neb treatments and IS/Flutter valve.

14. Place Foley early to monitor fluid status, then remove at earliest stable time when resuscitation is complete and UOP is below 2000/day then I & O cath every 4-6 hours (keep volume < 500ml)

15. Use stress ulcer prophylaxis for at least 4 weeks.

16. If not intubated, consult Dysphagia Team and order swallow study in acute SCI patients with cervical spinal cord injury or halo fixation (Use early enteral nutritional support if patient cannot take PO.

17. Bowel program: Provide appropriate fluids. Bowel care needs to be scheduled at the same time of the day at least daily or BID. Schedule ingestion of food or liquids approximately 30 min prior to bowel care (gastrocolic response). Use a water-soluble lubricant with rectal digital stimulation, manual evacuation and suppository insertion; may need to use lidocaine gel for patients with autonomic dysreflexia. Empty bladder before bowel care. Place patient in upright or side lying position for bowel care, if able.

18. Reflexic Bowel: Manual evacuation as needed until rectum free of stool that could interfere with suppository insertion. Insert Bisacodyl suppository and wait 5-15 min for stimulant to work. Start and repeat rectal digital stimulation every 5-10 min until all stool has passed

19. Areflexic/ spinal shock. Manual evacuation as needed until rectum free of stool. Start and repeat rectal digital stimulation every 5-10 min and manual evacuation until all stool has passed. Patient to use Valsalva if able; perform transabdominal colonic massage in clockwise manner to stimulate peristalsis and propel stool

20. Medications: Step 1: Miralax 17g po/per tube daily as well as Senna 2 tabs po/per tube qhs; for reflexic bowel, order Bisacodyl suppositories scheduled BID to be used with rectal digital stimulation. Monitor effect for 3-5 cycles.

21. Medications Step 2: If Step 1 not successful or adynamic ileus, add Reglan 10mg po/per tube/ IV QID. Do not discontinue step 1.

22. Bowel Care is completed when: a) Stool flow has stopped or b) Rectum is empty or c) no further stool comes out after two rectal digital stimulation at least 10 min apart or d) Mucus is coming out without stool or e) Tightening of internal anal sphincter occurs

References:

(2008). Early acute management n adults with spinal cord injury A clinical practice guideline for health-care professionals. The Journal of Spinal Cord Medicine, 31(4), 408-479.doi:10.1043/1079-0268-31.4.408

(2006). Bladder management for adults with spinal cord injury. Journal of Spinal Cord Medicine, 29(5), 527-573

Drassioukov, A., Eng, J., laxton, G., Sakakibara, B., Shum, S. (2010). Neurogenic bowel management after spinal cord injury: a systematic review of the evidence. Spinal Cord, 48(10), 718-733.doi:10.1038/sc.2010.14

http://www.surgicalcriticalcare.net/Guidelines/Acute%20Spinal%20Cord%20Injury%20Guideline%202012.pdf