Why do spinal injured patients die? Why do things go wrong ? Diagnostic dilemmas Management errors Misunderstanding spinal cord injuries Long term problems arise from shortsightedness
Incidence 20/million population per year RTA Motorbike car pedestrian cyclist Falls jumped pushed Sports Diving horseriding rugby Infections Tumours Discs Iatrogenic
Pathophysiology of spinal cord injury Direct trauma Neuronal dysfunction/ death Ischaemia Haematoma Hypotension Hypoxia Oedema
Respiratory Afferents Intrapulmonary receptors Vagus Stretch/proprioreceptors ribs/intercostals T1-T12 Clavicles Low Cervical Chemoreceptors Carotid body Chemoreceptors Brainstem
Respiratory dysfunction Lumbar Unable to cough Low thoracic é chest wall compliance ê Vital capacity High thoracic éé chest wall compliance êê Vital capacity poor expansion. Basal collapse C5/C6 Diaphragms and accessory only C3/C4/C5 Accessory only Above C3 Very little
Respiratory autonomic dysfunction Bronchial hypersecretion Bronchial hyper-responsiveness
Respiratory monitoring Lung function FVC, PEFR, Speech, RR FVC> 1L FVC < 1L FVC= 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 normal and chest is clear Extubate onto noninvasive bipap
How to intubate? Emergency or elective? Awake or sedated or asleep? Suxamethonium?
Acute cardiovascular changes Vasodilation ßà 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 management CVP monitoring PA catheter Oesophageal doppler Inotropes Chronotropes Temporary pacing Why Bother ?
NASCIS III Methylprednisolone 30mg/Kg over 15 minutes wait 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