Early Acute Management in Adults with Spinal Cord Injury - 46

EARLY ACUTE MANAGEMENT IN ADULTS WITH SPINAL CORD INJURY

71. If the clinical exam is unreliable, MRI findings or electrodiagnostic studies may be useful for determining prognosis.
(Scientific evidence–I/III/IV; Grade of recommendation–A; Strength of panel opinion–5)

Rationale: Diagnostic testing can provide additional information on neurological classification or prognosis in patients with potentially unreliable clinical examinations. Cord hemorrhage on both early and postoperative MRI is associated with ASIA A injuries, and thus a poor prognosis for motor recovery (Flanders et al., 1996; Schaefer et al., 1992; Selden et al., 1999). Although the clinical examination is the single best predictor of neurological improvement (Selden et al., 1999), MRI findings of hemorrhage and edema modestly improve the ability to predict motor recovery at 1 year (Flanders et al., 1996). In another MRI study of SCI, the presence of extensive edema was found to provide a poorer prognosis; hemorrhage length of 4 mm or longer had a poor prognosis for neurological recovery at long-term follow-up (Boldin et al., 2006). Calancie and colleagues (2004) used surface electromyography to measure lower limb deep tendon reflexes in the first weeks postinjury. They found that the absence of large-amplitude responses and of a crossed adductor response was predictive of motor-complete status at follow-up. Findings on early somatosensory-evoked potentials predict ambulation recovery, but they are no more accurate than the clinical examination of a cooperative and communicative patient (Curt and Dietz, 1997; Jacobs et al., 1995). Compared with clinical neurological assessment, motor-evoked potentials provide no prognostic information on the likelihood of recovering strength in initially paralyzed muscles (Macdonell and Donnan, 1995).

Many clinicians are involved with the care of the patient and are developing plans for the rest of the hospitalization, if not longer. Evaluations by various members of the multidisciplinary team using standardized guidelines should assess the type, level, and severity of the injury to aid in the development of a comprehensive plan of care. Pathways, standing orders, and protocols for patients with SCI that allow for the early evaluation, assessment, and treatment by physical therapists, occupational therapists, rehabilitation nurses, and speech and language pathologists immediately trigger the involvement of these and other rehabilitation team members. Early intervention by rehabilitation specialists may shorten length of stay during the acute hospitalization phase by preventing secondary complications and moving the patient more quickly toward discharge to the next level of care. 73. Prescribe interventions that will assist the recovery of persons with SCI, including preventive measures against possible secondary complications. Educate patients and families about the rehabilitation process and encourage their participation in discharge planning discussions.
(Scientific evidence–NA; Grade of recommendation–NA; Strength of panel opinion–5)

Rehabilitation Intervention
72. Develop protocols that allow rehabilitation specialists to become involved early in the management of persons with SCI, immediately following injury during the acute hospitalization phase.
(Scientific evidence–NA; Grade of recommendation–NA; Strength of panel opinion–5)

Rationale: Individuals with SCI present with deficits in a variety of areas. The rehabilitation team is trained to help improve function and prevent further deterioration in many of these areas. Especially vital is to initiate range of motion exercises of all joints within the first week after injury and to continue them during the acute phase. Stretching of the joints should begin as soon as either a loss of range of motion or an increase in tone is detected across the joint. Generally, the rehabilitation discipline listed below is responsible for implementing the following types of interventions. Specific responsibilities will differ among staffs in different facilities; for example, initial prescription of an appropriate wheelchair may be undertaken by a rehabilitation nurse, a physiotherapist, or occupational therapist. Physical Therapy Range of motion and strengthening exercises. Pulmonary interventions, such as pulmonary hygiene, percussion, vibration, suctioning, postural drainage, mobilization, training of accessory muscles and/or glossopharyngeal pistoning breathing, cough, and deep breathing exercises; working with respiratory therapists and nursing staff.

Rationale: Although the initial phase of treatment of newly injured patients centers on medical interventions to resuscitate and stabilize, this phase can last several days. During this time, the patient is often moved from the emergency room to the operating room to the ICU or appropriate unit.

Early Acute Management in Adults with Spinal Cord Injury

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