Update on critical care for acute spinal cord injury in the setting of polytrauma

Abstract

<jats:p>Traumatic spinal cord injury (SCI) often occurs in patients with concurrent traumatic injuries in other body systems. These patients with polytrauma pose unique challenges to clinicians. The current review evaluates existing guidelines and updates the evidence for prehospital transport, immobilization, initial resuscitation, critical care, hemodynamic stability, diagnostic imaging, surgical techniques, and timing appropriate for the patient with SCI who has multisystem trauma. Initial management should be systematic, with focus on spinal immobilization, timely transport, and optimizing perfusion to the spinal cord. There is general evidence for the maintenance of mean arterial pressure of &gt; 85 mm Hg during immediate and acute care to optimize neurological outcome; however, the selection of vasopressor type and duration should be judicious, with considerations for level of injury and risks of increased cardiogenic complications in the elderly. Level II recommendations exist for early decompression, and additional time points of neurological assessment within the first 24 hours and during acute care are warranted to determine the temporality of benefits attributable to early surgery. Venous thromboembolism prophylaxis using low-molecular-weight heparin is recommended by current guidelines for SCI. For these patients, titration of tidal volumes is important to balance the association of earlier weaning off the ventilator, with its risk of atelectasis, against the risk for lung damage from mechanical overinflation that can occur with prolonged ventilation. Careful evaluation of infection risk is a priority following multisystem trauma for patients with relative immunosuppression or compromise. Although patients with polytrauma may experience longer rehabilitation courses, long-term neurological recovery is generally comparable to that in patients with isolated SCI after controlling for demographics. Bowel and bladder disorders are common following SCI, significantly reduce quality of life, and constitute a focus of targeted therapies. Emerging biomarkers including glial fibrillary acidic protein, S100β, and microRNAs for traumatic SCIs are presented. Systematic management approaches to minimize sources of secondary injury are discussed, and areas requiring further research, implementation, and validation are identified.</jats:p>

A case series of penetrating spinal trauma: comparisons to blunt trauma, surgical indications, and outcomes

“…Guidelines for acute care and surgical management of spine trauma are generally focused around blunt injuries. 30 However, there are publications addressing some of the more pressing questions for penetrating spinal trauma. Fractures due to penetrating injury are typically stable, especially in comparison with blunt injuries.…”

“…vast composite epidemiological data available for blunt spinal injuries that have been used to create guidelines for the classification and management of blunt spine trauma, 30 data on penetrating spine trauma are relatively lacking. Consequently, there is significant variability in penetrating spinal trauma management practices with most trauma centers relying on blunt spine trauma guidelines, which may be ill-equipped for the distinct patient population and mechanism of penetrating injury.…”

A review of novel trends in management of canine spinal cord injury

“…An initial assessment aimed at identification of life-threatening injuries affecting principal arteries, lungs, liver, spleen, kidneys, and long bones is very important (Hachem et al 2017). A first-line care involves the support of breathing and circulation, followed by an appropriate immobilisation of the vertebral column with the aim to limit further damage of the SC while transporting the patient (Yue et al 2017). Many animals after SCI present with pulmonary dysfunction, cardiovascular instability, and hypotension/ hypovolaemic shock due to the vasodilation of visceral arteries or blood loss.…”

“…Many animals after SCI present with pulmonary dysfunction, cardiovascular instability, and hypotension/ hypovolaemic shock due to the vasodilation of visceral arteries or blood loss. Hypovolaemia and hypoxaemia contribute to secondary spinal cord damage, so rapid correction of SC perfusion, and maintaining oxygenation via hemodynamic support helps to prevent further neurologic deterioration (Yue et al 2017). In dogs with a mean arterial blood pressure < 90 mmHg, an aggressive fluid resuscitation is needed (Fehlings et al 2017).…”

The classifications of subaxial cervical spine traumatic injuries. Part 1. General principles

“…При политравме наличие повреждения СМ резко снижает вероятность восстановления витальных функций на фоне интенсивной терапии [4,5]. У пациентов с грубым неврологическим дефицитом общая летальность при первичной госпитализации достигает 17% [6].…”