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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6022_Библиотеки_им_академика_М_И_Перельмана
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fracturesshouldbeimmobilizedassoonaspossibletolimitmovementand
pain.Thetimingofoperativefixationwilldependonthepatient’sinjury
burdenandhemodynamicstability.Communicationbetweenallteamsis
importantforprioritizingfracturefixation.
External:Anyopenwoundassociatedwitharterialhemorrhageor
abnormalitiesinclotting(i.e.,anticoagulants)canresultinsignificantblood
lossandthereforetraumaticshock.Dependingonthescenario,direct
pressure,woundpacking,tourniquets,orwhipstitchingshouldbeutilized
tohelpcontrolthisbleeding.
Afteranassessmentforhemorrhagicshock,othertypesofshockshouldbe
entertainedinthetraumapatientpresentingwithhemodynamicinstability.More
commoncausesincludethefollowing:
Neurogenicshock:Thosepatientspresentingwithhighspinalcordinjuries
willlosesympathetictone,resultinginaninabilitytorespondwithnormal
“fightorflight”actionsofthebody.Inadditiontothecluesofparalysis,
thesepatientswillnotbeabletomountatachycardicresponseandwill
havehypotensionalongwithanormalorlowheartrate.Althoughthefull
examinationofthepatientwithanSCIisoutofthescopeofthischapter,it
willprovideseveralcluestothisentity.Paralysisisthemostlikelyfinding
butinthealteredorunresponsivepatient,thismightbedifficultto
ascertain.Itmustalsoberecognizedthatitisnotuncommonforatrauma
patienttopresentwithtwoformsofshock(i.e.,hemorrhagicand
neurogenic).Onceidentified,initialtreatmentforpatientswithneurogenic
shockincludeensuringadequatehydrationandprovidinganalphaagentto
assistinprovidingvasculartone(seeChapter12).
Other:Occasionally,thetraumapatientwillhaveanantecedentproblem
thatprecipitatesthetrauma:
Cardiogenicshock:Oftencausedbyamyocardialinfarction,failureofthe
hearttodeliverappropriateflowtotherestofthebodyneedstobea
consideration,especiallyintheelderlyorthosewithsignificant
comorbidities.Onceunderconsideration,theworkupincludesECG,
cardiacenzymes,andechocardiogramalongwithpromptcardiology
consultation.Optionsforimmediatetherapyincludeensuringadequate
hydrationandtheuseofinotropes.
Septicshock:Anuntreatedorsevereinfectioncanresultinsepticshock.
Althoughnotthemostlikelycauseofshockinthetraumapatient,itshould
beconsideredwhenthemorecommonetiologiesofshockareruledout.
Clueswithregardtoisolatedsepticshockaretemperatureextremes,warm
extremities,andobviousexternalsourcesorrecenthistoryof
illness/infection.Thesepatientsshouldhaveculturesofblood,urine,and
respiratoryfluidsentpriortothepromptinitiationofantibioticsandsource
control.
CONCLUSION
Thepatientwho sustainstraumaticinjuryneedstobeevaluated asrapidly and
thoroughly as possible. A mature healthcare system will provide seamless
evaluationand intervention from the timeofinjurythroughout hospitalization.
Thetraumaevaluation,basedontheATLSprinciplesofidentifyingandtreating
life-threateninginjury,followedbyacomprehensiveexamination,willensureall
injurieswillbe identified.Inthosepatientspresentinginshock, theteammust
identify the source quickly and begin treatment in order to ensure positive
outcomes.
REFERENCES
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CollegeofSurgeons;2018.
2. CommitteeonTrauma—AmericanCollegeofSurgeons.Resources for Optimal Careof the Injured
Patient.Chicago,IL:Author;2014.
3. BarracoRD,ChiuWC,BardM.PracticeManagement GuidelinesfortheAppropriateTriage ofthe
Victim of Trauma. Eastern Association for the Surgery of Trauma. 2010.
