Why do spinal injured patients die? Diagnostic dilemmas Management errors Misunderstanding spinal...

Why do spinal injured patients die?

Diagnostic dilemmas

Management errors

Misunderstanding spinal cord injuries

Why do things go wrong ?

Long term problems arise from shortsightedness

Incidence20/million population per year

RTAMotorbikecarpedestriancyclist

Fallsjumpedpushed

SportsDivinghorseridingrugby

Infections Tumours Discs Iatrogenic

SCIWORA

Spinal Cord Injury Without Radiographic Abnormality

Neuronaldysfunction/ death

Direct trauma

Haematoma Ischaemia

Hypotension

HypoxiaOedema

Pathophysiology of spinal cord injury

Cardiorespiratoryphysiology

Respiratory Afferents

Intrapulmonary receptors VagusStretch/proprioreceptors ribs/intercostals T1-T12Clavicles Low Cervical

Chemoreceptors Carotid bodyChemoreceptors Brainstem

Respiratory dysfunction

Lumbar Unable to cough

Low thoracic chest wall compliance Vital capacity

High thoracic chest wall compliance Vital capacitypoor expansion. Basal collapse

C5/C6 Diaphragms and accessory only

C3/C4/C5 Accessory only

Above C3 Very little

0

200

400

600

800

1000

1200

1400

1 2 3 4 5 6 7 8 9 10 11

Week

fvc

Respiratory autonomic dysfunction

Bronchial hypersecretionBronchial hyper-responsiveness

Respiratory monitoring

Lung function FVC, PEFR, Speech, RR

FVC> 1LFVC < 1LFVC= Tidal volume

Pulse oximeter

Blood gasses

Watch closely in an appropriate environment for several days

Respiratory treatment

Oxygen

A good physiotherapist

NIPPB (Birding)

Non-invasive ventilation

Invasive ventilation

Tracheostomy

Respiratory treatment

What if they do get ventilated ?

Weaning is likely to be slow and difficult

Wait until pulmonary compliance is normaland chest is clear

Extubate onto noninvasive bipap

How to intubate?Emergency or elective?

Awake or sedated or asleep?

Suxamethonium?

Acute cardiovascular changes

Vasodilation Vasoconstriction

T4-T6

Hypotension

Loss of cardiac sympathetics

Bradycardia

Acute cardiovascular changes

Be carefull…..

Postural hypotension

Vagal stimulation (tracheal suction)

Pressure sores

Cardiovascular management

Judicious fluid managementCVP monitoringPA catheterOesophageal doppler

Inotropes

ChronotropesTemporary pacing

Why Bother ?

NASCIS III

Methylprednisolone

30mg/Kg over 15 minuteswait 45 minutes

5.4 mg/Kg/Hr for 23 hours if >4 hours post injury

5.4 mg/Kg/Hr for 47 hours if >4 but <8 hours