Spinal cord injury

 

Acute spinal injury:

Airway

Reasons for difficulty:

·      Retropharyngeal swelling

·      Full stomach, ileus

·      Inability to cough

·      Anterior column injury: neck extension unsafe

·      Posterior column injury: neck flexion unsafe

·      Need traction by surgeon

Respiratory

·      Hypoventilation -> T2RF

·      Atelectasis -> T1RF

·      N.B. swelling -> “rising lesion’’ -> unexpected diaphragm paralysis

Cardiovascular

Spinal shock:

·      Unopposed PSNS

o   Bradycardia (40-50bpm)

o   If relative tachycardia: suspect blood loss

o   Give atropine before suction or intubation

·      Sympathectomy

o   Hypotension (60-80mmHg)

·      Lasts 3 days to 8 weeks (??)

Other

·      Poikilothermia

·      Pressure sores

·      Urinary retention -> IDC

·      Ileus -> NGT

 

Chronic spinal injury:

Airway

·      ±Restricted neck ROM

·      ±Difficult intubation

·      Delayed gastric emptying -> risk of aspiration

Breathing

·      Impaired intercostals ± diaphragm.

·      Restrictive ventilatory deficit. Better supine!

·      Tracheostomy in 20%

·      Obesity/OSA common

Circulation

·      PSNS predominant -> bradyarrhythmias

·      SNS humoral only -> slow response to hypotension

·      Low blood volume

·      Risk of autonomic hyperreflexia

·      Coronary artery disease common

Gastrointestinal

·      Unopposed PSNS -> peptic ulcers

Neuromuscular

·      Upregulated extrajunctional receptors

·      Avoid sux – especially 48 hours to 6 months

General care

·      Temp: impaired thermoregulation

·      Pressure care: insensate + spasticity + ↓muscle + ↓blood flow

·      Bladder: retention common

·      Bowel: constipation, inability to empty

·      VTE: lower limb venous stasis

Pain

·      Chronic pain: somatic vs neuropathic

Psychology

·      Depression

·      Drug misuse

 

Autonomic dysreflexia (ADR):

Definition

·      Dysregulated autonomic response to a noxious stimulus below the level of a spinal cord injury

Risk factors

·      High lesion (above T6 = above splanchic)

·      Complete lesion

·      Longstanding lesion (but can occur from 4 days?)

Precipitant

·      Surgical stimulus

·      Pressure injury

·      Bladder distension

·      Bowel distension

Features

·      Hypertension ↑20%

·      Reflex bradycardia (if above)

·      Reflex vasodilatation (above)

·      Symptoms: anxiety, flushing, sweating, headache, blurred vision

Treatment

·      Fix the cause

·      Sympatholysis: opioid, alpha blockade

Prevention

·      Neuraxial

·      Regional

 

Most information from BJA Education:

https://academic.oup.com/bjaed/article/15/3/123/279317

 

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