Priority
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Issues
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Caveats and complicating features
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Airway
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Decision regarding intubation
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- Anybody with a fracture around C4-5 needs early intubation
- About 1/3rd of patients will require intubation within the first 24 hours after their injury.
- It is therefore better to perform a controlled "semi-elective" intubation rather than a panic-driven emergency intubation.
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Intubation as appropriate
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- May be made difficult by inline stabilisation
- In later stages (after 4 or so days) suxamethonium is contraindicated.
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Tracheostomy
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- This may be an inevitable consequence of high C-spine injury: in one retrospective review, "all patients with complete injuries at the C5 level and above required a definitive airway and tracheostomy"
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Respiratory
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Support of spontaneous breathing
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- If the diaphragm is working, that does not mean the respiratory function is normal. Mechanics will be disturbed by failure of the other muscles of respiration.
- Paradoxically, sitting the patient upright will actually make the situation worse - their lungs perform better when supine.
- NIV is apparently an option in the early stages. Shallow mechanically impaired breaths lead to atelectasis, and NIV can reverse this process to some degree
- High-flow nasal prongs may provide some protection.
- As spasticity of the chest wall muscles progresses, the chest wall becomes rigid and respiratory mechanics improve; maximum inspiratory effort may recover to about 60% of predicted pre-injury levels.
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Mechanical ventilation
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- Dependence on this may last until after discharge. The family should be aware of this.
- A fair proportion of patients with injuries below C4 can eventually be weaned, but it may take up to 2 weeks before this process can begin.
- Denervation of most of the body's muscles will likely decrease the total CO2 production; the demand on ventilation will reflect this.
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Secretion control
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- Pneumonia is a leading cause of death in the spinal cord injury population; VAP is very common
- Poor secretion clearance due to poor cough is the main problem.
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Circulatory
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Vasodilated shock
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- This is due to sympathetic tone failure (neurogenic shock)
- One typically manages this with fluids, at least intially
- Unfortunately, this is an attempt to increase blood pressure by relying on increasing stroke volume by increasing preload; therefore there may come a point where further increases in preload will be fruitless
- Noradrenaline is the drug of choice at this stage.
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Bradycardia
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- This is due to unopposed parasympathetic tone in the sinus node, leading to sinus bradycardia.
- Apparently, the first 14 days after the injury are the worst.
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Haemodynamic areflexia
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- These patients will be very sensitive to changes in volume, as they are unable to adjust their cardiac output or smooth muscle tone in response to changes in circulating volume.
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Definitive management
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Surgical decompression
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Surgical stabilisation
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- The bones are broken, and must be surgically reduced.
- It is unclear when the best time to operate might be. Do you leave it for a little while, or do you operate immediately?
- Arguments for early stabilisation are largely from convenience; nursing care is simpler with a stable spine.
- Some evidence exists that polytrauma patients benefit (or at least, aren't harmed by) early open reduction of spinal fractures.
- Some evidence also exists that in unstable polytrauma patients, estensive spinal surgery should be delayed (as the perioperative morbidity is increased)
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Corticosteroids?
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- For a time, on the basis of the NASCIS and NASCIS II trials everybody adopted the early use of methylprednisone.
- These days, it has gone out of fashion, and is no longer recommended. In fact various eminent neurosurgical societies have issued statements against their use.
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Endocrine and environmental
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Monitoring of electrolytes
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- There are several electrolyte disturbances to be expected:
- Hyponatremia (SIADH)
- Hypercalcemia (osteoporotic resorption)
- Hyperaldosternoism and hypokalemia
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Management of diabetes
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- Insulin resistance develops due to inactivity, muscle wasting and adiposity.
- Diet may require adjustment (see below).
- Sympathetic response to hypoglycaemia is abolished; there will be no warning of severe hypoglycaemia.
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Temperature control
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- Quadriplegic patients are unable to use cutaneous blood flow to self-regulate their body temeprature
- Careful attention is required to prevent hypothermia
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Renal / urinary
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Neurogenic bladder
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- Needless to say, these people need catheters to empty their bladder. Hydronephrosis will result from overdistension otherwise (it will fill to ~150% capacity before the denervated sphincters will release the urine).
- Botox may be the answer to this.
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Renal calculi
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- Hypercalcemia of dissolving bone scan give rise to renal calculi. These will not be apparent until the patient or carer are alerted to their presence by gross haematuria.
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Pyelonephritis
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- Presence of calculi and catheters gives rise to chronic urinary tract colonisation and frequent infections.
- Generally, pyuria merits antibiotic therapy, but prophylaxis seems excessive and will probably lead to the development of resistance.
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Gastrointestinal
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Acute gastric dilatation amd the "body cast syndrome"
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- Gastric emptying is impaired because of a loss of sympathetic control of autonomic reflexes.
- A dilated stomach and a lax lower oesophageal sphincter are a recipe for aspiration.
- An NG tube for decompression is one option.
- A post-pyloric nasoduodenal tube for feeding is another option.
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Ileus
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- Intestinal oedema due to pooling of blood, opiate analgesia as well as lost control of evacuation. All are going to cause ileus.
- Lots of rehabilitative strategies are available, such as regular enemas, stool softeners, digital rectal stimulation etc.
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Stress ulceration
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- A common complication early in the process
- Largely due to unopposed vagal stimulation of the stomach secretory functions
- Greatest risk of gastric ulceration is between the fourth and tenth day after the spinal injury.
- Later, risk of perforated ulcer revers to population average
- Ergo, a brief course of PPI is indicated.
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FASTHUG issues
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Feeding
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- Early protein intake should be high (~ 2g/kg/day) in polytrauma patients
- Subsequenetly, worsening insulin resistance may merit a low-carbohydrate diet.
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Thromboprophylaxis
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- The risk is greatly increased not just from immobility but the whole polytrauma setting.
- In the first 72 hours, that risk is lower; one can safely withold heparin during that time.
- Mechanical devices are insufficient prophylaxis on their own
- Standard twice-a-day heparin doses are also apparently not good enough
- Low molecular weight heparin is apparently the recommended choice of agent
- Prophylaxis should continue for a minimum of 8 weeks
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