Podcast
Questions and Answers
What type of spinal cord injury is characterized by fractures of the vertebral peduncles and facets?
What type of spinal cord injury is characterized by fractures of the vertebral peduncles and facets?
Which symptom is primarily associated with spinal cord injuries at the C1-C3 level?
Which symptom is primarily associated with spinal cord injuries at the C1-C3 level?
What is a common treatment approach for spinal cord injuries?
What is a common treatment approach for spinal cord injuries?
Which spinal cord injury level is likely to experience significant bradycardia during suctioning due to unstable high injuries?
Which spinal cord injury level is likely to experience significant bradycardia during suctioning due to unstable high injuries?
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What happens to sympathetic function as a result of a C7 spinal cord injury?
What happens to sympathetic function as a result of a C7 spinal cord injury?
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What is the primary physiological response below the spinal cord lesion in spinal cord injury?
What is the primary physiological response below the spinal cord lesion in spinal cord injury?
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Which of the following symptoms is NOT commonly associated with spinal cord injury?
Which of the following symptoms is NOT commonly associated with spinal cord injury?
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What triggers the severe symptoms seen in spinal cord injury that involves sympathetic response?
What triggers the severe symptoms seen in spinal cord injury that involves sympathetic response?
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Which condition is commonly linked to the development of Horner's syndrome following a spinal cord injury?
Which condition is commonly linked to the development of Horner's syndrome following a spinal cord injury?
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What is the first step in treating the conditions arising from a spinal cord injury?
What is the first step in treating the conditions arising from a spinal cord injury?
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What is an essential consideration during airway assessment for patients with potential cervical spine issues?
What is an essential consideration during airway assessment for patients with potential cervical spine issues?
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What is a main contraindication for using the sitting position during cervical spine surgery?
What is a main contraindication for using the sitting position during cervical spine surgery?
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Which airway intubation technique may be utilized when there is a risk of complications in cervical spine surgeries?
Which airway intubation technique may be utilized when there is a risk of complications in cervical spine surgeries?
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What is a common postoperative concern related to excessive fluid accumulation?
What is a common postoperative concern related to excessive fluid accumulation?
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What complication may arise from venous air embolism (VAE) during surgery?
What complication may arise from venous air embolism (VAE) during surgery?
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What should be monitored continuously when a patient is positioned sitting for cervical spine surgery?
What should be monitored continuously when a patient is positioned sitting for cervical spine surgery?
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What is a possible nerve injury associated with improper positioning during cervical surgery?
What is a possible nerve injury associated with improper positioning during cervical surgery?
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What factor increases the risk of venous air embolism (VAE) during surgery?
What factor increases the risk of venous air embolism (VAE) during surgery?
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What complication may occur if a venous air embolism (VAE) is untreated?
What complication may occur if a venous air embolism (VAE) is untreated?
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Which measure should be taken to minimize air entrainment during a venous air embolism?
Which measure should be taken to minimize air entrainment during a venous air embolism?
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What is the recommended oxygen concentration to be provided if nitrogen oxide (N2O) is in use during an emergency?
What is the recommended oxygen concentration to be provided if nitrogen oxide (N2O) is in use during an emergency?
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In lumbar disc surgery, what position is typically utilized?
In lumbar disc surgery, what position is typically utilized?
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What is a potential risk during posterior fossa surgery concerning paradoxical air embolism?
What is a potential risk during posterior fossa surgery concerning paradoxical air embolism?
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Which monitoring technique is crucial during thoracolumbar spine surgery?
Which monitoring technique is crucial during thoracolumbar spine surgery?
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During lumbar and thoracolumbar surgeries, which additional item is advised as part of routine preparation?
During lumbar and thoracolumbar surgeries, which additional item is advised as part of routine preparation?
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What is a common incidence percentage of venous air embolism (VAE) in the sitting position?
What is a common incidence percentage of venous air embolism (VAE) in the sitting position?
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What is a common risk associated with C7 spinal cord injury?
What is a common risk associated with C7 spinal cord injury?
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What essential management is required for airway control in patients with spinal cord injury?
What essential management is required for airway control in patients with spinal cord injury?
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What generally occurs due to neurogenic pulmonary edema following acute CNS injury?
What generally occurs due to neurogenic pulmonary edema following acute CNS injury?
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Which type of edema results from increased capillary hydrostatic pressure in the lungs?
Which type of edema results from increased capillary hydrostatic pressure in the lungs?
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What indicates the first signs of neurogenic shock associated with spinal cord injury?
What indicates the first signs of neurogenic shock associated with spinal cord injury?
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What is a primary pharmacologic treatment given within the first 8 hours after spinal cord injury?
