SCI: the First 24 Hours
Spinal cord injury (SCI) strikes seemingly at random, coming out of nowhere to unleash its mayhem on the unsuspecting. In the blink of an eye, lives are thrown off track and into an alien world of paralysis. A goal of SCI Lawyers is to offer those who suddenly find themselves in SCI-land a roadmap to move forward, and thrive, amidst these changes – especially here in Southern California.
SCI is caused by the blunt force of impact. The force could be the result of medical wrongdoing, a fall, a sports injury, or most often, a car or motorcycle wreck. The trauma may kill nerves in the spinal cord that transmit information from the brain to the body, and from the body to the brain. Loss of these nerves can result in paralysis.
The immediate injury to the cord can also produce bleeding, swelling and biochemical chaos at the injury site; this may contribute to further nerve loss and continue for hours, days, and even weeks, after injury. While nothing can be done to reverse the crushing impact that caused the injury, many experiments have shown that so-called secondary damage can be minimized, thus reducing the degree of disability.
The management of trauma involves a complex system of care, including immobilization, evacuation and emergency treatment. While it is said that the first 24 hours are the most critical in trauma medicine, people who sustain a major accident don’t get a chance to make many decisions during this period. Someone calls 911, the ambulance or helicopter shows up. Emergency techs, taught to be very careful removing people from accident scenes, to avoid worsening the injury, typically use rigid cervical collars for immobilization, with supportive blocks on a backboard to secure the entire spine of patients.
The injured party doesn’t pick what hospital to get sent to, or what physician team will respond. In larger population areas of the U.S., SCI cases are handled by skilled trauma centers (Level I is the highest level; Level II is similarly specialized but usually not associated with a teaching hospital). Research has shown that a specialized trauma center setting, with a full range of highly trained hands on staff, including emergency doctors, neurosurgery, orthopedic surgery, anesthesiology, and skilled nursing greatly increases chances for survival and recovery.
The first hours after a spinal cord injury are critical: doctors not only need to preserve spinal cord function in the likely presence of a broken backbone, there may be numerous other complications. People with spinal cord injuries often show up in the ER with cuts, internal injuries, broken bones or burns. There is also a relatively high rate of head injury associated with SCI. This further supports the need for early transfer to a Level I center.
A seriously injured person may arrive in the emergency room with multiple injuries; he or she may be unconscious, or mentally impaired. The priority is to make sure the airways are clear, that the person is breathing, and that circulation is maintained. Medical assessments are made, including blood pressure and vital capacities. If breathing ability is reduced, assistance may be necessary. In some cases a ventilator may be used. In most cases of spinal cord injury, the patient will likely go into “spinal shock,” meaning that all reflexes are gone. The injured person may experience issues with heart rate and blood pressure. Fluids may be replaced. Higher levels of SCI are prone to low blood pressure, which can lead to pooling of blood in the arms and legs. ER physicians sometimes use a type of drug (vasopressors – dopamine, norepinephrine, phenylephrine) to treat low blood pressure.
Injured persons are examined for neurological damage; doctors use what’s called an AIS score (ASIA Impairment Scale) to measure motor function below the injury; this is derived by testing ten muscle groups in the elbow, wrist, fingers, hips, knees, ankles and toes. Sensation is also measured, using light touch or pinprick across the 28 sensory zones in the body. These tests may be made several times over the course of the first days of injury as motor and sensory scores can change, for better or worse.
The patient may then be brought to the radiology area. There, technicians will do a CT scan, and most likely also an MRI. A CT scan (or CAT scan) is best for viewing injuries to bone. It has the advantage of speed – it takes less than five minutes. An MRI is best for examining soft tissue and ligament injuries – very useful in diagnosing spinal cord damage – but can take up to 30 minutes.
Depending on the specific damage to the bones of the back, a patient may require surgery. The neurosurgeon on call decides when to begin surgery, soon after injury, within the first 24 hours, or to wait for the cord to heal for a few days.
One goal may be to take pressure off spinal cord tissue, especially removing bone fragments that may be pressing on the cord. If the bones are damaged, the surgeon may stabilize the spine, and may take bone from the patient’s hip to rebuild the bone. Other options include use of metal hardware such as plates, screws and rods to fortify the backbone and to eliminate pressure on the cord.
Other medical issues often arise early on after SCI. Deep vein thrombosis is common, the result of poor circulation and blood clotting in the lower extremities. The greatest risk is for a clot to move through the bloodstream and into the lungs, resulting in a life-threatening situation. The blood-thinning drug heparin may be used to addresses this complication; and some patients may wear compression socks. In some quads, a filter is inserted in a major artery to reduce the risk that a loose clot will reach the lungs.
Bladder and bowel management can begin as soon as a patient with SCI is stabilized. Nutrition is an important part of critical care too. If swallowing is an issue, food by tube may be necessary.
Pain accompanies SCI in most cases; doctors will balance pain management with the need for further assessments of nerve function.
Skin care is a critical issue for people with SCI. A pressure sore is a skin infection that can occur if pressure on skin is not relieved often. A sore can begin even after a few hours of limitation on movement. In acute care, pressure relief over areas where a patient’s bones are close to the surface (like the hip bones) starts right away, shifting every 30 minutes.
Injuries above the T6 level are often accompanied by the body’s inappropriate response to poor regulation of blood pressure. This indicates over-activity of the part of the nervous system that controls heart rate, breathing and digestion, things we don’t think about. This can be a serious, life-threatening complication that must be closely watched. For more about AD, see the Reeve Foundation Paralysis Resource Center.
Spinal cord injury patients may be asked to participate in a clinical trial. Some of these experimental therapies begin within the first few hours or days of injury, which complicates the decision to participate.
Moving on to Rehab
Up to now, most decisions have been made by the emergency staff. But soon the patient is stabilized and transferred to long term care. Now is when the patient has to start taking charge and becoming a partner with the medical and rehab teams. The earlier the better for assessment and treatment by physical and occupational therapists, rehab nurses, speech and language pathologists, and rehab psychologists. Early intervention may prevent secondary complications and thereby shorten length of acute hospitalization.
Expectations for Recovery:
It’s not necessarily possible to anticipate the level of a person’s expected recovery the first day after spinal cord injury. After three days or so, though, it may be possible to assess with good accuracy the expected outcomes for a particular injury.