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andexpertiseofatraumacenterinoptimizingcareforacuteSCIalsoinfluence
the risk of pressure injury development (92). Indeed, individuals initially
admittedtoanon-SCIlevelonetraumacenterwerealmostthreetimesaslikely
todevelopapressureinjurywhencomparedtopersonswhoreceivedcareatan
organizedSCItraumacenter(34%vs.12%,respectively)(92).Inasubsequent
study, specialized SCI trauma centers for acute care (26.7%) also reported
substantially lower rates of pressure injury after initial SCI occurrence when
compared to nonspecialized trauma centers (51.5%), which further confirmed
theimportanceofdedicatedSCI-specificcenters(93).Personshospitalizedina
nonspecialized trauma center were also more likely to suffer from multiple
pressureinjuriesthanthosetreatedinaspecializedSCItraumacenter(24.2%vs.
2.2%,respectively)(93).Regardingtiminganddurationofpressureinjury,50%
ofhospital-acquiredpressureinjuriesoccurredwithin30daysofadmissionand
themediantimeforclosureofpressureinjuryduringhospitalizationwas31days
(94). Thus, pressure injury development remains a significant source of
morbidityinthenewlyinjuredindividual.
Earlyinterventionandcontinuedvigilanceisimportantinthepreventionof
pressureinjuries.Intheinstancethatanactualpressureinjurydevelops,timely
detectionallowsfortheimplementationofeffectivetreatmentstrategiesthatcan
minimize associated morbidity,mortality,and cost associatedwith these often
preventablecomplications. Furtherdetails onpressureinjuries arediscussedin
Chapters29and30.
GASTROINTESTINALCOMPLICATIONS
Thereisriskofanumberofcomplicationsof the gastrointestinal (GI) system
during the first month of SCI, which include reflex ileus (4.6%), acute
gastroduodenalulcerationandhemorrhage(4.2%),andpancreatitis(11.5%)(95–
97). Individuals with cervical and upper thoracic injuries exhibited higher GI
complicationrates thanthosewith lower thoracicorlumbosacral injuries(98).
Given that acute abdominal pathology is challenging to identify in the SCI
population, a low-level threshold is needed to avoid underdiagnosis or
misdiagnosisofGIcomplications.
ColonicmotilityimpairmentoccursearlyafterSCI.Anadynamicileusisa
functional obstruction of the intestinal tract without the actual presence of
mechanicalblockage.Ileusoccursmostoftenduringthefirst2daysafterinjury
andmostcommonlyimproveswithin2to3daysofonset(99).Duringtimeof
ileus,absentorhypoactivebowelsoundsmaybepresent(96).Ileusisthoughtto
be caused by acute loss of both sympathetic and parasympathetic innervation
duringspinalshock(99).Diagnosiscanbemadethroughphysicalexamination
and radiographic imaging. Subsequent bowel distension and insufficient
eliminationmayresultinnauseaandemesis,poorlungexpansion,anorexia,and
inadequatevenousreturn(3).
Managementofileuscaninvolvebowelrestwithatemporarilyhaltinoral
feeding. Nasogastric decompression (without suction) is instituted until the
return of bowel sounds (99). Pharmacologic approaches include prokinetic
agents such as metoclopramide, which help to increase gastric motility.
Metoclopramide acts predominantly in the foregut through cholinergic and
dopaminergicreceptors(100).However,cautionisadvisedregardingprolonged
useofmetoclopramide,giventheserioussideeffectsincludingawarningwith
linkage to tardive dyskinesia (101,102). In cases of persistent ileus,
erythromycinmayalsobetrialed(103).IleussecondarytoSCImayalsorespond
toneostigmineorintravenouslidocaine(104,105).
Unsurprisingly,pepticulcerperforationhasthehighestoccurrencewithinthe
firstmonth after initial injurywithreported rates from 1% to5.5%(106,107).
ThegreatestriskforGIbleedisduringtheinitial3to17dayspostinjury(107).
