CRITICAL CARE OF
SPINAL CORD INJURY
Dr. Amr EL-Said
Professor of Anaesthesia
& Intensive Care
Faculty of Medicine
Ain Shams University
Case Presentation
26-year-old male with unstable
cervical fracture following motor
vehicle crash is placed in halo
for immobilization and is admitted to ICU. Few
hours later, he develops acute hypoxemic
respiratory failure that improves significantly with
noninvasive positive pressure ventilation.
Halo Brace
Spinal Cord Injury
It can cause myelopathy or damage
to nerve roots or myelinated fiber
tracts that carry signals to & from
brain. This injury could also damage
grey matter in central part of cord,
causing segmental losses of interneurons
& motor neurons.
Epidemiology
• In the United States

12,000 cases/year
• In China

60,000 cases/year
• Male predominance

4:1
• Average age

38 years old
Classification
American Spinal Injury Association &
International Spinal Cord Injury Classification System
• A   "complete" spinal cord injury, no motor or
•
•
•
•
sensory function preserved in sacral segments S4-S5.
B   "incomplete" spinal cord injury, sensory but not
motor function preserved below neurological level & includes
sacral segments S4-S5.
C   "incomplete" spinal cord injury, motor function
preserved below neurological level with more than half of
key muscles below neurological level have muscle grade < 3.
D   "incomplete" spinal cord injury, motor function
preserved below neurological level with at least half of key
muscles below neurological level have muscle grade ≥ 3.
E   "normal“, motor & sensory scores are normal.
Segmental Spinal Cord Level & Function
LEVEL
FUNCTION
LEVEL
FUNCTION
C1-C6
Neck flexors
L1, L2, L3,
L4
Thigh flexion
C1-T1
Neck extensors
L2, L3, L4
Thigh adduction
C3, C4, C5
Supply diaphragm (mostly C4)
L4, L5, S1
Thigh abduction
C5, C6
Shoulder movement, raise arm
(deltoid); flexion of elbow
(biceps); C6 externally
rotates arm (supinates)
L5, S1, S2
Extension of leg at hip
(gluteus maximus)
C6, C7
Extends elbow & wrist
(triceps & wrist extensors);
pronates wrist
L2, L3, L4
Extension of leg at knee
(quadriceps femoris)
C7, T1
Flexes wrist, Supply small
muscles of the hand
L4, L5, S1,
S2
Flexion of leg at knee
(hamstrings)
T1 –T6
Intercostals & trunk above
the waist
L4, L5, S1
Dorsiflexion of foot (tibialis
anterior); extension of toes
T7-L1
Abdominal muscles
L5, S1, S2
Plantar flexion of foot;
flexion of toes
Complications
• BP changes - can be extreme (autonomic hyperreflexia)
• Complications of immobility:
•
•
•
•
•
•
•
•
•
•
•
•
–
–
–
–
Deep vein thrombosis
Pulmonary infections
Skin breakdown
Contractures
 risk of injury to numb areas of body
 risk of kidney damage
 risk of Urinary tract infections
Loss of bladder control
Loss of bowel control
Loss of sensation
Loss of sexual functioning (male impotence)
Muscle spasticity
Pain
Paralysis of breathing muscles
Paralysis (paraplegia, quadriplegia)
Shock
Causes
• Trauma (automobile crashs, falls, gunshots, diving accidents,
war injuries)
• Tumor (meningiomas, ependymomas, astrocytomas,
metastatic cancer)
• Ischemia resulting from occlusion of spinal BV (dissecting
aortic aneurysms, emboli, arteriosclerosis)
• Developmental disorders (spina bifida, meningomyelocoele)
• Neurodegenerative diseases (Friedreich’s ataxia,
spinocerebellar ataxia)
• Demyelinative diseases (Multiple Sclerosis)
• Transverse myelitis (resulting from stroke, inflammation)
• Vascular malformations (AVM, dural arteriovenous fistula
[AVF], spinal hemangioma, cavernous angioma & aneurysm)
Protocol of Management
1. Initial Management & Evaluation
• “A” “B”
Immobilize cervical spine, Protect airway & ensure
adequate oxygenation & ventilation.
