Management of Spinal Cord Injury (in Cri5cal Care by an Anaesthe5st)

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1 Management of Spinal Cord Injury (in Cri5cal Care by an Anaesthe5st) Dr Ma& Wiles Consultant in Neuroanaesthesia & Neurocri5cal Care Sheffield Teaching Hospitals NHS Founda5on h&p://sthjournalclub.wordpress.com/

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3 Objec5ves Describe the physiological basis, and evidence for, the treatment strategies in the spine cord injured pa5ent, including: Immobilisa5on Steroids Blood pressure op5misa5on Surgery

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5 Dürer s Rhinoceros

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7 Epidemiology of SCI Incidence per million per annum cf TBI 4000 per million 70-80% occur in males

8 Epidemiology Year Number Median age % aged > 50 years Trauma5c Coma Data Bank UK Four Centre Study EBIC Core Data Survey Ro&erdam Cohort Study Austrian Severe TBI Study (mean) 45 TARN Review (mean) Not reported Italian TBI Study RAIN Study (UK) Not reported

9 Epidemiology of SCI Incidence by loca5on Cervical 75% Thoracic 10% Lumbar 10% Incidence of fractures with SCI Cervical 40-50% Thoracic >95% Lumbar > 85%

10 Case History 21 year motorcyclist, RTC vs car at 50 mph GCS E 1 V 1 M 4 Isolated head injury Transferred to regional neurosurgical unit for medical management

11 Airway & Cervical Spine Cervical spine 5% & Spinal cord 2.5% Triggers for intuba5on: Inability to maintain and protect own airway regardless of conscious level Inability to maintain adequate oxygena5on with less invasive manoeuvres (PaO 2 < 13kPa) Inability to maintain normocapnia (spontaneous PaCO 2 <4.0 kpa or > 6.0kPa) GCS 8 Pa5ents undergoing transfer with: Deteriora5ng conscious level ( 2 points on motor scale) Significant facial injuries Seizures.

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13 Manual In- line Stabilisa5on Origin uncertain ATLS guidance 1984 Data from cadaveric studies, healthy volunteers and case series (n=96) Direct laryngoscopy/intuba5on cause less cervical movement than a jaw thrust Several studies suggest MILS has no effect on cervical segment movement Method Grade 1 Grade II Grade III Op5mal posi5oning MILS

14 Cervical Collars Sundstrøm et al. Journal of Neurotrauma 2014 Most spinal injuries are stable; those that are unstable have already caused irreversible damage Collars do not immobilise the cervical spine Exaggerated rate of secondary SCI without collars Numerous associated complica5ons Authors suggest: Spinal board with head blocks & straps Collars only for difficult extrica5on Unconscious, nonintubated trauma pa5ents should be transported in modified leu lateral

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16 Why bother? Clearing the Spine Avoidance of skin damage secondary to collars (6-67%) Ulcera5on Sepsis 30 degree head- up 5lt to reduce pneumonia Exacerba5on of raised ICP Increased demands on nursing care Exacerba5on of agita5on especially in TBI

17 Clearing the Spine 7 missed injuries of which 3 unstable Sensi5vity/Specificity of CT >99.9% (cf NEXUS 99%) - ve LR < 0.001% 1 in every 4776 pa5ents have missed injury

18 (My) Rules for Clearing the Spine HRCT CT of C- spine (1-2 mm slices) C0 T2 (but T4 be&er) Reported by consultant MSK/neuroradiologist Discussed with spinal/neurosurgical consultant [Consider AP/lateral C- spine radiographs] CT reconstruc5ons of thoracolumbar spine AP/Lateral radiographs thoracolumbar views NB. Semi- rigid collar (Aspen/Philadelphia) in interim

19 Neurological Deteriora5on auer Surgery Due to prolonged deforma5on and/or hypotension Hyperflexion worse than hyperextension Both are unlikely during DL AFOI may not be safer Several claims in US Closed Claims Database 5% pa5ents with SCI will deteriorate Early (24 h) Later (1-7 days) Late (weeks [post- trauma5c ascending myelopathy])

20 Steroids for Acute SCI Bracken MB; Cochrane Database 2012

21 NASCIS II Design Mul5centre, prospec5ve, randomised, double- blind trial. PaHents 487 pa5ents with acute spinal cord injury (95% follow up) Exclusions Injuries below L1, children RandomisaHon Treatment 1: Methlyprednisolone 30 mg kg - 1 bolus, then 5.4 mg kg - 1 h - 1 for 23 hours Treatment 2: Naloxone 5.4 mg kg - 1 bolus, then 4.5 mg kg - 1 h - 1 for 23 hours Treatment 3: Placebo

22 NASCIS II Assessment Motor scale (0-5) in 14 muscle groups (total 70) Sensory (Pin prick & touch) in 29 dermatomes (total 58) (Author s) Results Pa5ents receiving steroids within 8 h had a sta5s5cally significant improvement of 5 points on the motor score at 6 months and 1 year (P=0.03) Safety Wound infec5on & PE doubled in steroid group (NS)

23 NASCIS II All +ve results are from post hoc analyses Time cut off (8 h) is arbitrary 78 discrete post hoc tests 60 t- tests for neurological outcomes

24 Timing of Surgery

25 Correct hypotension (SBP <90mmHg) ASAP (III) Target MAP mmhg for 7 days post injury (III) Compared to historical controls >50% with cervical injuries will require vasopressors Complica5ons common in first 7 days post injury Hypotension, bradycardia Ven5latory failure on average 4.5 days post injury Intuba5on rates: C5 100% cf 79% C6

26 Breathing 1. Fa5gue of innervated muscles 2. Chest trauma 3. Ascension of the spinal lesion 4. Retained secre5ons 5. Abdominal distension splin5ng diaphragm Close observa5on Physiotherapy plus humidified oxygen Early tracheostomy

27 Circula5on 1. Spinal shock 2. Coexis5ng (missed) trauma5c injuries If lesion > T6, may need vasopressor support Cau5on with excessive fluids Target MAP > 80 mmhg? Role of rela5ve hypercarbia

28 General ICU Care Normoglycaemia <10 mmol/l associated with improved outcome Feeding Enteral ideally, within 72 hours, full rate by 1/52 VTE prophylaxis 15-20% risk of VTE; IPC then LMWH auer 72 hours Stress ulcer prophylaxis 10% risk of stress ulcers Chest physiotherapy 70% pneumonia rate Pressure area/eye care Specialised ma&resses or beds Removal of hard collars

29 Summary Avoid hypotension & hypoxia Hypotension in SCI is bleeding un5l proved otherwise Trust no- one, believe nothing, give oxygen There is no place for steroid therapy Much of the best care is suppor5ve & SHO work LMWH Stress ulcer prophylaxis Aperients Surgical 5ming is s5ll uncertain

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