Afteracuteinjury,stressulcerprophylaxiswitheitherhistamine-2(H2)receptor
antagonistorprotonpumpinhibitors(PPIs)isrecommendedforatleast4weeks
inallindividuals(108).PPIsmaybemoreeffectiveinpreventingbleedingwhen
compared to H2 blockers, but prolonged use of PPIs may be associated with
increasedriskofClostridiumdifficileinfection(3).Cliniciansshouldweighthe
risks versus benefits of prolonged courses of PPIs beyond 4 weeks.
Corticosteroid use is associated with increased risk of GI bleeding and ulcer
perforationinhospitalizedpatients(109).
Additionally, Pirolla et al. demonstrated an incidence rate for acute
pancreatitis of 11.53% in acute SCI (97). As such, the authors recommend
screeningforpancreatitiswithserumamylaseandlipaselevelsintheindividual
with acute SCI (97). Further imaging with CT or MRI may be required
secondary to limited physical examination findings in SCI patients, given the
potentialabsenceofsensation.Theoccurrenceofacutepancreatitisorelevated
pancreatic enzymes are more likely in patients with complete neurological
injuries(AISA),cervical-orthoracic-levelneurologicalinjuries,orpresenceof
an adynamic ileus (97). Steroid use is also associated with acute pancreatitis
(110).
WithregardtotheupperGItract,cliniciansshouldmaintainalowthreshold
for screening for dysphagia in individuals with cervical-level SCI. The
occurrence of dysphagia in those diagnosed with acute tetraplegia was 41%
(111).Significantpredictorsfordysphagiaincludetracheostomyandmechanical
ventilation,spinalsurgeryutilizingananteriorcervicalapproach,thepresenceof
a halo-vest, and older age (112,113). Early detection of dysphagia allows for
appropriate dietary modifications and reduction in potential respiratory
complications,such as aspiration pneumonia. Enteralfeedingis preferred over
the parental route and can be safely initiated within 72 hours of injury as
medically appropriate (114). Indeed, early eternal nutritional support is
associatedwithimprovedoutcomes,decreasedcomplicationrates,anddecreased
lengthofstayinmultitraumapatients(3).UsingtheSpinalNutritionScreening
Tool (SNST), one multicentered prospective study demonstrated that
undernutritionorriskforundernutritionwasassociatedwithsignificantlylonger
length of stay and higher mortality rate at 12 months (115).Additionally,the
highestnutritionalriskwasfoundinpersonswithSCIwhopreviouslyrequired
ICUcare,mechanicalventilation,orartificialnutritionalsupport(115).
Appropriatesurveillancewith laboratory testing and use of GI prophylaxis
canhelpminimizesecondaryGIcomplicationsintheindividualwithacuteSCI.
Diagnosisof abdominal pathologycan be challenginginindividuals withSCI.
Forinstance,classicalsignsofanacuteabdomenthatincludeabdominalmuscle
rigidity,abdominaltenderness,andreboundtendernessareoftenabsentinthose
withacervicallevelofinjury(106).Inadditiontolaboratorytesting,radiologic
studiesare often needed to correctly identifytheunderlying GI pathology and
guide further treatment (106). Finally, evaluation for dysphagia and
implementation of feeding with the goal of providing appropriate nutrition
supportremainsanimportantcomponentofGImanagement.
NeurogenicBowel
Neurogenicbowelisoneofthemostcommonsecondarymedicalcomplications
in SCI. In individuals with upper motor neuron bowel dysfunction, reflexmediateddefecationmaynotoccuruntiltheterminationofspinalshock,which
may last hours to weeks (116). Once a patient begins enteral feeding, bowel
movements should occur with the assistance of an established bowel program
(3). A neurogenic bowel program should be initiated during the acute
hospitalizationperiod to minimize complications such as colorectal distention,
obstruction,orimpaction(95,98).Inbrief,abowelprogramshouldbescheduled
atthe same time each day,typically 30 minutes after the ingestionof foodto
elicit the gastrocolic response if the patient is on an oral diet. Moreover, the
bowelprogramshouldbeperformedatleastonceevery2days.Dietandfluids
canhelptomodifystoolconsistency.Sinceinitiationofthebowelprogrammay
involve significant education of both the patient as well as acute care teams,
particularly nurse providers, training early onduring the hospital stay may be
beneficial.Whilethebowelprogramstartsinacutecare,itscomponentsmaybe
continually adjusted to achieve predictive and effective evacuation (98). (See
Chapter23forfurtherdetailsonestablishinganeffectivebowelprogram.)
