Presentation on theme: "CRITICAL CARE OF SPINAL CORD INJURY Dr"— Presentation transcript:
1CRITICAL CARE OF SPINAL CORD INJURY Dr CRITICAL CARE OF SPINAL CORD INJURY Dr. Amr EL-Said Professor of Anaesthesia & Intensive Care Faculty of Medicine Ain Shams UniversityImprovement just by overcoming challengesDr. Foudeh & Kamal already discussed some of the challenges of pain management but when it comes in specific to the challenges to the use of opioid.No 1 is the fear of abuse and addiction and Dr. X and Y already addressed this point. I just want to share with you one chart………The second barrier to the use of opioids is the side effects.Slide about safety of Durogesic Vs Morphine.D12 Slides… specially safety.Then another challenge is the short duration of action of most opioids while you need to give them around the clock as Dr. X&Y highlighted.The use TTS is an option but it doesn’t offer you the fast titration and the easy intake of oral tablets.How to sum all these benefits in the same product. Jurnista……
2Case Presentation 26-year-old male with unstable cervical fracture following motorvehicle crash is placed in halofor immobilization and is admitted to ICU. Few hours later, he develops acute hypoxemic respiratory failure that improves significantly with noninvasive positive pressure ventilation.
4Spinal Cord Injury It can cause myelopathy or damage to nerve roots or myelinated fibertracts that carry signals to & frombrain. This injury could also damagegrey matter in central part of cord,causing segmental losses of interneurons& motor neurons.
5Epidemiology In the United States 12,000 cases/year In China 60,000 cases/yearMale predominance 4:1Average age 38 years old
6Classification American Spinal Injury Association & International Spinal Cord Injury Classification SystemA "complete" spinal cord injury, no motor or sensory function preserved in sacral segments S4-S5.B "incomplete" spinal cord injury, sensory but not motor function preserved below neurological level & includes sacral segments S4-S5.C "incomplete" spinal cord injury, motor function preserved below neurological level with more than half of key muscles below neurological level have muscle grade < 3.D "incomplete" spinal cord injury, motor function preserved below neurological level with at least half of key muscles below neurological level have muscle grade ≥ 3.E "normal“, motor & sensory scores are normal.
7Segmental Spinal Cord Level & Function C1-C6Neck flexorsL1, L2, L3, L4Thigh flexionC1-T1Neck extensorsL2, L3, L4Thigh adductionC3, C4, C5Supply diaphragm (mostly C4)L4, L5, S1Thigh abductionC5, C6Shoulder movement, raise arm (deltoid); flexion of elbow (biceps); C6 externally rotates arm (supinates)L5, S1, S2Extension of leg at hip (gluteus maximus)C6, C7Extends elbow & wrist (triceps & wrist extensors); pronates wristExtension of leg at knee (quadriceps femoris)C7, T1Flexes wrist, Supply small muscles of the handL4, L5, S1, S2Flexion of leg at knee (hamstrings)T1 –T6Intercostals & trunk above the waistDorsiflexion of foot (tibialis anterior); extension of toesT7-L1Abdominal musclesPlantar flexion of foot; flexion of toes
8Complications Deep vein thrombosis Pulmonary infections Skin breakdown BP changes - can be extreme (autonomic hyperreflexia)Complications of immobility:Deep vein thrombosisPulmonary infectionsSkin breakdownContractures risk of injury to numb areas of body risk of kidney damage risk of Urinary tract infectionsLoss of bladder controlLoss of bowel controlLoss of sensationLoss of sexual functioning (male impotence)Muscle spasticityPainParalysis of breathing musclesParalysis (paraplegia, quadriplegia)Shock
10Protocol of Management 1. Initial Management & Evaluation“A” “B” Immobilize cervical spine, Protect airway & ensure adequate oxygenation & ventilation.Two-person oral intubation with in-line cervical spine traction.Do not electively place too-small tube.Serial ABG to assess ventilation and oxygenation.“C” Stabilize blood pressure.Resuscitation with crystalloid, red cells and colloid to stabilize SBP to mm Hg.Other sources of potential hemorrhagic shock must also be ruled out.If patient is adequately resuscitated and remains hypotensive, dopamine infusion should be initiated.Insert nasogastric or orogastric tube.Insert Foley catheter if there are no signs of genitourinary trauma.“D” Perform baseline neurological assessment.```Other CNS injuries should be ruled out.Cervical spine (AP & lateral views) & supine chest x-ray.Abdominal assessment (CT scan, peritoneal lavage, or FAST ultrasound).
