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Case Presentation 26-year-old male with unstable cervical fracture following motor vehicle crash is placed in halo for immobilization and is admitted to ICU. Few hours later, he develops acute hypoxemic respiratory failure that improves significantly with noninvasive positive pressure ventilation.

Halo Brace

Spinal Cord Injury It can cause myelopathy or damage to nerve roots or myelinated fiber tracts that carry signals to & from brain. This injury could also damage grey matter in central part of cord, causing segmental losses of interneurons & motor neurons.

Epidemiology In the United States  12,000 cases/year In China  60,000 cases/year Male predominance  4:1 Average age  38 years old

Classification American Spinal Injury Association & International Spinal Cord Injury Classification System A   "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.

Segmental Spinal Cord Level & Function C1-C6 Neck flexors L1, L2, L3, L4 Thigh flexion C1-T1 Neck extensors L2, L3, L4 Thigh adduction C3, C4, C5 Supply diaphragm (mostly C4) L4, L5, S1 Thigh abduction C5, C6 Shoulder movement, raise arm (deltoid); flexion of elbow (biceps); C6 externally rotates arm (supinates) L5, S1, S2 Extension of leg at hip (gluteus maximus) C6, C7 Extends elbow & wrist (triceps & wrist extensors); pronates wrist Extension of leg at knee (quadriceps femoris) C7, T1 Flexes wrist, Supply small muscles of the hand L4, L5, S1, S2 Flexion of leg at knee (hamstrings) T1 –T6 Intercostals & trunk above the waist Dorsiflexion of foot (tibialis anterior); extension of toes T7-L1 Abdominal muscles Plantar flexion of foot; flexion of toes

Complications Deep vein thrombosis Pulmonary infections Skin breakdown BP changes - can be extreme (autonomic hyperreflexia) Complications of immobility: Deep vein thrombosis Pulmonary infections Skin breakdown Contractures  risk of injury to numb areas of body  risk of kidney damage  risk of Urinary tract infections Loss of bladder control Loss of bowel control Loss of sensation Loss of sexual functioning (male impotence) Muscle spasticity Pain Paralysis of breathing muscles Paralysis (paraplegia, quadriplegia) Shock

Causes Trauma (automobile crashs, falls, gunshots, diving accidents, war injuries) Tumor (meningiomas, ependymomas, astrocytomas, metastatic cancer) Ischemia resulting from occlusion of spinal BV (dissecting aortic aneurysms, emboli, arteriosclerosis) Developmental disorders (spina bifida, meningomyelocoele) Neurodegenerative diseases (Friedreich’s ataxia, spinocerebellar ataxia) Demyelinative diseases (Multiple Sclerosis) Transverse myelitis (resulting from stroke, inflammation) Vascular malformations (AVM, dural arteriovenous fistula [AVF], spinal hemangioma, cavernous angioma & aneurysm)

Protocol 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 100-110 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).

Protocol of Management 2. Methylprednisolone Bolus & Infusion Steroids 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 INJURY Dose: 30 mg/kg administered as IV bolus over 15 minutes,45 minute pause; then 23 hour continuous infusion of 5.4 mg/kg/hr.

Protocol of Management 3. Radiological Diagnosis & Assessment CT scan or MRI of spine may show location & extent of damage & reveal problems (hematomas). Myelogram may be necessary in rare cases. Somatosensory evoked potential (SSEP) testing. Spine x-rays may show fracture or damage to bones of spine.

Protocol of Management 4. Surgical Stabilization Rapid 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).

Protocol of Management 5. Cardiovascular Support CVP & 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.

Vasoactive Agents Agent Common Dosage Ranges Comments Dopamine (µg/kg/min) 1–10 Has primarily β-adrenergic effects at low doses & primarily α-adrenergic effects at higher doses; a commonly used agent in SCI Dobutamine 5–15 Most prominent effect is augmentation of cardiac performance but may lower systemic blood pressure so generally less useful agent in SCI Epinephrine (µg/min) 1–8 Both α- and β-adrenergic effects, may promote arrhythmias Norepinephrine 1–20 Has some β-adrenergic but predominately α adrenergic effects; a useful agent for BP support, especially in cervical and high thoracic SCI Phenylephrine 10–100 Exclusively α–adrenergic agent; should be used with caution in cervical SCI because of potential for reflex bradycardia

Protocol of Management 6. Respiratory Support 1/3 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 with FVC < 12–15 ml/kg  for assisted ventilation. Abdominal binding and nursing patients supine can offset decline in pulmonary function due to flaccid abdominal muscles.

Protocol of Management 6. Respiratory Support Frequent 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

Roto- Bed

Protocol of Management 6. Respiratory Support Physiotherapy 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 is associated lung injury (contusion or underlying infection).

Protocol of Management 7. Gastrointestinal Decompression 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-Urinary Foley Catheter is placed at time of admission and should be continued until patient stability permits.

Protocol of Management 9. Metabolic Early stabilization and early physical therapy consultation to increase mobilization may decrease immobilization complications i.e. hypercalcemia. Temperature regulation. Hyperglycemia  Good glycemic contol. 10. Extremities DVT 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.

Protocol of Management 11. Pain Management Acute 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. Nutrition Nutritional 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.

Protocol of Management 13. Skin All 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.

Protocol of Management 14. Psycho-Social Depression, anxiety and confusion. Psychiatry and Social Work consults may be necessary. Rehabilitation. 15. General Avoid full bladders, constipation, or painful sensations.

The 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.

Pharmacological agents useful for endotracheal intubation immediately after injury include Etomidate 0.3-0.4 mg/kg as single bolus. Succinylcholine 1.0-1.5 mg/kg as single bolus. Midazolam 1 mg bolus every several minutes. repeated as necessary Fentanyl 25-100 µg bolus every several minutes repeated as necessary. All of above.

Patient 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 12-15 ml/kg, RR 15-18/min & PEEP 5 cm H2O FiO2 0.3 with PSV, set at level of 20 cm H2O, & CPAP of 5 cm H2O

Which 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.

Patient 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.

Which one of following dose ranges of dopamine is LIKELY to maximize inotropic effect while minimizing vasopressor effect? 1 – 2 µg/kg/min 4 – 8 µg/kg/min 10 – 15 µg/kg/min 15 – 20 µg/kg/min

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