Spinal Cord Injuries in Critical Care

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Spinal Cord Injuries in Critical Care

• How do you manage?

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INTRODUCTION

• Almost 50 of all patients with acute traumatic
  spinal cord injury (SCI) are admitted to a
  Critical Care Unit prior to their transfer to a
  specialist SCI Centre.
• Therefore, it is not unreasonable to expect
  critical care practitioners to maintain an
  appropriate awareness of the specific care needs
  of SCI patients admitted for critical care.

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Do I know what we do?

• Do I understand why do we do it?
• Should we do it differently?
• Should we do it for different reasons?

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Critical Care is Rehabilitation

• Rehabilitation is a continuous process,
• beginning at the moment of injury, and is an
• integral part of Critical Care.
• If Critical Care and Rehabilitative Care are
• not combined, people with SCI are subject to
• serious clinical and economic consequences
• that could otherwise have been prevented.
• (Oakes 1990)

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THE CHALLENGE

• Acute SCI patients are most at risk of developing
  preventable complications when admitted outside
  of SCI Centres.
• Critical Illness is the commonest reason for
  delayed transfer to a specialist centre.
• Pre-transfer complications increase length of
  stay, care costs and long-term quality of life
  for the SCI person.
• Many unplanned post-admission transfers of SCI
  patients to Critical Care are avoidable

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EARLY COMPLICATIONS

• Secondary neurological deterioration
• Pressure ulcers leading to sepsis
• HCAIs VAPs
• Pulmonary oedema (overinfusion)
• Renal impairment (diuretic use)
• VTE
• Gastric bleeding
• Colorectal dysfunctional morbidity / necrosis
• Joint contractures
• Anxiety, Pain, Depression
• Increased Dependency

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CRITICAL CARE ISSUES 2000

• Understanding spinal shock
• Clearing the cervical spine
• The use of cervical collars
• Steroid therapy
• Turning/positioning patients
• Head-tilting for SCI patients
• Thromboprophylaxis
• Gastric protection
• Enteral feeding
• Bowel management
• Patient transfer guidelines
• The SCI-LINK scheme
• www.spinal.co.uk/on-lineshop (With thanks to the
  SCI-LINK Critical Care Forum)

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Do I know what we do?

• Do I understand why do we do it?

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SPINAL SHOCK

• Within traumatic SCI, we need to remember that
• Hypotension
• Bradycardia
• Oliguria
• Poikilothermia
• are normal only for paralysed patients with
  complete lesions above T6
• We must remember to treat the dynamic trend, not
  the value of these observations

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CLEARING THE SPINE

• Demands a rigorous process involving
• Accident History
• Mechanism of Injury
• Clinical Examination
• Radiological Interpretation
• Documentation of clearance by authorised staff
• 3 Scenarios following diagnosis
• Actual SCI (Neurological impairment)
• Potential SCI (Orthopaedic spinal injury)
• Uncleared SCI (Unconscious / Multi-trauma)

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CERVICAL COLLARS

• Raised ICP
• Limited evidence to suggest any risk if properly
  selected, sized and fitted
• Range of collars available Aspen model
  preferred
• Significant ICP is gt20 (Neuro consensus)
• Pressure sores
• Limited incidence if properly selected, sized and
  fitted
• Range of collars available Aspen preferred for
  extended use
• May be loosened or removed between turning if
  appropriate to clinical scenario
• Person ordering removal must be a) authorised
  and b) must document decision in patient notes
  before removal with reference to criteria
  evidence used to inform clearance.

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STEROID THERAPY

• There is NO credible clinical evidence supporting
  the ROUTINE use of high-dose steroids in human
  traumatic SCI
• Inappropriate use of steroids increases risk of
  systemic complications, extending time in ICU by
  an average 21 days
• All steroid use should be discussed with
  specialist centre staff first

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SURGICAL PRINCIPLES (Bedbrook. 1985)

• Surgical judgement or surgical balance is of
  much greater importance than surgical technique.
  The advantages or disadvantages of any particular
  method of acute management of spinal injuries
  must be considered before a particular programme
  of management is laid down to suit the
  individual, as well as the individuals
  fractures.
• This implies informed consent must be satisfied
  before operation including notation of treatment
  options offered to patient / next-of-kin
  

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AVOIDABLE ADMISSIONSA Critical Care Tale of Two
Hospitals

• ST ELSEWHERES
• Admits 11 SCI patients
• 6 were operated on 2-14 days after admission and
  all after prior discussion with SCI Centre
• 2 patients were already in ITU and 2 ward-based
  patients underwent pre-planned 48-hour admission
  to ITU
• These 4 patients totalled 70 bed nights between
  them