BLADDERMANAGEMENT
Neurogenic bladder is a common issue after acute SCI, characterized by the
inabilitytovoidvoluntarily.Duringtheperiodofspinalshock,urinaryretention
iscommon in bothcompleteand incompleteSCIsecondary due totheloss of
genitourinary(GU)tractreflexactivity(3).Transurethralbladdercatheterization
shouldbeinstitutedassoonaspossibleunlessurethralinjuryissuspected,which
may be accompanied by further pelvic trauma (117). Signs of urethral injury
includebloodatthemeatus,hematuria,orahigh-ridingprostateinmales(3).
Anindwellingcatheterallowsforprecisemonitoringof urinaryoutput and
facilitatestheaccurateassessmentoffluidbalanceintheacutephasefollowing
SCI. However, specific to patients with neurogenic bladder, an indwelling
catheterin those with acuteSCIprovides further benefits, particularlyensured
bladderemptying.Whileconcernsforcatheter-associatedurinarytractinfections
(CAUTIs) often lead to early removal of indwelling catheters in patients, the
updated 2014 Association for Professional in Infection Control and
Epidemiology (APIC) guidelines for prevention of catheter-associated urinary
tract infection (CAUTI) recommend that certain individuals with SCI may
requireeitheranindwellingurinarycatheterorasuprapubiccatheter(118).We
recommendmaintaininganindwellingcatheterduringtheacutephaseofinjury
while patients are being medically stabilized and may require urgent fluid
resuscitationorIVmedications.
Careful maintenance of indwelling catheters include avoidance of kinked
catheter tubing, routine emptying of leg bag before it reaches half-full, and
monitoring for slow drainage or obstruction due to catheter encrustation or
stones (119). Indwelling urethral catheters are recommended to be changed
every2to4weeksastheriskofcatheterencrustationincreaseswithhowlong
an individual catheter is kept in place (117). Continued use of an indwelling
catheteraftertheinitialacuteperiodpostinjuryisrecommendedforpersonswith
poor hand function, high fluid intake, cognitive impairment, elevated detrusor
pressure,inthemanagementofvesicoureteralreflux,topreventdevelopmentof
autonomicdysreflexia with bladder filling, and/orthosewith limited caregiver
assistance(117).
From a medical standpoint, indwelling urethral catheterization may be
removedwhenanindividualishemodynamicallystableandnolongerrequires
significant amounts of IV administration. The APIC recommends intermittent
catheterization(IC)programfor individualswho cancatheterize independently
(118). Functionally, an individual should have the physical ability to
independentlyperformICand the cognitive ability to adhere to the scheduled
regimenandfluidrestrictionrequiredtoeffectivelymanageICindependently.
An IC program consists of either an individual with SCI or his or her
caregivertemporarilyinsertingacatheterintothebladderonaroutineschedule
todrainthebladder.Thenormalbladdercapacityis500ml;ICvolumesshould
be maintained below normal bladder capacity to reduce the risk of bladder
overdistensionandischemia.TheuseofanICprogrameliminatestheneedfora
constant indwelling catheter. While IC is considered the gold standard for
bladdermanagementinSCI,severalreasonsexistfordelayingan ICprogram.
ComplicationsassociatedwithICprogramincludeUTI,bladderoverdistension,
and urinary incontinence (unless volumes are closely monitored), urethral
trauma, urethral false passage development, urethral stricture, autonomic
dysreflexia,andbladderstones(117).
