The Management of the Patient with an Acute Spinal Cord Injury D. J. Brown

Transcription

1 The Management of the Patient 1 Associate Prof. Director Victorian Spinal Cord Service Austin Health Melbourne, Victoria, Australia 2 3 Continuity of care A prevention C triage / transfer U emergency / ICU T spinal surgery E acute spinal ward Rehabilitation Reviews Outpatient clinics Community nurses Country clinics Long term care and follow up in community Readmission 1

2 People killed on Victorian roads Dec 1981: Dec 1970: Jan 1974: Compulsory Compulsory Rural speed seatbelt wear for seatbelt wear 100km/hr child Radar intro May 1984: Zero 1200 July 1976: alcohol P Random Aug 1983: breath test Red light camera 1990: 1000 Booze bus Mar 1986: Speed camera 800 Nov 1996: Laser speed gun 600 Dec 1993: Mobile radar Triage Large forces Severe injury or death of another victim Head injury or unconsciousness Elderly person or evidence of disease of the spine Other severe injury of the patient Patient complaint of pain in neck or back, of loss of feeling or of paralysis 5 Triage of spinal cord injury Force vs. Strength of vertebral column Large force vs. Young spine Small force vs. Old or diseased spine 6 2

3 Severe Head Injury = spinal cord injury Unconscious Patient 7 Management of the trauma victim To prevent more cord damage Movement Metabolic To prevent complications 8 Accident scene History - of accident - of pain, etc. - of sensation - of movement 9 3

4 Accident scene (2) Examination - Sensation - Motor power - (Reflexes) - Pulse 10 Sacral neurologic examination Sensation Voluntary anal contraction Sacral reflexes 11 Light touch 2 - Normal 1 - Decreased 0 - Nil Pin prick Hyperaesthesia or other abnormal sensations 12 4

5 Sensory level 13 C2/3 C4 C5 C6 C7 C8 T1-2 T4 T7 T10 T12 L1-2 L3 L4 L5 S1 S2 S3/4/5 Neck Upper shoulder and anterior upper chest Lateral aspect of shoulder Radial forearm, thumb and index finger Middle finger, median strip of palm and back of hand Ring and little finger, ulnar forearm Proximal medial arm and axilla Nipple line Lower costal margin Umbilicus Groin Proximal anterior thigh Anterior knee Anterior lower leg Great toe, medial dorsum of foot Lateral border foot, sole and along Achilles tendon Proximal posterior thigh (narrow central band) Genitals and saddle area Motor grading 0. No movement 1. Flicker or small amount of movement 2. Full range, gravity eliminated 3. Full range against gravity 4. Full range against resistance 5. Normal 14 Motor level 15 C1-3 C4 C5 C6 C7 C8 T1 T2-T12 T7-L1 L2 L3 L4 L5 S1 S2 S2/3/4 Neck muscles Diaphragm, trapezius Deltoid, biceps Extensor carpi radialis Triceps, extensor digitorum Flexor digitorum Hand intrinsics Intercostals Abdominals Ileopsoas, adductors Quadriceps Medial hamstrings, tibialis anterior Lateral hamstrings, tibials posterior, peroneals Extensor digitorum, extensor hallucis, gastrocnemius and soleus Flexor digitorum, flexor hallucis Bladder, lower bowel 5

6 ASIA score A = COMPLETE no sacral sensory or motor function Zone of Partial Preservation B = INCOMPLETE sacral sensory but no motor function C= INCOMPLETE most motor below < 3/5 D= INCOMPLETE most motor below > 3/5 E = NORMAL Key sensory points 16 Reflexes Examination - Sensation - Motor power - (Reflexes) - Pulse 17 Neurologic deterioration 1. Mismanagement 2. Metabolic deterioration 18 6

7 Swimming & Lifesaving, Water Safety for all Australians, 6 th Edition, Royal Life Saving Society - Australia productdetail.asp?id=1089&cat=

8 Reference Gunn BD, Eizenberg N, Silberstein M, McMeeken JM, Tully EA, Stillman BC, Brown DJ and Gutteridge GA; How should an unconscious person with a suspected neck injury be positioned? Prehospital Disaster Med (1995) 33: Adult Child

9 Transport Maintain neutral midline position and use spine board or ambulance trolley 25 Approach Resuscitation Treat multi-trauma Ensure skeletal stability Manage implications of spinal damage

10 Primary hospital Nasogastric tube Intravenous/Central line Indwelling catheter Temperature control Cervical collar Respiratory management 28 Bladder management Prevent overdistension Fluid balance 29 Intravenous access Fluid resuscitation Administration of drugs Administration of fluids 30 10

11 Spinal shock A period of hypoactivity of the spinal cord below the level of injury lasting for hours to weeks after spinal cord injury 31 Spinal shock (2) Features Loss of reflexes Flaccid paralysis of striated muscles Flaccid paralysis of bladder Paralytic ileus Loss of sympathetic tone in high paraplegia and quadriplegia 32 Respiratory complications in spinal shock Flaccid paralysis of intercostal muscles Flaccid paralysis of abdominal muscles 33 11

12 Inspiration Normal Quadriplegia e.g., C4 in spinal shock 1. Diaphragm descends 1. Diaphragm descends 2. Chest expands 2. Intercostals drawn in 3. Air drawn into lungs 3. Small amount of air drawn in 34 Respiratory complications Paralytic ileus Acute gastric dilatation Haemo +/- haemopneumothorax Lung contusion 35 Respiratory past history Smoking Asthma Other respiratory conditions such as bronchiectasis 36 12

13 Cervical and mid thoracic cord lesions Admit to respiratory ICU Physiotherapy Antibiotics Early intubation Ventilation Tracheostomy 37 Paralytic ileus Usually lasts 0-10 days Need nasogastric tube to prevent aspiration of gastric contents into lungs and acute dilatation of stomach 38 Acute abdominal trauma Non SCI Acute SCI Guarding/Rigidity Flaccid paralysis Paralytic ileus Paralytic ileus Pain No pain Beware if relative tachycardia 39 Diagnostic investigation Abdominal CT Peritoneal lavage 13

14 Cord lesion T6 and above Loss of sympathetic tone Vasodilation Hypotension Poikilothermia Unopposed vagal tone on heart brachycardia Leads to cardiovascular instability 40 Cord lesion T6 and above Treatment of severe bradycardia Atropine 300 g 2 hourly to 3mg/day Theophylline 80mg tds Cardiac pacing 41 Radiology CT MRI Adequate plain films Long AP LAT (Including upper T1) Open mouth AP to show C1, C2 Obliques cervical 42 14

15 CT 43 MRI 44 Verterbral column stabilisation Achieve normal alignment Treatment does not improve neurology Options Closed reduction + traction Closed reduction + external function Closed reduction + internal function Reduces down time by 5-7 weeks 45 15

16 DVT prophylaxis Low molecular weight Heparin; e.g., Clexane 40mg S/C daily Calf stimulators 46 Prophylaxis against G.I.T. ulceration H2 antagonist + antacid 47 Skin care 48 16

17 Summary 1. Prevention of further neurologic damage 2. Management of sequelae of cord damage 49 Acknowledgements Thank you to my colleagues and patients with spinal cord injury for their help and support in developing acute spinal cord injury management