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