Two-person oral intubation with in-line cervical spine traction.
Do not electively place too-small tube.
Serial ABG to assess ventilation and oxygenation.
• “C”
Stabilize blood pressure.
Resuscitation with crystalloid, red cells and colloid to stabilize SBP to
100-110 mm Hg.
Other sources of potential hemorrhagic shock must also be ruled out.
If patient is adequately resuscitated and remains hypotensive, dopamine
infusion should be initiated.
Insert nasogastric or orogastric tube.
Insert Foley catheter if there are no signs of genitourinary trauma.
• “D”
Perform baseline neurological assessment.
```Other CNS injuries should be ruled out.
Cervical spine (AP & lateral views) & supine chest x-ray.
Abdominal assessment (CT scan, peritoneal lavage, or FAST ultrasound).
Protocol of Management
2. Methylprednisolone Bolus & Infusion
•
•
•
Steroids should not be given to patients with:
Only spinal cord injury of nerve root or cauda equina.
Gunshot or penetrating injury to spine.
Life threatening morbidity.
STEROIDs MUST ONLY BE GIVEN WITHIN 8
HOURS OF INJURY
Dose: 30 mg/kg administered as IV bolus over 15
minutes,45 minute pause; then 23 hour continuous
infusion of 5.4 mg/kg/hr.
Protocol of Management
3. Radiological Diagnosis & Assessment
• CT scan or MRI of spine may show
location & extent of damage
& reveal problems (hematomas).
• Myelogram may be necessary
in rare cases.
• Somatosensory evoked potential
(SSEP) testing.
• Spine x-rays may show fracture
or damage to bones of spine.
Protocol of Management
4. Surgical Stabilization
• Rapid alignment of spine to normal anatomic position.
Follow up x-ray evaluation to confirm adequate
alignment.
If neurosurgical stabilization is postponed, halo
traction is recommended.
• If spinal cord compression is caused by mass (such as
hematoma or bony fragment), surgery may be necessary
(decompression laminectomy).
Protocol of Management
5. Cardiovascular Support
• CVP & arterial line for monitoring.
• Adequate volume resuscitation.
• Patients may require vasoactive agents (dopamine or
epinephrine) to maintain SBP > 100 mm Hg.
• Patients may also develop bradycardia.
Attempt to avoid vagal maneuvers.
Unless patient becomes hypotensive with bradycardic
episodes, there is no indication for ttt.
If bradycardia is associated with hypotension, bolus of
atropine, 0.5 mg IV, to be repeated at 0.5 mg
increments up to total of 2 mgs.
Temporary cardiac pacing is rarely required in these
patients.
Vasoactive Agents
Agent
Common Dosage
Ranges
Comments
Dopamine
(µg/kg/min)
1–10
Has primarily β-adrenergic effects at low doses &
primarily α-adrenergic effects at higher doses; a
commonly used agent in SCI
Dobutamine
(µg/kg/min)
5–15
Most prominent effect is augmentation of cardiac
performance but may lower systemic blood pressure
so generally less useful agent in SCI
Epinephrine
(µg/min)
1–8
Norepinephrine
(µg/min)
Phenylephrine
(µg/min)
Both α- and β-adrenergic effects, may promote
arrhythmias
1–20
Has some β-adrenergic but predominately α
adrenergic effects; a useful agent for BP support,
especially in cervical and high thoracic SCI
10–100
Exclusively α–adrenergic agent; should be used with
caution in cervical SCI because of potential for
reflex bradycardia
Protocol of Management
6. Respiratory Support
• 1/3 of cervical SCI patients will require intubation.
• Any intervention before neck is stable or fixed
requires cervical in-line stabilization.
• Work of breathing can be gauged by assessing patient
comfort, trends in RR, changes in ability and quality of
speech, and monitoring for increasing PaCO2.
