When is Basic Life Support (BLS) versus Advanced Life Support (ALS) indicated for a spinal cord injury patient?

Spinal Cord Injury: BLS vs ALS Transport Decision Algorithm

Spinal cord injury patients require Advanced Life Support (ALS) transport in most cases, particularly those with injuries above T6 due to the high risk of respiratory compromise, hemodynamic instability, and neurological deterioration requiring advanced interventions. 1

Primary Assessment Factors

Injury Level Considerations

• High cervical injuries (C1-C4): ALWAYS require ALS due to high risk of respiratory failure and neurological deterioration 2
• Mid-cervical injuries (C5-C8): Require ALS due to potential respiratory compromise and autonomic dysfunction 3
• Upper thoracic injuries (T1-T6): Require ALS due to sympathetic disruption and cardiovascular instability 3
• Lower thoracic/lumbar injuries (T7 and below): May be appropriate for BLS if:
  • Patient is hemodynamically stable
  • No respiratory compromise
  • No other significant traumatic injuries

Physiological Parameters Requiring ALS

• Respiratory distress or insufficiency
• Hemodynamic instability (SBP <90 mmHg)
• Bradycardia (<60 bpm) or other dysrhythmias
• Altered mental status
• Need for advanced airway management
• Need for medication administration (vasopressors, etc.)

BLS Transport Criteria

BLS transport may be appropriate ONLY when ALL of the following conditions are met:

• Injury below T6 level
• Normal vital signs (HR, BP, RR, SpO2)
• No respiratory compromise
• Full consciousness
• No other significant traumatic injuries
• Short transport time to definitive care

ALS Requirements for SCI Management

ALS providers have essential equipment and training for SCI management including:

• Advanced airway equipment: For early intubation in high cervical injuries 1, 4
• Cardiac monitoring: For detecting and managing dysrhythmias 1
• IV access and fluid administration: For maintaining MAP >85 mmHg 2
• Medication administration: For managing hypotension, bradycardia, and pain
• End-tidal CO2 monitoring: For respiratory assessment and ventilation management 1

Special Considerations

Neurogenic Shock

• Characterized by hypotension and bradycardia due to loss of sympathetic tone
• Common in injuries above T6
• Requires ALS interventions (IV fluids, vasopressors, atropine) 5, 3

Respiratory Compromise

• Progressive respiratory failure may develop rapidly in cervical injuries
• Patients with injuries at C5 or above often require ventilatory support 5
• Early recognition and management by ALS providers is critical

Termination of Resuscitation Considerations

• BLS and ALS have different termination of resuscitation (TOR) protocols 1
• ALS TOR rules have higher specificity (94-100%) for predicting poor neurological outcomes
• For traumatic SCI arrests, at least 30 minutes of resuscitative efforts should be attempted before considering termination 4

Decision Algorithm

1. Initial Assessment:

   • Determine level of injury (cervical, thoracic, lumbar)
   • Assess vital signs and neurological status
   • Evaluate respiratory function

2. Immediate ALS Criteria (any ONE warrants ALS):

   • Injury at or above T6
   • Respiratory distress or SpO2 <94%
   • Hemodynamic instability (SBP <90 mmHg)
   • Bradycardia (<60 bpm)
   • GCS <15 or deteriorating mental status
   • Multiple trauma

3. BLS Consideration (ALL must be present):

   • Injury below T6
   • Stable vital signs
   • No respiratory compromise
   • Fully alert and oriented
   • Isolated SCI without other significant injuries
   • Short transport time

Common Pitfalls to Avoid

• Underestimating respiratory deterioration: Patients with cervical injuries may initially appear stable but can rapidly develop respiratory failure 2
• Failing to recognize neurogenic shock: Hypotension without tachycardia should raise suspicion in SCI patients
• Inadequate spinal immobilization: Both BLS and ALS require proper spinal motion restriction techniques 1
• Delayed transport: Definitive care should not be delayed regardless of provider level

Remember that spinal cord injuries, especially those above T6, represent a time-sensitive emergency where advanced interventions may be needed rapidly. When in doubt, ALS transport provides the safest option for managing potential complications.