why do spinal injured patients die? diagnostic dilemmas management errors misunderstanding spinal...
TRANSCRIPT
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Why do spinal injured patients die?
Diagnostic dilemmas
Management errors
Misunderstanding spinal cord injuries
Why do things go wrong ?
Long term problems arise from shortsightedness
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Incidence20/million population per year
RTAMotorbikecarpedestriancyclist
Fallsjumpedpushed
SportsDivinghorseridingrugby
Infections Tumours Discs Iatrogenic
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SCIWORA
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Spinal Cord Injury Without Radiographic Abnormality
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Neuronaldysfunction/ death
Direct trauma
Haematoma Ischaemia
Hypotension
HypoxiaOedema
Pathophysiology of spinal cord injury
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Cardiorespiratoryphysiology
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Respiratory Afferents
Intrapulmonary receptors VagusStretch/proprioreceptors ribs/intercostals T1-T12Clavicles Low Cervical
Chemoreceptors Carotid bodyChemoreceptors Brainstem
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Respiratory dysfunction
Lumbar Unable to cough
Low thoracic chest wall compliance Vital capacity
High thoracic chest wall compliance Vital capacitypoor expansion. Basal collapse
C5/C6 Diaphragms and accessory only
C3/C4/C5 Accessory only
Above C3 Very little
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0
200
400
600
800
1000
1200
1400
1 2 3 4 5 6 7 8 9 10 11
Week
fvc
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Respiratory autonomic dysfunction
Bronchial hypersecretionBronchial hyper-responsiveness
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Respiratory monitoring
Lung function FVC, PEFR, Speech, RR
FVC> 1LFVC < 1LFVC= Tidal volume
Pulse oximeter
Blood gasses
Watch closely in an appropriate environment for several days
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Respiratory treatment
Oxygen
A good physiotherapist
NIPPB (Birding)
Non-invasive ventilation
Invasive ventilation
Tracheostomy
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Respiratory treatment
What if they do get ventilated ?
Weaning is likely to be slow and difficult
Wait until pulmonary compliance is normaland chest is clear
Extubate onto noninvasive bipap
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How to intubate?Emergency or elective?
Awake or sedated or asleep?
Suxamethonium?
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Acute cardiovascular changes
Vasodilation Vasoconstriction
T4-T6
Hypotension
Loss of cardiac sympathetics
Bradycardia
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Acute cardiovascular changes
Be carefull…..
Postural hypotension
Vagal stimulation (tracheal suction)
Pressure sores
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Cardiovascular management
Judicious fluid managementCVP monitoringPA catheterOesophageal doppler
Inotropes
ChronotropesTemporary pacing
Why Bother ?
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NASCIS III
Methylprednisolone
30mg/Kg over 15 minuteswait 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