What is a primary pharmacologic treatment given within the first 8 hours after spinal cord injury?
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What factor differentiates spinal shock from neurogenic shock?
What factor differentiates spinal shock from neurogenic shock?
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Which intervention is essential for preventing deep vein thrombosis (DVT) in patients post spinal cord injury?
Which intervention is essential for preventing deep vein thrombosis (DVT) in patients post spinal cord injury?
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Why might a patient with an acute spinal cord injury be treated as having a full stomach?
Why might a patient with an acute spinal cord injury be treated as having a full stomach?
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What condition may occur within minutes to hours after a severe spinal cord injury?
What condition may occur within minutes to hours after a severe spinal cord injury?
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What is a common symptom of neurogenic shock?
What is a common symptom of neurogenic shock?
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What is a typical consequence of a spinal cord injury above T6?
What is a typical consequence of a spinal cord injury above T6?
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What role does intubation play in the management of spinal cord injury patients?
What role does intubation play in the management of spinal cord injury patients?
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What are H2 blockers and antacids used to manage in spinal cord injury patients?
What are H2 blockers and antacids used to manage in spinal cord injury patients?
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Study Notes
Spinal Cord Injury
- Flexion injuries - anterior subluxation or fracture dislocations of the vertebral bodies
- Hyperextension injuries - transverse fractures of the vertebra, disruption of the anterior longitudinal ligaments, posterior dislocations
- Vertical compression - burst fractures and ligamentous rupture
- Rotational injuries - fractures of the vertebral peduncles and facets
-
System effects of SCI
- Depend on the site or level of injury and phase
- Hypotension, bradycardia, hypothermia - especially if C7 or higher
- Bladder and bowel dysfunction
- Alteration in sweating
-
Respiratory dysfunction
- C1-C3: complete injury will result in respiratory failure due to diaphragmatic paralysis
- All systems can be affected
-
Treatment is aimed at:
- Immobilization
- Medical stabilization
- Spinal alignment
- Operative decompression, and spinal stabilization
- C1-4 - likely to be very unstable, high injury often expect bradycardia with suctioning - even when later
- Higher injuries may become asystolic from certain stimulation - like intubation
- Cardiac accelerator - T1-T4
- C7 injuries - minimal sympathetic function - still difficult to manage
- Injuries at C7 or higher: JUST INTUBATE THAT HOE!!$$!!
- Patients with C7 injury are also unable to manage temp - hypothermia risk
Evaluation and Assessment in the ED
- ABCDE
- Airway management critical
- Neuroprotective strategies
Acute Care of SCI
-
External splinting and immobilization - initial
- Immobilization and medical stabilization are kind of 'side-by-side' rather than separate
- About 20% of SCIs are complete
- Have to determine what their function is - it varies between types of incomplete
- Spastic vs flaccid quadriplegia
-
Medical stabilization
- Airway management/oxygen delivery
- Airway - may require intubation in the field or in the ED - if not, why not?
- In-line manual cervical immobilization must be maintained during intubation
- 100% Oxygen - RSI or Modified RSI
- Supplemental oxygen - normal LOC, Gag reflex, patent airway
- Blind nasal technique - not often used - risk of basilar fractures
- Fiberoptic technique - non emergent - if you're good at it use it
- ↑ C7→ respiratory failure
- Neurogenic Pulmonary Edema (NPE)
- Pulmonary interstitial and alveolar fluid d/t acute CNS injury
- Develops within minutes to hours after a severe injury / insult
- Resolution usually begins within several days
- Signs & symptoms- dyspnea, tachypnea, tachycardia, basilar rales
- CXR- heart size normal with bilateral alveolar filling
- BP, CO, and PCWP (PaOP) - normal
- Cardiogenic Pulmonary Edema (CPE)
- Increased capillary hydrostatic pressure secondary to elevated pulmonary venous pressure
- Accumulation of fluid with low-protein content in the lung interstitium and alveoli
- → Pulmonary veins and LA venous return → LV output
- Cardiovascular support
- Initial substantial autonomic discharge - compression of sympathetic nerves
- Severe HTN and arrhythmias, LV failure, MI, pulmonary capillary leak
- Usually not seen in the ED because hypotension occurs from spinal shock and hypovolemia - usually out in the field
- Rhythm disturbances - bradycardia, primary asystole, SVT, Afib
- Resolve in 14 days
- Initial substantial autonomic discharge - compression of sympathetic nerves
- Gastrointestinal
- Acute SCI- GI tract atonic
- Gastric distention
- Risk for aspiration - stomach will have in it what was in it at the time of injury - treat as full stomach
- Gastritis
- Stress ulcers
- Hypochloremic metabolic alkalosis
- H2 blockers, antacids
- Genitourinary
- Bladder - flaccid after SCI
- Foley catheter → also to help ensure that they're not retaining
- Adequate hydration
- Temperature Control
- At or above C7 - unable to conserve heat in a cold environment through vasoconstriction - and they can't shiver
- Prone to hypothermia
- DVT prevention
- Immobility → DVT (12-24%) and PE (10-13 %)
- Mechanical compression devices, TED hose, and heparin
- Radiologic evaluation
- Look at adequacy of alignment; MRI you can see soft tissues unlike with CT scan
- Neuroprotective strategies
- Spinal alignment
- Immobilization - backboard, c-spine, etc.
