Optimizing ED Management of Spinal Cord Injury: A Diagnosis

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Optimizing ED Management of Spinal Cord InjuryA
Diagnosis Treatment Protocol
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Scott Weingart, MDAssistant ProfessorDirector
of ED Critical CareElmhurst Hospital
CenterMount Sinai School of MedicineNew York, NY
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Objectives

• Improve pt outcome in spinal injuries
• Know how to image trauma patients
• Improve treatment of spinal cord injuries
• Improve Emergency Medicine practice

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A Clinical Case
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Get them offof the Board
SCI Procedure
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Protect the Spine from Further Injury
SCI Procedure
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Properly Use Clinical Prediction Rules
SCI Procedure
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8 No midline tenderness 8 No distracting
injury 8 No Neurodeficit 8 No Alcohol or
Drugs 8 No Altered Mental Status 8 No pain
with neck movement   Ann Emerg Med. 1992
Dec21(12)1454-60.
Nexus C-Spine Rule
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NEJM 20033492510-8 and Ann Emerg Med
423395-402.
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Perform Appropriate Screening Studies
SCI Procedure
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8 Plain Films8 CT Scan8 Flexion-Extension8 MRI
Screening Studies
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Confirmed Fracture
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Rule OutOther Injuries
SCI Procedure
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Perform Appropriate Follow-up Studies
SCI Procedure
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Stable or Unstable?
SCI Procedure
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Unstable Fractures
Jefferson Bit Off A Hangmans Thumb Jefferson 
C2 Burst Fx Bifacet Dislocation or Fracture
Odontoid  II-body or III-Lateral masses Any Fx
with dislocation/subluxation Hangmans 
posterior C2 secondary to hyperextension
Teardrop  anterior chip of any vertebrae
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Confirmed Cord Injury
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Administer Steroids based on Hospital Protocol
SCI Procedure
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Solumedrol 30 mg/kg bolusand then 5.4 mg/kg/hr
for23 additional hours if given within 3 hours
of injury or47 hours if given between 3 and 8
hours
Steroids
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Introduce the patient to a Neurosurgeon
SCI Procedure
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Perform a Detailed Spinal Cord Exam
SCI Procedure
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Determine their Level
SCI Procedure
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Determine Complete vs. Incomplete
SCI Procedure
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Important Parts of Testing

• Sacral Sensory Sparing
• Voluntary Anal Sphincter Contraction
• Sensation/Motor below the Level of Injury
• Bulbocavernous Reflex

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Anterior
The First 48 Hours. Spinal Injury Association.
http//www.spinal.co.uk/
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Posterior
The First 48 Hours. Spinal Injury Association.
http//www.spinal.co.uk/
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Hemi-Section
The First 48 Hours. Spinal Injury Association.
http//www.spinal.co.uk/
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Central
The First 48 Hours. Spinal Injury Association.
http//www.spinal.co.uk/
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Maintain Blood Pressure at All Times
SCI Procedure
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Push that MAP
SCI Procedure
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May need fluids, pressors, inotropes, and/or blood
MAP Push
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Beware of theVagus
SCI Procedure
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Be careful when suctioning and intubating.Keep
atropine at bedside
Vagal Precautions
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Intubate Early / Intubate Safely
SCI Procedure
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Patient Outcome

• Received Anterior Posterior Fixation
• Received Tracheostomy
• MAPS maintained for 1 week
• Weaned to Trach Collar
• Intensive OT/PT/Psych Support
• Discharged to Acute Rehab Day 9

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Further Reading

• Guidelines for the Management of Acute Cervical
  Spine and SCI. Neurosurg 200250(3)suppl-1-200
• Valadka AB. Neurotrauma Evidence-Based Answers
  To Common Questions.
• UK Spinal Injuries Association. The First
  48-hours. http//www.spinal.co.uk/

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Questions?? www.ferne.orgferne_at_ferne.orgScot
t Weingart, MDgatsby_at_eudoramail.com817.977.3384
Ferne_2006_aaem_sa_weingart_bic_spine.ppt