• Status of the ABCs.

• The patient's level of consciousness (GCS or equivalent in plain language).

• Has he or she changed under your care?

• Scalp/head injuries that can be visualized.

• Results of any x-rays/labs and other injuries.

• Mechanism of injury, if known.

Early evaluation and treatment of the patient with spine/spinal cord injury (S/SCI) is not difficult, as long as some basic principles are remembered and followed.

Always suspect the presence of these types of injuries. Patients with head injuries and/or unconsciousness, supraclavicular injuries, or those involved in high-speed vehicular accidents are all suspect, as is the patient in whom there is an obvious neurologic deficit which can be traced to the spinal cord.

The second principle is immobilization.

All patients who are suspected of having S/SCI should be completely immobilized on a spine board with collar and sandbags. The ATLS course and skill stations provide a basis for the techniques and equipment used in immobilization; common sense, and ingenuity may be needed in situations where standard equipment is unavailable.

Concurrent with the suspicion and immobilization phases is the assessment of the ABCs. The airway and breathing of the S/SCI patient may be compromised by:

1. Local neck trauma or

2. Impairment of diaphragmatic/accessory muscle function.

These patients may appear to have satisfactory respiratory function upon initial evaluation, but they frequently tire; this is best prevented by early intubation with (attention to immobilization), rather than waiting until the patient gets into serious trouble during transfer.

The next factor to assess is "C." A spinal cord injury, especially one that achieves complete physiologic or

physical transection of the spinal cord, causes a sympathectomy. This is manifested by hypotension and bradycardia. The concurrence of SCI with hypotension and bradycardia is known as neurogenic shock; it is crucial to the survival of the patient to diagnose and treat any concomitant hypovolemic shock, since the SCI patient is unable to mount the characteristic tachycardia of hypovolemic shock. The SCI patient's neurologic dysfunction interferes with evaluation of the abdomen, pelvis, and legs, all places where significant causes of hypovolemic shock may lurk. Since the sympathectomy effect has essentially increased the volume of the intravascular tank, volume expansion may not have much of an effect on the blood pressure (BP). A BP of 90 mmHg, however, is adequate for perfusion in the supine position (which this patient will be in since he or she is properly immobilized). A foley catheter should be inserted to prevent bladder distention and assess renal function as an indicator of perfusion.

Neurologic assessment of the patient is necessary to determine his or her initial status and to document

any improvement or decrement in function. While a formal neurologic exam is required, impressions of the patient's neurologic function can be gained from his or her conduct during the initial phases of evaluation and resuscitation; how does he or she respond to the painful stimuli of IVs and blood drawing? Does the patient’s arms and legs move in response to stimuli? Flaccidity of muscles and absence of reflexes are the rule in the early hours and days following spinal cord injury; this symptom complex is known as spinal shock, and it usually is replaced by the classic spasticity and hyperactive reflexes of upper motor neuron lesions in several days to weeks following the injury. A critical determination is the presence or absence of sacral sensation; its presence denotes an incomplete spinal cord injury (some messages are getting past the injury), and signals a much more hopeful prognosis for return of neurologic function than for the patient in whom it is absent.

The primary job of the persons caring for a patient with a (potential) S/SCI is to prevent worsening of the neurologic status. This includes proper immobilization and continuous re-evaluation of the neurologic status. Definitive treatment is performed at a center with neurosurgical or orthopedic spine expertise.

Controlled studies have demonstrated improved neurologic outcome in patients with spinal cord injury who receive steroids early after the injury. Steroid administration is indicated for non-penetrating spinal cord injury, but it must be given within 8 hours of the injury. The dosing of methylprednisolone is 30 mg/kg IV bolus over 15 minutes. Forty-five minutes after bolus completion, start methylprednisolone infusion at 5.4 mg/kg/hr for 23 hours.

Vital information for the accepting physician includes the patient's neurologic status and course while under observation, the status of the ABCs, and any associated injuries. Careful transfer of the patient must be carried out, and pretransfer thought given to any untoward events which might be anticipated by the patient's status. Pretransfer intubation may need to be considered, depending upon severity of injury, distance, mode of transfer, and sophistication of personnel accompanying the patient.

Prevention is the best treatment for spinal cord injuries. The GMO can help prevent spinal cord injuries by encouraging each patient to use seat belts, drive a car with an airbag, and avoid driving while intoxicated. Also encourage patients to avoid traveling as a passenger with an intoxicated driver. Diving represents another mechanism of injury, particularly in locations where depth/obstacles may be unknown. The neurosurgical community has encouraged the feet first, first time campaign to try to minimize the occurrence of diving-related SCI. Prevention works best.