• ST ALLSORTS
• Admits 13 SCI patients
• 11 are operated on within 24 hours of admission
  and all before referral to SCI Centre
• 3 patients already in ITU but 3 HDU and 5 ward
  patients required unplanned ITU admission
• These 11 patients totalled 379 ITU bed nights
  between them

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TURNING AND HANDLING

• 2-4 hourly turning is recommended to prevent
  fluid stasis as well as pressure relief
• Manual turning is staff intensive but mechanical
  turning beds are available
• Never use dynamic pressure relieving mattresses
  for acute SCI patients
• Spinal logrolling should be familiar to CCU staff
• Failure to implement regular turning increases
  risk of multiple complications of bedrest
• Flat-lifter scoop stretchers are also available
  for transfers

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REALITY BITES

• Despite requests from SCI Centre team, a 22
  year-old male paraplegic patient was not turned
  during first 10 days of his ward admission to
  hospital for the following reasons quoted in
  notes
• lack of staff
• fear of further compromising spinal cord
• unnecessary because he is now on a dynamic
  pressure relieving mattress
• He subsequently developed hydrostatic pneumonia
  (requiring ITU admission intubation and
  ventilation for 21 days) and 3 x Grade 3 pressure
  ulcers requiring surgical repair (extending his
  stay in the SCI Centre by 90 days).

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HEAD-TILTING

• All requests to raise patients head / tilt bed
  should be referred to SCI Centre staff
• Refer to ICS ventilation care bundle
• Preserving brain takes priority over protecting
  spinal cord
• Start with 10-15 degrees, increase slowly
• Do not exceed 30 degrees head-up
• Keep collar in situ if possible

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THROMBOPROPHYLAXIS

• Anticoagulation and full-length TED / PCD
  supported by BD physiotherapy exercise of
  paralysed limbs must commence within 24 hours of
  injury exceptions must be documented with
  rationale
• Thromboembolism is silent but usually preceded by
  pyrexia, SVT or bizarre behaviour

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GASTRIC PROTECTION

• 10 of post-injury SCI deaths due to gastric
  bleeding
• Chemical prophylaxis must commence within 24
  hours of admission
• And continue until transfer to SCI Centre

Question How do you diagnose A cute abdomen
in a SCI patient?
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ENTERAL FEEDING

• All SCI patients present with loss of peristalsis
  as part of spinal shock
• Usually lasts 2-5 days
• Keep patient Nil enterally for first 48 hours,
  then review (British Dietetic Association 2007)
• Give TPN during this time if nutritionally
  compromised
• Paralytic ileus leads to splinting of diaphragm,
  gastric reflux and necrotising bowel distension,
  usually requiring surgical intervention

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BOWEL MANAGEMENT

• All SCI patients present with neurogenic bowel
  dysfunction
• Most require digital bowel procedures
• Digital removal of faeces is a safe and
  legitimate technique for a patient with a
  flaccid bowel
• Bowel distension in patients with lesions above
  T6 can trigger autonomic dysreflexia
• Failure to provide appropriate bowel care may
  constitute clinical negligence (RCN/NPSA/ACA)

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New MASCIP Publicationwww.mascip.co.uk
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PATIENT TRANSFER

• National Training for Transfer programme
  includes patient with actual or potential SCI
• Must liaise with SCI Centre
• Fit for Transfer criteria must be met
• Appropriate mode of transport
• Provide TOD and ETA
• Spinal protection as agreed
• Provision of an informed escort
• ALL notes, images and test results
• Inform centre of any change in condition en route
  

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SUPPORTING PRE-TRANSFER CARE ENVIRONMENTS

• SCI Centre liaison information via telephone,
  fax, e-mail or websites
• SCI Centre outreach for serious delays to
  transfer, centre staff may visit CCU to advise or
  teach care
• SCI-LINK a scheme to train and support SCI
  Link-Workers within local hospitals
• www.mascip.co.uk
• Peer Support SIA outreach scheme for patients
  and families
• www.spinal.co.uk

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CRITICAL CARE NEEDS

• Common practices between CCUs
• (The SCI Integrated Care Pathway)
• Informed underpinning knowledge
• (Why we do what we do in-house education)
• Core skills and competencies
• SCI Link-Workers / Skills for Health
• Confidence in our own abilities
• Auditable performance standards

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Do I know what we do?

• Do I now understand why we do it?
• Should we do it differently?
• Should we do it for different reasons?
• Do we have a care pathway?

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What if I dont work in Critical Care?

• Do I understand what we do?
• Should we do it differently?
• Should we do it for different reasons?
• Do we have a care pathway for our clinical area?

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• www.mascip.co.uk
• www.spinal.co.uk
• www.bascis.pwp.blueyonder.co.uk
• www.spinal-research.org