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providers.JSpinalCordMed.2008;31(4):403–479.doi:10.1080/10790268.2008.11760744
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and the associated emergency department outcomes. J Neurotrauma. 2015;32(24):2008–2016.
doi:10.1089/neu.2015.4016
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1998;29(9);677–683.doi:10.1016/S0020-1383(98)00161-2
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andtraumateamactivation:effectsonresourceutilizationandpatientcare.JTrauma.1997;43(1):61–
64.doi:10.1097/00005373-199707000-00014
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12
Neuro-CriticalCareManagementofAcute
SpinalCordInjury
BeverlyHon,JingWang,PeterYonclas,andSteven
Kirshblum
INTRODUCTION
Eachyear,anestimated17,500newcasesofacutetraumaticspinalcordinjuries
(SCIs)occur in theUnitedStates (1). ManagementofacuteSCI begins in the
fieldimmediatelyfollowinginjury.Mortalityatthetimeofinitialinjuryranges
from48%to79%withanadditional4.4%to16%ofdeathsoccurringpriorto
hospitaldischarge(2). Aggressive monitoring of acute SCI in the criticalcare
settingisassociatedwithimprovedmorbidityandmortality(2).
Fromacriticalcarestandpoint,themainobjectiveimmediatelyfollowinga
traumaticeventis medical stabilization. From a rehabilitation perspective, this
period is also vital for implementationof time-sensitiveinterventions that can
limitsecondaryinjuryandpreventorminimizecomplications.Thescopeofthis
chapter is to discuss the early interventions for individuals who sustain a
traumaticSCI.Thisincludestheearlyprehospitalmanagement;initialcareupon
arrival to the hospital including neuroprotective agents and rapid neurological
examination;andlastly,asystem-basedreviewofSCIissuesencounteredduring
theacutephaseofinjury.
INFIELDMANAGEMENT
AcuteairwaymanagementfortraumaticSCIbeginsatthesceneofinjury.Upon
initialtriageofthescene,evaluationandestablishmentofasecureairwayand
breathingisapriority.Adefinitiveairwayisindicatedinapatientwith altered
mentationorwithcompromisedphonation.Inpersonswithsuspectedorknown
injury to the cervical spine, providers should perform endotracheal intubation
with rapid sequence induction along with application of cricoid pressure and
maintenance of manual inline spine stabilization (3). Individuals with high
cervical lesions (above C3) suffer from paralysis of the diaphragm, the major
inspiratorymuscle(innervatedC3–C5),andexpiratorymuscles(innervatedT5–
T12),often necessitatingimmediate intubation(4).Once adefinitive airwayis
established,oxygenation andventilationare monitoredandsupplemental highconcentrationoxygen with or without bag-mask ventilation can be initiated as
needed (5). Early management is based on the Advanced Trauma and Life
Support(ATLS)protocols,whicharediscussedingreaterdetailinChapter10.
Aftersecuring an airway and regulating breathing, ATLS providers should
alsoidentifyandinitiateresuscitationofcirculationifcompromiseis apparent.
Shock results in decreased perfusion to tissues, leading to cellular injury and
tissue damage. In persons suspected of traumatic SCI, hypotension should be
assumedsecondarytohypovolemiaorhemorrhageuntilotherwiseexcluded(6).
Initial management of shock is centered on volume resuscitation with
intravenous(IV) fluids. Standard ATLSprotocol calls forbolusofcrystalloids
followed by colloids through large-bore peripheral IV or central access if
available(5).
CervicalstabilizationinindividualswithpotentialSCIisanimportantpartof
infield management. When the mechanism of injury raises concern for SCI,
ATLS protocol calls for early cervical spine stabilization at the scene (5).
Additionally, clinical symptoms or signs predictive of cervical spinal injury
include change in mental status, spinal pain or tenderness, presence of
intoxication, focal neurological deficit, or distracting painful injury (3–7). In
individuals with suspected SCI, the Consortium for Spinal Cord Medicine
Clinical Practice Guidelines (CPG) on early acute management specifically
recommends the use of a rigid cervical collar and supportive blocks on a
backboardwithstrapstosecuretheentirespine(3).Usingthelogrolltechnique,
multiple providers should assist in transferring, repositioning, and turning the
patienttomaintainspinalalignmentduringearlyprehospitalmanagement(3,5).