- Head tongs or halo traction devices for unstable injuries
- Bed rest, log rolling for thoracic and lumbar fractures
- Surgical interventions - for things immobilization won't help
- Reduction, stabilization for dislocations that cannot be reduced by traction or manipulation
- Decompression within first 2 hours of injury - best long term outcomes
- Physiologic therapy
- Cooling
- Hypertension
- Maintain stable glucose levels - elevated glucose levels can be detrimental, esp with ischemia
- Nanomaterials - chemical substances developed to get where they need to → help with inflammation, inhibitory factors, and promote axon regeneration
- Pharmacologic therapy
- Controversial and no longer used
- Methylprednisolone - 30 mg/kg initially over 15 min
- 45 - minute pause
- Followed by an infusion of 5.4 mg/kg/hr for 23 hours, within the first 8 hours of injury
- Mannitol - 0.25-1.0 g/kg
- For inflammation: Corticosteroids
- Surgical Reduction / Surgical Management
- Decompression - ~2 hour = great success
- Reduction and stabilization
- Alignment
- Spinal alignment
- Airway management/oxygen delivery
Shock States in SCI
-
Neurogenic Shock - hemodynamic phenomenon
- SCI above T6
- S/s- Hypotension, bradycardia, vasodilation
- Caused by loss of sympathetic outflow below the level of the SCI
- Hypotension may be fluid resistant - phenyl and *norepi
-
Spinal shock - neurologic phenomenon
- Loss of motor, reflexes, sensation below level of injury
- Hypotension, bradycardia in initial phase
- May last hours - weeks
SCI Symptoms
- Spinal cord injury → a concussion like injury to spinal cord within minutes of the injury
-
Spinal Shock - total sensory and motor loss → NEUROLOGIC PHENOMENON
- Signs & symptoms - total loss of power, reflexes, sensation
- Lack of sympathetic outflow -
- Flaccid paralysis, loss of reflexes below the level of the lesion, paralytic ileus, and loss of visceral and somatic sensation, vascular tone, and vasopressor reflex occurs
- The lack of sympathetic outflow can cause vasodilatation, pooling of blood in peripheral vascular beds, postural hypotension and bradycardia
- Shock usually ends within 24 hours - may last longer
- Recovery→ hyperreflexia, hypertonicity, clonus
- Return of reflex activity ↓ injury → end of shock
- Minimal recovery with complete injury
- > injury > shock
- Know: variety of s/sx and lack of sympathetic outflow
-
4 Phases of Spinal Shock
- Phase 1 - (0-1 days) - A complete loss or weakening of all reflexes below the level of spinal cord injury which usually lasts for a day.
- Afferent impulses are transmitted to the isolated spine
- Afferent stimulation tolerated in healthy uninjured patients
- SCI → massive sympathetic response elicited → adrenal gland & SNS
- Response is uninhibited by the brainstem and hypothalamus d/t injury
- Neural plasticity- ability of the nervous system to reorganize/ change its function, structure or connections in response to ("intrinsic or extrinsic") stimuli
- Physiology
- Loss of supraspinal control over sympathetic preganglionic neurons
- Vasoconstriction occurs below the lesion
- Vasodilation occurs above the lesion
- Carotid and aortic arch baroreceptor activation
- ↓HR, ventricular dysrhythmias, and CHB from reflex activity
- Common symptoms include:
- Severe hypertension, bradycardia, tachycardia,
- Hyperreflexia, muscle rigidity and spasticity
- Profuse diaphoresis/sweating,
- Changes in skin color -pallor, redness, blue-grey skin color, flushing above the lesion,
- Intense headache
- "Untreated can cause seizures"
- Less common
- Horner's syndrome-aka oculosympathetic palsy- Pupillary constriction, ptosis, decreased sweating
- Other causes :
- Medication side effects - use of illegal stimulants such as cocaine and amphetamines
- Guillain-Barre syndrome
- Subarachnoid hemorrhage
- Severe head trauma, and other brain injuries
- Usually a full bladder (ensure foley is draining) or stool impaction
- Treatment?
- Stop the stimulus!!
