Lower Spinal Cord Injury Management Protocol (for SCI without neurogenic shock, T6 and below)

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Lower Spinal Cord Injury Management Protocol (for SCI without neurogenic shock, T6 and below) Neuro Spinal immobilization and log roll orders Additional imaging as needed Brace per spine recommendations Multimodal Pain management Gastrointestinal Bowel regimen: Trauma bowel Regimen: o (Senna +MiraLAX) AND o bisacodyl suppository, qday Nursing order: Administer bowel regimen as ordered; notify provider if no daily BM Musculoskeletal/Integument Begin PROM on admission if stable PT/OT orders after stabilization Early mobility o OOBTC when cleared by Spine o Frequent position changes Podis Boots to prevent foot drop Genitourinary Discontinue Foley per CL 30-15.05 Indwelling Urinary Catheters: Insertion, Maintenance, and Discontinuation If patient unable to void, initiate scheduled I/O catheterization q6h; if UOP>500ml, increase frequency Psych/Dispo Consider psych consult to evaluate patient as depression/anxiety are common after SCI Communicate early with Case Management to determine disposition options Consider PM&R consult

Upper Spinal Cord Injury Management Protocol (In addition to Lower SCI Management Protocol interventions:) Cardiovascular Avoid hypotension Vasopressors for MAP goals as indicated, norepinephrine first line agent If persistent vasopressor requirement: Consider midodrine 5mg q8h, and titrate up to 40mg/day If bradycardic, consider pseudoephedrine and/or glycopyrrolate as alternatives Consider for Intubation: Patients unable to swallow Patients with increasing O2 requirement Patients with atelectasis, or plugging on cxr Paradoxical respiratory pattern Persistent need for frequent suctioning of airway Peek Expiratory Flow <5L Inability to manage secretions Respiratory Respiratory Care Guidelines: Non-intubated SCI patients Early Tracheostomy Protocol/ Respiratory Care Guidelines for Intubated SCI patients Respiratory Care Guidelines for Ventilatory weaning of SCI patients

Early Tracheostomy Protocol/ Respiratory Care Guidelines for Ventilated SCI patients Indications for Early Tracheostomy (2 or more of the following) Guaifenesin 20ml (400mg) q6h x 5 days then prn Albuterol PRN Daily pcxr x 5d then PRN Consider abdominal binder Early mobility: turn q2h, OOB bid C4 and above motor complete injury Early ETT requirement Flail chest Paradoxical respiratory pattern Persistent need for frequent suctioning of airway Peek Expiratory Flow <5L Consider Tracheostomy if: Need for multiple operative interventions Failed extubation Tracheostomy/ ETT in-place Secretion management strategies Initial Ventilator settings: SIMV/PRVC preferred initial mode Heated circuit on ventilator PS to deliver goal TV on spontaneous breaths IPV HIT (Hyper Inflation Therapy) Quad cough Suction PRN Bronchoscopy prn Planned extubation? Consider extended 0/0 SBT Respiratory Care Guidelines for Nonintubated SCI patients

References Beom, T., & Seo, H. (2018). The need for early tracheostomy in patients with traumatic cervical cord injury. Clinics in Orthopedic Surgery 10(20). Berney, S., et al. (2011), The acute respiratory management of cervical spinal cord injury in the first 6 weeks after injury: a systematic review. Spinal Cord 49, 17-29. Branco, B., et al. (2011). Incidence and clinical predictors for tracheostomy after cervical spinal cord injury. J Trauma 70(1), 111-115. Consortium for Spinal Cord Medicine. (2005). Respiratory Management following Spinal Cord Injury: A clinical practice guideline for health-care professionals. J Spinal Cord Medicine, 28, 259-293. Ditunno, J., Cardenas, D., Formal C., & Dalal, K. (2012). Advances in the rehabilitation management of acute spinal cord injury. Handbook of Clinical Neurology, 109(181-194). Fehlings, M., el al. (2017). A clinical practice guideline for the management of acute spinal cord injury: introduction, rationale, and scope. Global Spine Journal 7(3S), 84S-94S. Hadley, M., Walters, B., et al. (2013). Guidelines for the management of acute cervical spine and spinal cord injuries. Neurosurgery. 72 (Supp), S1- S259. Saadeh, Y., et al. (2017). The impact of blood pressure management after spinal cord injury. Neurosurgical Focus. 43(5)E20. Schwartzburger, G. & Stein, D. (2016). Critical Care of Traumatic Cervical Spinal Cord Injuries: Preventing Secondary Injury. Seminars in Neurology, 36(6), 577-585. Yue, J., et al. (2017). Update on critical care for acute spinal cord injury in the setting of polytrauma. Neurosurgical Focus 43(5).

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