Post on 14-Dec-2015
Acute Spinal Cord InjuryTrauma is the leading cause of injury
1.5% to 3.0% cervical spine injury in major trauma4% to 5% have injury to upper cervical spine C1-
C3
Injury can also occur at thoracic and lumbar spinal area
Clinical ManifestationDepend on the extent and level of the injury
InitiallyFlaccid ParalysisLoss of Sensation below level of injuryClassified by the terms of the American Spinal Injury
Association
Physiological EffectsDepends on Level of Injury
More severe at cervical level and less sever caudally
Reduction of blood pressure Loss of sympathetic nervous system activity and a
decrease in systemic vascular resistance Bradycardia resulting from loss of T1-T4 sympathetic
innervation to the heart Can be seen in Thoracic or Lumbar Injury but more
common with Cervical Injury
Another Term for these findings is spinal shock Lasts 1-3 weeks
With Cervical and Thoracic Injury
Major cause or morbdityAlveolar hypoventilation Inability to clear secretionsMore respiratory muscle impairment with cervical
injuryAspiration of gastric contentsPneumoniaPulmonary Embolism
Do we always need an x-ray?
Well Stoelting talks about how x-rays are over used, pt can be evaluated on the following five criteriaNo midline cervical spine tendernessNo focal neurologic deficitsNormal sensoryNo intoxicationNo painful distracting injury
Anesthesia ManagmentAirway Management
Special Care with Direct LaryngoscopyNeck movement minimizedIf collar in place have another provider maintain C-
Spine immobillization with their hands, document appropriately
If no collor on trauma pt, ensure clearance from trauma team is noted in the chart
Avoid HypotensionMaintain Spinal Cord Perfusion
More Airway TipsOther options to Direct Laryngoscopy
Glidescope Awake Fiberoptic Laryngoscopy
Pt must be cooperativeCan have visualization problems with blood, secretions
and anatomic deformitiesCoughing can be detrimental to the pt
Awake TracheotomyOnly used as a last resort and for the most challenging
airways (i.e. facial fractures, deformities)
No matter what method you use always have manual in line stabilization in place
Systemic SystemsAbsence of compensatory sympathetic nervous
systemDrastic drop in blood pressure can be noted
Changes in body position, blood loss, or positive pressure ventilation
Liberal Intravenous Infusion of crystalloid solutionFill the intravascular spacesAcute blood loss should be treated rapidly
EKG changes are common especially with a cervical spine injury
Breathing best managed by ventilatorLoss of accessory muscles
Body Temperature should be maintained and monitoredPts become poikilothermic below level of injury
GA can be done with anesthetic gases or TIVACaution with Nitrous Oxide as it can expand gas in
closed spacesEspecially in Basilar Skull Fractire of Rib FractireCan worsen a pneumocephalus or a pneumothroax
Arterial hypoxemia is commonMonitor Pulse Oximetry and Oxygen
Supplementation
Muscle Relaxation?Base decision on location of operative site and
the level of spinal injury
PancuromiumSympathomimetic effects
SuccyncholineNo excess potassium release seen with an initial
spinal cord injury after a few hours
Chronic Spinal Cord Injury Anesthesia Focus should be to prevent Autonomic
Hyperreflexia Non-Depolarizing Muscle Relaxant Drugs are the drug of choice
Depolarizing Muscle Relaxants will provoke hyperkalemia Particularly for the initial 6 months after the injury Do not use after 24 hours of injury
May see varying of heart rate and blood pressures Chronic immobile patients should always have a high suspicion
of pulmonary thromboemolism Intercostal Muscle impairment can lead to difficulty in
extubation Impaired Cough and Excessive Secretions
Continue Baclofen and Benzodiazepines to prevent withdrawal symptoms
Autonomic HyperreflexiaAutonomic Hyperreflexia Syndrome
Associated with the body’s resolution of the effects of spinal shock
Commonly associated with injuries at or above T-6Presentation
Sudden hypertensionBradycardiaPounding headacheBlurred visionSweating and flushing of skin above the point of
injury
How do we treat it?Patients at risk should be treated to prevent
stimulation below the lesion, even though no prior history all spinal cord patients are at risk.
Prior to intiating a surgical stimulusGeneralNeuraxialRegional
Use short acting vasodilators to treat hypertention
Spinal Cord TumorsAnesthesia Management
Area of tumor and size with resulting neurological compromise can vary the treatment needed
Airway ManagementCervical Tumors may obstruct the view of the airway
Severe movement can cause further damage
Avoid hypotension and anemiaSupplemental OxygenMaintain spinal cord perfusion and oxygenation
Caution in use of depolarizing muscle relaxants