Rapid neurological examination as part of the triage process by either
emergency responders or upon arrival to the hospital may offer valuable
information on the status of the spinal cord. Early detection of SCI may
influencewhetherthepatientisbroughttoatraumacenterwithspinespecialists
andcanfacilitateearlyinitiationofspinalcord–directedtherapies.Oneclinical
assessmentthatcanbeemployedbyearlyresponders isthe SPinalEmergency
Evaluation of Deficits (SPEED) test,which has been validatedretrospectively
andfoundtobecapableofrapidlydeterminingtheseverityand levelofinjury
(8).Basedonthisexamination,injuryseverityandmotorcompletenessofinjury
can be assessed through a combination of ankle movement and light touch
sensationatS1.Additionally,impairedgripstrengthalongwithpositivepainin
thecervicalspinecanaccuratelypredictacervicallevelinjury.
The mechanical forces that can cause an SCI can also lead to concurrent
traumaticbrain injury(TBI). IncidenceofTBI in theSCI population hasbeen
estimated to be between 25% and 74% (9,10). Risk factors associated with a
concomitantTBIincludecompleteneurologicalinjury,cervicallevelofSCI,and
alcoholintoxicationattimeofinjury(10).InitialevaluationofpersonswithSCI
shouldthereforeincludeassessmentforTBI.TheGlasgowComaScale(GCS)is
commonlyusedtoidentifythepresenceofTBIandcharacterizetheseverityof
injury.InitialGCSshouldbeobtainedaspartofinfieldmanagement.
IMMEDIATEHOSPITALIZATIONPERIOD
InitialTriage
Upon arrival to the trauma bay or emergency room (ER), individuals should
undergo immediate assessment for SCI. For individuals who did not require
immediateintubation and mechanical ventilation, providers should continueto
monitor the respiratory status carefully. For instance, while a patient with an
injury below C6 may not initially present with significant respiratory
compromise at the scene of injury due to preserved diaphragm function,
respiratorydeclinecan occursecondary toimpairmentofrespiratoryaccessory
muscles,includingtheclavicularheadofthepectoralismajor(innervatedbythe
C5–C7 spinal nerves), and intercostals/abdominal muscles (innervated at each
thoraciclevel).Initialpulmonaryassessmentshouldincludeimagingwithchest
radiographs and arterial blood gas (ABG) (11). Early elective intubation may
prevent progression into respiratory failure in at-risk populations. A more
detailed discussion of intubation can be found in the following respiratory
section.
Ideally, pressure injury prevention should begin as early as the ER.
Individualsshouldberemovedfromarigidbackboardassoonaspossibleafter
initial spine stabilization and transferred to a firm padded surface while
maintaining spinal and skin precautions (3). Cervical spine stabilization is
maintained until more complete neurologicaland radiographic assessment can
be completed after initial resuscitation efforts. Cervical spinal clearance is
completed by the trauma team based on clinical and radiographic findings as
discussed further. Approaches to and timing of surgical stabilization are
discussedinChapter13.
Often,thediagnosisofSCImaybedelayedduetoemergentmanagementof
othermorelife-threateninginjuries.Asmentionedearlier,theSPEEDtestcanbe
usedforrapidassessmentforseverityandlevelofinjuryintheERsetting(8).
Interventionssuch as intubationorsedation can limit anindividual’s ability to
participatein a neurological examinationdueto impaired cognitive status.For
persons unable to complete a full neurological examination in the ER due to
cognition or medical stability,a more comprehensive neurological assessment
canbecompletedinthecriticalcareunitoncethepatientisclinicallystableand
able to participate in the full International Standards for Neurological
Classification of SCI (ISNCSCI) examination (see clinical assessment section
below)todeterminethelevelandseverityoftheinjury.
Shock
Inthe ERortrauma bay,close monitoringandmanagement ofhypotensionto
maintainsufficienttissueperfusionandresolveshockinpersonswithSCIisan
important goal of initial resuscitation efforts. The most recent Consortium for
Spinal Cord Medicine CPG and Congress of Neurological Surgeons (CNS)
recommendmonitoringandmaintenanceofmeanarterialpressure(MAP)above
85 mmHg for a minimum of 7 days after injury (3,12). Neurologically, the
purposeof regulation of MAPis to ensureadequatespinal cord perfusion and
hopefullyreducesecondaryinjury.Spinalcordperfusionpressure(SCPP)canbe
calculatedbytakingthedifferencebetweenMAPandintraspinalpressure(ISP).