11Protocol of Management 2. Methylprednisolone Bolus & InfusionSteroids should not be given to patients with:Only spinal cord injury of nerve root or cauda equina.Gunshot or penetrating injury to spine.Life threatening morbidity.STEROIDs MUST ONLY BE GIVEN WITHIN 8 HOURS OF INJURYDose: 30 mg/kg administered as IV bolus over 15 minutes,45 minute pause; then 23 hour continuous infusion of 5.4 mg/kg/hr.
12Protocol of Management 3. Radiological Diagnosis & AssessmentCT scan or MRI of spine may showlocation & extent of damage& reveal problems (hematomas).Myelogram may be necessaryin rare cases.Somatosensory evoked potential(SSEP) testing.Spine x-rays may show fractureor damage to bones of spine.
13Protocol of Management 4. Surgical StabilizationRapid alignment of spine to normal anatomic position.Follow up x-ray evaluation to confirm adequate alignment.If neurosurgical stabilization is postponed, halo traction is recommended.If spinal cord compression is caused by mass (such as hematoma or bony fragment), surgery may be necessary (decompression laminectomy).
14Protocol of Management 5. Cardiovascular SupportCVP & arterial line for monitoring.Adequate volume resuscitation.Patients may require vasoactive agents (dopamine or epinephrine) to maintain SBP > 100 mm Hg.Patients may also develop bradycardia.Attempt to avoid vagal maneuvers.Unless patient becomes hypotensive with bradycardic episodes, there is no indication for ttt.If bradycardia is associated with hypotension, bolus of atropine, 0.5 mg IV, to be repeated at 0.5 mg increments up to total of 2 mgs.Temporary cardiac pacing is rarely required in these patients.
15Vasoactive Agents Agent Common Dosage Ranges Comments Dopamine (µg/kg/min)1–10Has primarily β-adrenergic effects at low doses & primarily α-adrenergic effects at higher doses; a commonly used agent in SCIDobutamine5–15Most prominent effect is augmentation of cardiac performance but may lower systemic blood pressure so generally less useful agent in SCIEpinephrine(µg/min)1–8Both α- and β-adrenergic effects, may promote arrhythmiasNorepinephrine1–20Has some β-adrenergic but predominately α adrenergic effects; a useful agent for BP support, especially in cervical and high thoracic SCIPhenylephrine10–100Exclusively α–adrenergic agent; should be used with caution in cervical SCI because of potential for reflex bradycardia
16Protocol of Management 6. Respiratory Support1/3 of cervical SCI patients will require intubation.Any intervention before neck is stable or fixed requires cervical in-line stabilization.Work of breathing can be gauged by assessing patient comfort, trends in RR, changes in ability and quality of speech, and monitoring for increasing PaCO2.Spontaneous ventilatory parameters (TV, VC, maximum inspiratory effort) are monitored withFVC < 12–15 ml/kg for assisted ventilation.Abdominal binding and nursing patients supine can offset decline in pulmonary function due to flaccid abdominal muscles.
17Protocol of Management 6. Respiratory SupportFrequent turning of patients is necessary to avoid pressure sore formation, to maintain adequate suctioning and to prevent atelectasis.Patients who remain in cervical traction and are not able to be sat up may benefit from ROTO BED to improve pulmonary toilet.Bronchoscopy.ROTO Bed
19Protocol of Management 6. Respiratory SupportPhysiotherapy reduces accumulation of secretions and hence load placed on fatiguing muscles.Meticulous pulmonary toilet.Aerosol treatments (alupent, albuteral) may be helpful.Nebulized N-acetylcysteine, oral carbocysteine can help to loosen and clear secretions.Non-invasive ventilation (CPAP, Bilevel or pressure assisted non-invasive ventilation) can increase minute ventilation and FRC, improve compliance and reduce work of breathing.Mechanical ventilation is preferred when there isassociated lung injury (contusion or underlying infection).