• Spontaneous ventilatory parameters (TV, VC, maximum
inspiratory effort) are monitored with
FVC < 12–15 ml/kg  for assisted ventilation.
• Abdominal binding and nursing patients supine can
offset decline in pulmonary function due to flaccid
abdominal muscles.
Protocol of Management
6. Respiratory Support
• Frequent turning of patients is necessary to avoid
pressure sore formation, to maintain adequate
suctioning and to prevent atelectasis.
• Patients who remain in cervical traction and are not
able to be sat up may benefit from ROTO BED to
improve pulmonary toilet.
• Bronchoscopy.
ROTO Bed
Roto- Bed
Protocol of Management
6. Respiratory Support
• Physiotherapy reduces accumulation of secretions and
hence load placed on fatiguing muscles.
• Meticulous pulmonary toilet.
• Aerosol treatments (alupent, albuteral) may be helpful.
• Nebulized N-acetylcysteine, oral carbocysteine can
help to loosen and clear secretions.
• Non-invasive ventilation (CPAP, Bilevel or pressure
assisted non-invasive ventilation) can increase minute
ventilation and FRC, improve compliance and reduce
work of breathing.
• Mechanical ventilation is preferred when there is
associated lung injury (contusion or underlying
infection).
Protocol of Management
7. Gastrointestinal
• Decompression with orogastric or nasogastric tube.
• Early feeding and prokinetic agents (metoclopramide).
• Immediately GI prophylaxis with H2-antagonists,
Proton pump inhibitors.
• Bowel regime should be started on day 1 of admission
with regular use of laxatives (colace, orally and
dulcolax, per rectum daily).
8. Genito-Urinary
• Foley Catheter is placed at time of admission and
should be continued until patient stability permits.
Protocol of Management
9. Metabolic
• Early stabilization and early physical therapy
consultation to increase mobilization may decrease
immobilization complications i.e. hypercalcemia.
• Temperature regulation.
• Hyperglycemia

Good glycemic contol.
10. Extremities
•
•
•
•
DVT prophylaxis should be initiated on day 1:
Thigh high Ted hose, pneumatic compression.
Anticoagulants (heparin, low molecular weight heparin,
or warfarin).
Physical therapy consultation for range of motion
exercises and mobilization.
femoral IV access should be avoided.
Protocol of Management
11. Pain Management
• Acute pain due to Pressure sores (including occipital
sores), frequent turning and inability to scratch.
• Chronic neuropathic pain (Hyperesthesia and allodynia).
It is often opioid-resistant.
Gabapentin and amitriptyline are effective but need to
be commenced as early as possible.
Ketamine may be beneficial.
12. Nutrition
• Nutritional support should be started as soon as gastric
residuals indicate resolution of ileus.
• Enteral feeding is preferred & switch from parenteral
to enteral feeding should occur as soon as feasible.
Protocol of Management
13. Skin
• All pressure areas should be padded.
• Patient should be turned every two hours.
• Spasticity is common and Contractures can result from
spasticity.
Conservative measures such as stretches, splinting, and
casting.
good pain control.
Medication is often necessary; baclofen, dantrolene,
and gabapentin.
More invasive treatments; botulinum injections and
intrathecal baclofen.
Severe contractures may need to be released
Protocol of Management
14. Psycho-Social
• Depression, anxiety and confusion.
• Psychiatry and Social Work
consults may be necessary.
• Rehabilitation.
15. General
• Avoid full bladders, constipation, or painful sensations.
1.
2.
3.
4.
The decision is made to intubate this patient due
to gradual worsening although it is not emergent
at this time. Which of following is BEST option
for airway management?
Obtain expert consultation for flexible fiberoptic
intubation.
Rapid sequence intubation with an orotracheal
tube.
Immediate surgical cricothyrotomy.
Needle cricothyrotomy.
1.
2.
3.
4.
5.
Pharmacological agents useful for endotracheal
intubation immediately after injury include
Etomidate 0.3-0.4 mg/kg as single bolus.