Morerecently,directmeasurementof ISPvia an intraduralpressureprobe has
beendemonstratedtobesafeintheacutesetting(13).Careteamsshouldapplya
comprehensive approach toward both discovering the etiology of acute
hemodynamicinstabilityaswellasinstitutingappropriatetreatmentinresponse
to findings. After atraumatic event, hypotension may be secondary to one or
moreofthefollowing:hypovolemicshock,cardiogenicshock,or septicshock.
Morespecific topersonswith SCI, spinalshock and/or neurogenicshock may
alsobepresentandwillbethefocusofourdiscussion(3).
Spinalshockisdefinedastransientdepressionandeventualreturnofspinal
reflexescaudaltolevelofSCI(14).Inonemodelofspinalshockproposedby
Ditunnoetal.,thefourphasesofspinalshockconsistofareflexia/hyporeflexia
thatlasts0–1day,initialreflexreturnthatlasts1–3days,earlyhyperreflexiathat
lasts1–4weeks,andlatehyperreflexiathatlasts1–2months(14).
Neurogenic shock develops due to the loss of all sympathetic and
parasympathetic tone caudal to neurological level of injury. Incidence of
neurogenicshockincervicalSCIandthoracicSCIhasbeenestimatedbetween
13%and29%(15–19)and 5.5%and 7%,respectively(17,18).Incervical and
thoracic injuries, impairment of sympathetic nervous system (SNS) outflow
results in a rapid drop in peripheral resistance and blood pressure with
subsequentpoolingofbloodintheperipheralvasculature.Althoughthecranial
portionoftheparasympatheticnervoussystem(PNS)outflowisunaffectedand
unopposed,PNStoneintheentericvascularsystemaccentuateshypotension.In
the heart, impaired SNS outflow results in the absence of a physiological
chronotropicandionotropicresponsetohypotension,whileintactPNSoutflow
throughthevagusnervecanleadtoparadoxicalbradycardia.Inthedermis,loss
ofSNS tone and resultant vasodilation leads to temperature dysregulation and
hypothermia. This cascade of acute physiologic changes accounts for the
defining clinical features of neurogenic shock: hypotension, bradycardia, and
hypothermia.Whiletherearenodirecttreatmentsforneurogenicshock,clinical
managementofthesignsandsymptomsofneurogenicshockisoftenthefocus
of early acute management of SCI and is vital to prevent further secondary
injuryduetoitsimpactonneurorecoveryandprognosis.Durationofneurogenic
shockhasbeenshowntolastupto5weeks(20).
The first step in management for shock is fluid resuscitation through
administrationofIVfluidstoensureadequateintravascularvolume.Regarding
management of neurogenic shock, excessive fluid replacement without
addressing peripheral vascular tone can lead to pulmonary edema and third
spacing. Early initiation of vasopressors is important in the treatment of
neurogenicshock.TheConsortiumofSpinalCordMedicineCPGcurrentlydoes
notincludeaclearguidelineontheamountofvolumeresuscitationortimingfor
vasopressorinitiation(3). While lactateand basedeficitlevels canserve asan
indication for appropriate resuscitation in hemorrhagic shock, their utility in
neurogenic shock has not been studied. In addition, urinary output, central
venous pressure, or echocardiogram/inferior vena cava (IVC) ultrasonography
may also provide further insight into the adequacy of neurogenic shock
management,butnoknownformalstudiesexistatthistime.
