1.
Transfer to specialized spinal
cord injury center as soon as possible.
2.
Involve clinical liaison (PMR) in
ALL cases, EARLY after admission.
3.
Pressure relief over bony
prominences within 2 hours of injury (get off backboard, use sheepskin, turn
patient every 2 hours and apply Mepilex.
4.
Provide airway and ventilatory
support early in high tetraplegia (C5 and above) by intubation and mechanical
ventilation. If patient is intubated and not weaning-trach. (This has to be
patient specific. If patient maintaining own airway given him/her a chance to
maintain it.
5.
If trying to avoid mechanical
ventilation, evaluate baseline pulmonary function with TV, VC and NIF (bedside
spirometry every hour with documentation of effort/level) and monitor/assess
daily with chest films if needed and mucous production and clearance.
6.
Treat hypotension (MAP>85 with
fluid first, then Norepinephrine 0.05 mcg/kg/min-titrate to response) for a
minimum of seven days
7.
Do not use steroids unless
indicated by spine service.
8.
If surgery is performed, continue
post-operative ventilatory support past PACU because intraoperative events may
result in airway edema and respiratory compromise ie: prone positioning,
residual anesthetic agents. Continue until patient meets separation
requirements.
9.
Pain control-morphine or fentanyl
–intubated-fentanyl drip 50 mcg/hour (SAS 3-4) or morphine 2 mg/hour and nonintubated
Morphine 1-5 mg IV q1 hr pain, Fentanyl 50-100 mcg IV q1 then transition to our
pain protocol when extubated and eating and then start gabapentin [300 mg po
daily and titrate up to bid and tid (max
3600 mg/day)] and pregabalin (75 mg po bid, increase to 150 BID within 1 week
than increase to 300 po BID withing 2-3 weeks, Max 600 mg/day). Both drugs need
to be tapered off.
10. SCD’s and low molecular wt heparin or unfractionated
heparin- combination of both as there is evidence that SCD’s may enhance the
efficacy of heparin or lovenox. IVC filter only in those patients with active
bleeding expected to last more than 72 hours.
11. Tetraplegic patients should be admitted to ICU and considered for
mechanical ventilation. The incidence of ventilatory failure following
tetraplegia is as high as 74%. 95% of patients with injury at or above C5 may
require mechanical ventilation. Evidence shows monitoring ABG early after
injury may identify impending failure.
12. Trach early if expected to be ventilator dependent or a slow wean.
Early trach is associated with reduced LOS in ICU. Additional indications for
tracheostomy include advanced age, higher level of injury and preexisting
medical conditions.
13. Use Manually Assisted coughing or Quad coughing, NT suctioning,
neb treatments and IS/Flutter valve.
14. Place Foley early to monitor fluid status, then remove at earliest
stable time when resuscitation is complete and UOP is below 2000/day then I
& O cath every 4-6 hours (keep volume < 500ml)
15. Use stress ulcer prophylaxis for at least 4 weeks.
16. If not intubated, consult Dysphagia Team and order swallow study
in acute SCI patients with cervical spinal cord injury or halo fixation (Use early
enteral nutritional support if patient cannot take PO.
17. Bowel program: Provide appropriate fluids. Bowel care needs to be
scheduled at the same time of the day at least daily or BID. Schedule ingestion
of food or liquids approximately 30 min prior to bowel care (gastrocolic
response). Use a water soluble lubricant with rectal digital stimulation,
manual evacuation and suppository insertion; may need to use lidocaine gel for
patients with autonomic dysreflexia. Empty bladder before bowel care. Place
patient in upright or side lying position for bowel care, if able.
18. Reflexic Bowel: Manual evacuation as needed until rectum free of
stool that could interfere with suppository insertion. Insert Bisacodyl
suppository and wait 5-15 min for stimulant to work; if no result may use Enemeez.
Start and repeat rectal digital stimulation every 5-10 min until all stool has passed
19. Areflexic/ spinal shock. Manual evacuation as needed until rectum
free of stool. Start and repeat rectal digital stimulation every 5-10 min and
manual evacuation until all stool has passed. May use enemeez. Patient to use
Valsalva if able; perform transabdominal
colonic massage in clockwise
manner to stimulate peristalsis and propel stool
20. Medications: Step 1: Miralax 17g po/per tube daily as well as
Senna 2 tabs po/per tube qhs; for reflexic bowel, order Bisacodyl suppositories
scheduled BID to be used with rectal digital stimulation. Order Enemeez as
needed. Monitor effect for 3-5 cycles.
21. Medications Step 2: If Step 1 not successful or adynamic ileus,
add Reglan 10mg po/per tube/ IV QID. Do not discontinue step 1.
22. Bowel Care is completed when:
a) Stool flow has stopped or b) Rectum is empty or c) no further stool
comes out after two rectal digital stimulation at least 10 min apart or d)
Mucus is coming out without stool or e) Tightening of internal anal sphincter
occurs
References:
(2008). Early acute management n adults with
spinal cord injury A clinical practice guideline for health-care professionals.
The Journal of Spinal Cord Medicine, 31(4),
408-479.doi:10.1043/1079-0268-31.4.408
(2006). Bladder management for adults with
spinal cord injury. Journal of Spinal
Cord Medicine, 29(5), 527-573
Drassioukov, A., Eng, J., laxton, G.,
Sakakibara, B., Shum, S. (2010). Neurogenic bowel management after spinal cord
injury: a systematic review of the evidence. Spinal Cord, 48(10),
718-733.doi:10.1038/sc.2010.14
http://www.surgicalcriticalcare.net/Guidelines/Acute%20Spinal%20Cord%20Injury%20Guideline%202012.pdf
Clinical Practice Guidelines Spinal Cord
Medicine, Neurogenic Bowel Management in Adults with Spinal Cord Injury;
Consortium for Spinal Cord Medicine; Copyright 1998, Paralyzed Veterans of
America