- Positioning and airway management priority concerns
- Posterior cervical decompression -sitting or prone positions
- Anterior cervical decompression -supine position
- Intubation may be difficult
- Instability of the C spine or neck deformity - maybe not just cervical spine pts, cervical spine disease
- Airway assessment is essential - can they move their neck, can they do so without symptoms?
- Awake fiberoptic intubation - laryngectomy, some use for any cervical spine surgery
- Reinforced ETT
- Complicated by injury to the spinal cord during surgery leading to postoperative problems --
- Intubation - in line neck immobilization
- Neutral position intraoperatively and postoperatively
- Upper airway edema post op -
- Excessive fluid
- Prolonged dependency
- If you notice scleral edema be more cautious
- Positioning and monitors
- Sitting position
- CVP, Aline, routine monitors, 2 large bore IV's, precordial doppler with sitting, Bair Hugger, Fluid warmer, Foley, ?SSEP
- Considerations for Sitting Position
- Advantages - surgical exposure, ventilation/airway access, possible blood loss reduction
- Disadvantages - VAE, hemodynamic instability, nerve damage
- What nerve injuries could occur?
- Sciatic nerve damage
- Mid Cervical nerve damage - mayfield headrest - the surgeon adjusts flexion, ensure 3 fingers between chin and chest (document you told the surgeon)
- What is the main contraindication to using this position and why?
- R to L shunt - intracardiac (PFO) or intrapulmonary
- Venous Air Embolism- VAE - Massive air embolism → rare / catastrophic - Air entrainment occurs slowly and over a longer period of time - M&M related to volume of air and rate of accumulation - 3-5 ml/kg is deadly amount of air - Abnormal collection of air/gas that forms in the systemic venous circulation & blocks blood flow - ^ VAE risk - Surgical site > 20 cm above the heart - Can also occur in the lateral and prone positions - Sitting position + posterior fossa = VAE incidence ^ - 40-45% - Sitting + cervical laminectomy or surgeries in prone, lateral = 10-15% - What happens in VAE? - As air is cleared to the pulmonary circulation, PVR, PAP, and RAP ↑ - Dead space ventilation ↑→↓ETCO2 and↑PaCO2. Nitrogen appears - What will happen to HR and BP? - ↓BP and ↑ HR - Hypoxemia → partially occluded pulmonary vasculature & local release of vasoactive substances - Untreated, CO ↓ d/t to right heart failure and/or reduced LV filling - Treatment - Alert the surgeon to irrigate the field with saline → - Simultaneously, CRNA is aspirating from the CVP catheter - Discontinue N2O if in use and increase FiO2 to 100% - Provide cardiovascular support if needed - Compress both jugular veins lightly to minimize air entrainment - Change patient position if above measures fail to prevent ongoing VAE - VAE can lead to PAE - Air can pass to arterial side through a pulmonary vascular bed or PFO - Embolization of a coronary or cerebral vessel - This is known as a paradoxical air embolism - 25% have probe patent foramen ovale & 40-45% incidence of VAE in the sitting position + posterior fossa surgery → 10 -12% risk of PAE
- Sitting position
- What do we do differently? - Prone position - +/- CVP, 2 large bore IV's, Bair Hugger, Fluid Warmer, Foley, ?SSEP - Supine - 2 large bore IVs with routine monitors, Bair Hugger, Fluid warmer, +/- foley - 0/4 TOF during "body" of case
Considerations for Lumbar and Thoracolumbar Surgeries
-
Lumbar Disc Surgery - lumbar laminectomy/fusion
- D/t trauma injury, disease, or HNP
- Prone position
- 2 large bore IV's
- Routine Monitors
- Upper body Bair Hugger
- Fluid warmer
- Foley catheter
- 0/4 TOF during "body" of the case
-
Thoracolumbar Spine Surgery
- Corrects deformity, stabilize fractures, or resection of tumors
- Positioning, spinal cord monitoring, minimizing blood loss, and postoperative respiratory care.
- Anterior and posterior procedures - can be staged or done at one time
- Anterior approach → thoracotomy incision → endobronchial aka double lumen ETT
- Positioning- head and neck ?- midline (prone and lateral) - prevent compression
- What else do we need to do?
- Spinal cord monitoring
- SSEP
- Wake Up test or MEP
- Blood loss considerations
- Autologous donation, cell saver, induced hypotension
- Monitors - what's needed?
- Spinal cord monitoring
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Description
This quiz covers the various types of spinal cord injuries, including flexion, hyperextension, vertical compression, and rotational injuries. It also discusses the systemic effects of SCI such as hypotension and respiratory dysfunction, along with treatment approaches. Test your knowledge on the mechanisms and implications of spinal cord injuries.