Inaprospectivestudy,Levietal.maintainedMAPgreaterthan90mmHgin
50acuteSCIpatientsthroughfluidresuscitationanddopaminefor1weekpostinjury. At the 6-week follow-up, 82% of the patients demonstrated stable or
improvedspinalcordclassificationgradeusingtheFrankelgradingsystem.The
authors concluded that aggressive MAPgoals in acute SCI were safe (21). In
anotherprospectivestudybyValeetal.,64patientswithcervicalorthoracicSCI
were managed with volume resuscitation and vasopressors if necessary to
maintainMAPgreaterthan85mmHg(22).Whenlookingat1-year follow-up,
improvementby at least one ASIA Impairment Scale (AIS)gradewasseen in
60% of complete cervical SCI and 33% of complete thoracic SCI (22). In
incomplete SCI, the authors reported significant gains in ambulation, bowel
function, and bladder function (22). While the current Consortium of Spinal
CordMedicineCPG andCNS guidelinesrecommendMAPmaintenanceforat
least7days,severalstudiesdemonstratedgoodneurologicrecoveryasmeasured
byAIS/Frankelgradewithjust5daysofMAPmaintenance(3,12,23–27).
Withregardtovasopressorchoice,theConsortiumforSpinalCordMedicine
CPGbroadlyrecommendstheuseofdopamineandnorepinephrineforcervical
andhighthoracic-levelinjuriesduetotheiralphaandbetaadrenergiceffectson
the vasculature and heart. Phenylephrine, a pure vasoconstrictor, is
recommended for lower thoracic injuries where the SNS tone to the heart is
morelikelytobepreservedandhypotensionislargelydueto vasodilation(3).
Historically, dopamine had been the most widely used vasopressor (28).
However, Readdy et al. recently demonstrated that dopamine was associated
withahigherrateofcardiaccomplicationsthanwithphenylephrineinacuteSCI
(29).In another studyofacute traumatic centralcordsyndrome, Readdy etal.
demonstratedindividualsolderthan55yearsold(90.0%)sufferedsignificantly
morevasopressorassociatedcomplicationsthanthoseyoungerthan55yearsold
(57.1%).Furthermore,dopaminewasassociatedwithfivefoldincreasedoddsof
complications compared to phenylephrine in persons older than 55 years old
(30). Similarly, Inoue et al. demonstrated that vasopressor administration was
significantly associated with cardiac complications in persons older than 60
years(26). Finally,a study byAltaf et al. discovered that norepinephrinewas
moreeffectiveatincreasingSCPPwhencomparedtodopamine(67mmHgvs.
65 mmHg, respectively) (31). These factors suggest that the choice of
vasopressor used during management of neurogenic shock should be further
individualizedbasedonageandlevelofinjury.
EXAMINATION
RadiographicAssessment
Once the patient is medically stabilized, providers should proceed with
radiographicassessmenttoconfirmdefinitiveinjurytothespinalcordandaxial
skeleton. Determination if there is a cervical spine injury will help guide
duration for cervical immobilization and need for surgical management. The
current American Association of Neurological Surgeons (AANS) and CNS
guidelines from 2013 do not recommend radiographic evaluation prior to
discontinuationof cervicalimmobilizationin persons whoareboth awakeand
asymptomatic (free of neck painand neurological deficits) (32). In an awake,
symptomatic patient, high-quality computed tomography (CT) of the cervical
spine is the preferred method of initial imaging (32). Previously,in the 2002
versionoftheANNS/CNSguidelines,3-view(anteroposterior,lateral,odontoid)
x-ray(XR)hadbeenrecommendedasthefirst-lineimagingforthispopulation
with CT supplementation as needed. However, CT is currently recommended
overXR;asCTdemonstratessuperiorsensitivityinthedetectionofSCIandis
morereadily available in traumacentersthan in the past(33–36).Forpersons
with confirmed cervical spine injury, the current Consortium for Spinal Cord
Medicine CPG recommends imaging of the entire spine to rule out any
concurrentthoracicorlumbarinjuries(3).
Additional imaging is also indicated when a patient’s symptoms and/or
physicalexaminationdonotcorrelatewithinitialimagingfindings.Inapatient
with a negative CT report who continues to endorse pain or demonstrate
neurologicaldeficits,furtherimagingwithmagneticresonanceimaging(MRI)
shouldbe obtained. Similarly, in the obtundedpatientwith negative initialCT
findings,follow-upMRIisrecommendedifahighsuspicionofSCIexistsbased
onthemechanismofinjuryorclinicalpresentation.
As mentioned earlier, advanced imaging with MRI is indicated when
patient’s symptoms do not correlate with initial CT or XR findings. MRI
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