Elsevier

Resuscitation

Volume 66, Issue 2, August 2005, Pages 127-139
Resuscitation

Review
Spinal cord injury (SCI)—Prehospital management

https://doi.org/10.1016/j.resuscitation.2005.03.005Get rights and content

Abstract

Up to 20,000 patients annually suffer from spinal cord injury (SCI) and 20% of these die before being admitted to the hospital in the United States as well as in the European Union. Prehospital management of SCI is of critical importance since 25% of SCI damage may occur or be aggravated after the initial event. Prehospital management includes examination of the patient, spinal immobilisation, careful airway management (intubation, if indicated, using manual in-line stabilisation), and cardiovascular support (maintenance of mean arterial blood pressure above 90 mmHg) and blood glucose levels within the normal range. It is still not known whether additional specific therapy is useful. Studies have not demonstrated convincingly that methylprednisolone (MPS) or other pharmacological agents really have clinically significant and important benefits for patients suffering from SCI. Recently published statements from the United States also do not support the therapeutic use of MPS in patients suffering from SCI in the prehospital setting any more. Moreover, at this stage, it is not known whether therapeutic hypothermia or any further pharmacological intervention has beneficial effects or not. Therefore, networks for clinical studies in SCI patients should be established, as a basic requirement for further improvement in outcome in such patients.

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

References (67)

  • D. Toni et al.

    Influence of hyperglycaemia on infarct size and clinical outcome of acute ischemic stroke patients with intracranial arterial occlusion

    J Neurol Sci

    (1994)
  • B.E. Bledsoe et al.

    High-dose steroids for acute spinal cord injury in emergency medical services

    Prehosp Emerg Care

    (2004)
  • S. Sauerland et al.

    A CRASH landing in severe head injury

    Lancet

    (2004)
  • L.H.S. Sekhon et al.

    Epidemiology, demographics, and pathophysiology of acute spinal cord injury

    Spine

    (2001)
  • J. Surkin et al.

    Spinal cord injury in Mississippi. Findings and Evaluation, 1992–1994

    Spine

    (2000)
  • D.J. Thurman et al.

    Surveillance of spinal cord injuries in Utah, USA

    Paraplegia

    (1994)
  • R.M. Domeier et al.

    Prehospital clinical findings associated with spinal injury

    Prehosp Emerg Care

    (1997)
  • D.B. Michael et al.

    Coincidence of head and cervical spine injury

    J Neurotrauma

    (1989)
  • R.D. Stevens et al.

    Critical care and perioperative management in traumatic spinal cord injury

    J Neurosurg Anesthesiol

    (2003)
  • B.W. Chiles et al.

    Acute spinal injury

    N Engl J Med

    (1996)
  • L.T. Holly et al.

    Cervical spine trauma associated with moderate and severe head injury: incidence, risk factors, and injury characteristics

    J Neurosurg

    (2002)
  • M. Bernhard et al.

    Preclinic management of multiple trauma

    Anaesthesist

    (2004)
  • T.J. Hodgetts et al.

    Essential role of prehospital care in the optimal outcome from major trauma

    Emerg Med

    (2000)
  • A. Biewener et al.

    Impact of helicopter transport and hospital level on mortality of polytrauma patients

    J Trauma

    (2004)
  • J.E. Carvell et al.

    Complications of spinal surgery in acute spinal cord injury

    Paraplegia

    (1994)
  • M.J. Devivo et al.

    Benefits of early admission to an organised spinal cord injury system

    Paraplegia

    (1990)
  • T.A. Dyson-Hudson et al.

    Acute management of traumatic cervical spinal cord injuries

    Mt Sinai J Med

    (1999)
  • S. Podolsky et al.

    Efficacy of cervical spine immobilization methods

    J Trauma

    (1983)
  • Guidelines for management of acute cervical spinal injuries. Chapter 1. Cervical spine immobilization before admission to the hospital

    Neurosurgery

    (2002)
  • G.C. Velmahos et al.

    Intubation after cervical spinal cord injury: to be done selectively or routinely?

    Am Surg

    (2003)
  • D.J. Muckart et al.

    Spinal cord injury as a result of endotracheal intubation in patients with undiagnosed cervical spine fractures

    Anesthesiology

    (1997)
  • B.D. Davis et al.

    Role of rapid sequence induction in the prehospital setting: helpful or harmful?

    Curr Opin Crit Care

    (2002)
  • P.D. Sawin et al.

    Cervical spine motion with direct laryngoscopy and orotracheal intubation. An in vivo cinefluoroscopic study of subjects without cervical abnormality

    Anesthesiology

    (1996)
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    Presented in part at the Third International Interdisciplinary Congress “EuroNeuro 2002”, from 12–14 September 2002, in Munich, Germany by B.W. Böttiger.

    A Spanish translated version of the Abstract and Keywords of this article appears as Appendix at 10.1016/j.resuscitation.2005.03.005.

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