Whendecidingonneurogenicbladdermanagement,therearethreeimportant
goals, including preservation of the upper tract, decrease in lower tract
complications,andcompatibility withfunctionandlifestylegoals (117).While
previousthoughtrationalesuggestedanacontractiledetrusorduringacuteSCI,a
recent study published by Bywater et al. reported almost two-thirds of
individualsdevelopedunfavorableurodynamic activity categorized as detrusor
overactivity, detrusor sphincter dyssynergia, elevated maximum detrusor
pressure, vesicouretero-renal reflux, and low bladder compliance (120). Both
maintainingan indwellingcatheter andinitiatingan ICprogram areassociated
with risks and benefits in the individual with SCI and, as such, need to be
carefullydecidedupon andmonitored. Otherlesscommonmethodsof bladder
managementthatincludeCredeandValsalvaarediscussedindetailinChapter
22onbladdermanagement.
ANEMIA
AnemiaisacommoncomplicationfollowingacuteSCI.Initialbloodlossmay
occursecondarytotheinitialtraumaticeventorduring surgery.Inonereview,
estimatedbloodlossranged from674to3,556mLbasedonthecomplexityof
spinal surgery and requirement of fusion (121). Once a patient arrives in the
intensivecare unit, frequent phlebotomy furtherdepletesan individual’sblood
supply. In addition, aggressive resuscitation with IV fluids during the initial
injurymayalso lead to hemodilution. In a recent review evaluating restrictive
versusliberalredbloodcelltransfusionprotocols,theidealhemoglobinlevelfor
transfusion is unknown, given the limited number of individuals with SCI
included in the studies (122). Reduced hemoglobin concentrations, however,
lead to impairment in oxygen delivery to both brain and spinal cord tissues
(122).
Inoneprospectivestudy,Grossmanetal.reportedthat15.9%ofacuteSCI
developsevereanemia(hemoglobin≤8.0mg/dl)duringtheinitialhospitalization
period(123).Atinitialadmissionto rehabilitation,onestudyshowedthat65%
of patients were anemic (hemoglobin <13.0 g/dl) and 86.7% were
hypoalbuminemic (albumin <3.2 g/dl) (124). Previously, Huang et al., had
showed the most common form of anemia was normochromic-normocytic
during the acute phase of SCI (125). By 1 year after SCI, however, anemia
improves in most patients; in those who show persistent anemia, it may be
associatedwithconcurrentchronicinflammatoryconditions(124).
THERAPY
Early involvement of physical therapy (PT), occupational therapy (OT), and
speech therapy (ST) services in the acute care hospital setting remains an
important component of SCI care. PT focuses on early mobilization of the
patientasmedicallyappropriate(126).Inaddition,PTalsoeducatesthepatient
andfamilyaswellastheclinicalcareteamregardingrange-of-motionexercises
of the extremities to help maintain joint mobility as well as muscle mass.
Exercise programs are based on a person’s neurological status and medical
stability.OTassistsintheprovisionofappropriatesplintstomaintainanatomic
positioning of joints and to preventcontractureformation. Along with splints,
OT can also assess and educate persons with SCI about specialized tools for
activities of daily living and for communication. Finally, ST evaluates
swallowing function and treats dysphagia when present. For those with
tracheostomies,ST also works on communicationstrategiesthatcan include a
speakingvalve.Employingamultidisciplinaryapproachduringtheacutephase
ofSCIenablestheinitiationofrehabilitationstrategiesearlyonwiththegoalof
improving function and independence while minimizing complications from
immobility.
CONCLUSION
This chapter aims to highlight the importance and strategies of acute
managementoftraumaticSCIpatients.Betteroutcomesaregenerallyassociated
with early recognition of injury, management at an appropriate facility, and
timelyinitiationofappropriatenonsurgicalandsurgicaltreatments.Furthermore,
throughasystematicapproach,secondarymedicalcomplicationscanbereduced
orprevented. Proper management can reduce duration of acute hospitalization
andallowforearliertransitiontocomprehensiverehabilitation.
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