Succinylcholine 1.0-1.5 mg/kg as single bolus.
Midazolam 1 mg bolus every several minutes.
repeated as necessary
Fentanyl 25-100 µg bolus every several minutes
repeated as necessary.
All of above.
1.
2.
3.
4.
Patient has complete spinal cord transection
above C3. which one of following is MOST
APPROPRIATE setting for initiation of mechanical
ventilation?
FiO2 1.0 with SIMV, TV 6-8 ml/kg, RR 10-12/min
& PEEP 5 cm H2O.
FiO2 1.0 with PCV, set at level of 40 cm H2O, RR
10-12/min & CPAP of 10 cm H2O.
FiO2 0.3 with SIMV, TV 12-15 ml/kg, RR 1518/min & PEEP 5 cm H2O
FiO2 0.3 with PSV, set at level of 20 cm H2O, &
CPAP of 5 cm H2O
1.
2.
3.
4.
Which of following statements regarding noninvasive positive-pressure ventilation (NPPV) is
MOST CORRECT?
Less patient monitoring is required with NPPV
than invasive mechanical ventilation.
NPPV is not recommended for patients with
hemodynamic instability.
NPPV is rarely useful in treatment of respiratory
failure.
The need for specialized machines and masks
limits the utility of NPPV.
1.
2.
3.
4.
Patient presents to ICU with BP of 84/42 mm Hg,
HR of 110/min & flaccid paralysis of four
extremities. Which one of following is MOST
APPROPRIATE initial treatment?
Crystalloid volume resuscitation.
Immediate intubation & institution of mechanical
ventilation.
Initiation of vasopressors to achieve SBP>150 mm
Hg.
External transthoracic cardiac pacing if HR drops
below 75 beats/min.
1.
2.
3.
4.
Which one of following dose ranges of dopamine is
LIKELY to maximize inotropic effect while
minimizing vasopressor effect?
1 – 2 µg/kg/min
4 – 8 µg/kg/min
10 – 15 µg/kg/min
15 – 20 µg/kg/min
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Lin VWH, Cardenas DD, Cutter NC, Frost FS & Hammond MC (2002). Spinal Cord
Medicine: Principles and Practice. Demos Medical Publishing.
Kirshblum S, Campagnolo D & Delisa J (2001). Spinal Cord Medicine. Lippincott
Williams & Wilkins.
Qiu J (2009). "China Spinal Cord Injury Network: changes from within". Lancet Neurol
8 (7): 606–7.
Ron Walls MD, John J, Ratey MD, Robert I & Simon MD (2009). Rosen's
Emergency Medicine: Expert Consult Premium Edition - Enhanced Online Features and
Print (Rosen's Emergency Medicine: Concepts & Clinical Practice (2v.)). St. Louis: Mosby.
Klebin Phil (2007). Sexual Function of Men with Spinal Cord Injury.
Phillips BJ (2004). Spinal Cord Injuries: A Suggested Approach. The Internet Journal
of Emergency Medicine. Volume 2, Number 1.
Ball PA (2001). Critical Care of Spinal Cord Injury. SPINE. Volume 26, Number 24S, pp
S27–S30.
Baydur A, Adkins RH & Milic-Emili J (2001). Lung mechanics in individuals with spinal
cord injury: effects of level of injury and posture. J Appl Physiol; 90:405–11.
Denton M & McKinlay J (2009). Cervical Cord Injury and Critical Care. Cont Edu
Anaesth Crit Care & Pain; 9(3):82-86. Oxford University Press.
Brown R, DiMarco AF, Hoit JD & Garshick E (2006). Respiratory dysfunction and
management in spinal cord injury. Respir Care; 51:853–70.
Winslow C, Bode RK, Felten D, et al (2002). The impact of respiratory complications
upon length of stay and hospital costs in acute cervical spine injury. Chest; 121:1548–54.
Bach JR, Hunt D & Horton JA (2002). Traumatic tetraplegia: noninvasive
management in the acute setting. Am J Phys Med Rehabil; 81:792–7.