20Protocol of Management 7. GastrointestinalDecompression with orogastric or nasogastric tube.Early feeding and prokinetic agents (metoclopramide).Immediately GI prophylaxis with H2-antagonists, Proton pump inhibitors.Bowel regime should be started on day 1 of admission with regular use of laxatives (colace, orally and dulcolax, per rectum daily).8. Genito-UrinaryFoley Catheter is placed at time of admission and should be continued until patient stability permits.
21Protocol of Management 9. MetabolicEarly stabilization and early physical therapy consultation to increase mobilization may decrease immobilization complications i.e. hypercalcemia.Temperature regulation.Hyperglycemia Good glycemic contol.10. ExtremitiesDVT prophylaxis should be initiated on day 1:Thigh high Ted hose, pneumatic compression.Anticoagulants (heparin, low molecular weight heparin, or warfarin).Physical therapy consultation for range of motion exercises and mobilization.femoral IV access should be avoided.
22Protocol of Management 11. Pain ManagementAcute pain due to Pressure sores (including occipital sores), frequent turning and inability to scratch.Chronic neuropathic pain (Hyperesthesia and allodynia).It is often opioid-resistant.Gabapentin and amitriptyline are effective but need to be commenced as early as possible.Ketamine may be beneficial.12. NutritionNutritional support should be started as soon as gastric residuals indicate resolution of ileus.Enteral feeding is preferred & switch from parenteral to enteral feeding should occur as soon as feasible.
23Protocol of Management 13. SkinAll pressure areas should be padded.Patient should be turned every two hours.Spasticity is common and Contractures can result from spasticity.Conservative measures such as stretches, splinting, and casting.good pain control.Medication is often necessary; baclofen, dantrolene, and gabapentin.More invasive treatments; botulinum injections and intrathecal baclofen.Severe contractures may need to be released surgically.
24Protocol of Management 14. Psycho-SocialDepression, anxiety and confusion.Psychiatry and Social Workconsults may be necessary.Rehabilitation.15. GeneralAvoid full bladders, constipation, or painful sensations.
25The decision is made to intubate this patient due to gradual worsening although it is not emergent at this time. Which of following is BEST option for airway management?Obtain expert consultation for flexible fiberoptic intubation.Rapid sequence intubation with an orotracheal tube.Immediate surgical cricothyrotomy.Needle cricothyrotomy.
26Pharmacological agents useful for endotracheal intubation immediately after injury include Etomidate mg/kg as single bolus.Succinylcholine mg/kg as single bolus.Midazolam 1 mg bolus every several minutes. repeated as necessaryFentanyl µg bolus every several minutes repeated as necessary.All of above.
27Patient has complete spinal cord transection above C3 Patient has complete spinal cord transection above C3. which one of following is MOST APPROPRIATE setting for initiation of mechanical ventilation?FiO2 1.0 with SIMV, TV 6-8 ml/kg, RR 10-12/min & PEEP 5 cm H2O.FiO2 1.0 with PCV, set at level of 40 cm H2O, RR 10-12/min & CPAP of 10 cm H2O.FiO2 0.3 with SIMV, TV ml/kg, RR 15-18/min & PEEP 5 cm H2OFiO2 0.3 with PSV, set at level of 20 cm H2O, & CPAP of 5 cm H2O
28Which of following statements regarding non-invasive positive-pressure ventilation (NPPV) is MOST CORRECT?Less patient monitoring is required with NPPV than invasive mechanical ventilation.NPPV is not recommended for patients with hemodynamic instability.NPPV is rarely useful in treatment of respiratory failure.The need for specialized machines and masks limits the utility of NPPV.
29Patient presents to ICU with BP of 84/42 mm Hg, HR of 110/min & flaccid paralysis of four extremities. Which one of following is MOST APPROPRIATE initial treatment?Crystalloid volume resuscitation.Immediate intubation & institution of mechanical ventilation.Initiation of vasopressors to achieve SBP>150 mm Hg.External transthoracic cardiac pacing if HR drops below 75 beats/min.
30Which one of following dose ranges of dopamine is LIKELY to maximize inotropic effect while minimizing vasopressor effect?1 – 2 µg/kg/min4 – 8 µg/kg/min10 – 15 µg/kg/min15 – 20 µg/kg/min
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