Early Acute Management in Adults with Spinal Cord Injury - 15

CLINICAL PRACTICE GUIDELINE

These studies suffer from at least a partial selection bias as shown by Amin et al. (2005) in that a delay to referral to an SCI unit can be related to the management of associated injuries. However, Amin et al. showed that a delay from referral to admission may be related to an inadequate number of appropriate beds and is associated with a longer overall time in hospital. The definition of what is an inappropriate delay to referral or to transfer to an SIC has not been established. DeVivo et al. (1990) found statistically significant reductions in acute care and in total lengths of stay coupled with a highly significant reduction in pressure ulcers among patients admitted to the specialty spinal center within 1 day of injury compared with an otherwise comparable group of patients admitted to their spinal unit for rehabilitation only. Dalyan et al. (1998) showed that patients admitted to an SIC within 24 hours of injury had a lower rate of joint contractures. They also showed a link between the presence of a contracture and the occurrence of a pressure sore, both being associated with concomitant head injury. Yarkony et al. (1985) reviewed 181 spinal cord–injured patients admitted to the Rehabilitation Institute of Chicago following acute SCI. In their review, they analyzed the origin of the patients from either general hospitals or the acute care unit of a spinal center at Northwestern Memorial Hospital. They found that patients treated at the general hospital had a statistically significant increased incidence of contractures compared with the spinal center patients. Heinemann et al. (1989) showed equivalent final outcomes for patients from specialized centers versus general hospital centers passing through their rehab center, but the overall time in hospital was greater for those not coming from a specialized acute unit because of the relatively longer time spent in the acute unit in the nonspecialized hospitals. Length of stay may be shorter for patients with SCI admitted to a specialized system. Tator and colleagues (1993) found that patients treated in an acute spinal cord injury unit had a significant reduction in mortality, a significant reduction in length of stay, and a significant increase in neurological recovery (doubling of the neurological recovery scale). Amin et al. (2005) concluded that early liaison with a designated spinal injury center or unit is vitally important. Scivoletto et al. (2005) showed a better final outcome in those patients admitted to a rehab center earlier (< 30 days) than those admitted later. Before a patient with a spinal cord injury is transported from one facility to another, the following protocol should be completed to ensure that the patient’s condition is sufficiently stabilized:

Spine immobilization is adequate and secure. The airway is clear and can be maintained during transfer; consider intubation prior to transfer if PaCO2 is elevated or if ventilatory failure is likely to develop during a prolonged transfer. A chest tube is in place for any pneumoor hemothorax, especially if air transport is considered. Supplemental oxygen is being administered and ventilation (spontaneous or assisted) is adequate. IV (intravenous fluid) is patent and infusing at the desired rate. Hemodynamic parameters have been stabilized and can be monitored during transport. When indicated, nasogastric tube is in situ, draining freely, and connected to low suction. Indwelling urinary catheter is in situ and draining freely. Skin is protected from injury due to excessive pressure, especially over bony prominences, such as the sacrum, that contact the support surface, and any apparatus or debris that could cause pressure sores is cleared away. Neurological level and completeness of injury, as determined from a motor and sensory examination according to the International Standards Neurological Classification of SCI (see page X), are documented immediately prior to transferring the patient. All imaging and other records accompany the patient.
Adapted with permission from http://commons.bcit.ca/ elearning/Managing%20SCI.zip.

Spinal Stabilization during Emergency Transport and Early In-Hospital Immobilization Following Spinal Cord Injury
Rapid and safe transport of the spinal injury patient allows for early medical stabilization and institution of measures designed to preserve and potentially improve ultimate neurologic outcome. Interestingly, there is a lack of data from randomized controlled trials to support the practice of prehospital spinal immobilization in trauma patients. Only level III studies are available to support the use of spine immobilization for all patients with a

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Early Acute Management in Adults with Spinal Cord Injury

Table of Contents for the Digital Edition of Early Acute Management in Adults with Spinal Cord Injury