ReviewSpinal cord injury (SCI)—Prehospital management☆
Introduction
This paper presents an overview of current practice in the prehospital management of acute spinal cord injury (SCI). Epidemiology, examination, patient immobilisation, airway management, cardiovascular support, and pharmacological treatment are discussed.
The annual incidence of SCI including prehospital fatalities has been estimated at 43–77 per million inhabitants in the United States which equates to about 20,000 patients every year. About 20% of these patients die before they are admitted to the hospital [1], [2], [3]. This incidence of SCI is associated with a prevalence of about 200,000 patients in the United States [1].
Of these SCI patients 50–70% are between 15 and 35 years of age, while 4–14% are 15 years old or younger. The male-to-female ratio is 4:1. In 1990, the estimated costs for therapy of SCI in the United States were around US$ 4 billion per year [1]. Therefore, SCI is a major cause of mortality and morbidity in young individuals and as a result has a major impact on society as a whole.
The most frequent causes of SCI in adults are motor vehicle accidents (40%), falls (21%), acts of violence (15%), and sports-related injuries (13%). In children SCIs are mostly due to sports (24%) and water recreational activities (13%) [1], [4].
In a retrospective chart view of 331 patients, Domeier et al. described the distribution of SCI as 29% cervical, 24% thoracic, 37% lumbar, and 10% sacral, due to the varying stability of the spine (Fig. 1, Fig. 2) [5].
The following clinical symptoms associated with SCI are useful in identifying patients who require specific prehospital treatment: lumbar pain, head injury and altered mental status, cervical pain, neurological deficit, thoracic pain, and spinal tenderness (Table 1) [5].
It is very important to know that pain from SCI is not necessarily localized in the area of injury. In 18% of cervical, in 63% of thoracic, and in 9% of lumbar injuries, the pain is located elsewhere [5]. If there is pain in a site that can be related to SCI, it is necessary to take special care because the location of injury can be in another segment of the spine. Moreover, if a spinal injury is identified, there can be further injuries at other spine segments in up to 15% [6].
It is well known that SCI occurs in 5–10% of patients suffering from severe traumatic brain injury (TBI); conversely, 25–50% of patients with SCI have an associated head injury [7], [8]. Moreover, SCI occurs in 10–30% of patients with multiple trauma. The majority of trauma in Europe is blunt. Abdominal and thoracic trauma are often associated with severe haemorrhage; SCI occurs in up to 30% of these patients. Therefore, SCI should always be considered in patients with multiple trauma, as well as in those with minor trauma who report spinal pain and/or have sensory or motor symptoms, and in those with an altered mental status [9], [10].
Abdominal bleeding or traumatic brain injury in patients suffering from multiple trauma cause higher mortality rates than SCI. Therefore, it is necessary that in severely injured patients, treatment priorities should be established based on their injuries, vital signs, and the injury mechanisms, according to established advanced trauma life support (ATLS) principles. Therefore, prehospital treatment in patients with multiple trauma should be always conducted in accordance with the management of the principal life threatening injury, but the subsequent management of SCI must be born in mind all the time [11].
Section snippets
Prehospital management of SCI
The goal of prehospital management of SCI is to reduce neurological deficit and to prevent any additional loss of neurological function. Therefore, prehospital management at the scene should include a rapid primary evaluation of the patient, resuscitation of vital functions (airway, breathing, circulation; the “ABCs”), a more detailed secondary assessment, and finally definitive care (including transport and admission to a trauma centre). Moreover, after arrival at the scene, it is important to
Pharmacological treatment
Some experimental studies have suggested that treatment with methylprednisolone (MPS) may be beneficial in SCI [50], [51]. Possible positive effects of MPS are cell membrane stabilisation, inhibition of lipid peroxidation and a reduction of oxygen free radicals, increased blood flow, and a reduction of oedema and inflammation [9].
The most important clinical studies considered methylprednisolone (MPS) naloxone, tirilazad mesylate, and GM-1 gangliosides. Indeed, the clinical use of MPS was
Transportation and type of trauma centre
The choice of vehicle depends on the patient and the local setting. Both ground and helicopter transportation are possible. In order to make a decision about the type of trauma centre, it is necessary to consider the status of the patient (haemodynamically stable versus unstable). Stable patients should be transported to the nearest level 1 centre, if it can be reached within a given period. Sometimes a longer transportation time to a level 1 trauma centre is preferable. Unstable patients
Conclusions
There is no doubt that prehospital management of SCI is very important, since 25% of SCI damage may occur or be aggravated after the initial event. The prehospital management of acute SCI includes examination of the patient, spinal immobilisation, oxygenation, and careful airway management as well as cardiovascular support (Table 8). Emergency treatment to reduce the risk of a secondary SCI includes intubation of the trachea, if indicated (under manual in-line stabilisation), and maintaining
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Cited by (0)
Presented in part at the Third International Interdisciplinary Congress “EuroNeuro 2002”, from 12–14 September 2002, in Munich, Germany by B.W. Böttiger.
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A Spanish translated version of the Abstract and Keywords of this article appears as Appendix at 10.1016/j.resuscitation.2005.03.005.