What is the emergency management for a suspected spinal cord injury?

Emergency Management of Suspected Spinal Cord Injury

In suspected spinal cord injury cases, airway management should prioritize maintaining a patent airway while minimizing cervical spine movement, with videolaryngoscopy recommended as the preferred intubation method when available. 1

Initial Assessment and Stabilization

• Ensure scene safety before approaching the patient to prevent further harm 2
• Activate emergency medical services immediately for prompt medical attention 2
• Check responsiveness by tapping the victim and shouting to assess level of consciousness 2
• If unresponsive, assess airway, breathing, and circulation to identify life-threatening conditions 2
• If no breathing or abnormal breathing (gasping), begin CPR immediately 2

Airway Management

Manual Stabilization

• Initially use manual spinal motion restriction (placing hands on either side of the patient's head to hold it still) rather than immobilization devices 1
• For airway opening in suspected cervical spine injury, use jaw thrust without head extension rather than head tilt-chin lift 1
• If jaw thrust does not adequately open the airway, use head tilt-chin lift as maintaining a patent airway is the priority 1

Collar Management

• During tracheal intubation attempts, remove the semi-rigid or rigid cervical collar (at least the anterior portion) to improve mouth opening while maintaining stabilization 1
• Removing the collar improves glottic exposure while minimizing cervical spine movement 1

Intubation Techniques

• Where possible, use videolaryngoscopy for tracheal intubation in patients with suspected or confirmed cervical spine injury 1
• Consider using an adjunct such as a stylet or bougie when performing tracheal intubation in a patient whose cervical spine is immobilized 1
• If manual in-line stabilization (MILS) is used, have a low threshold for its removal if intubation becomes difficult 1

Supraglottic Airway Devices

• Second-generation supraglottic airway devices (SADs) should be considered in preference to first-generation SADs if needed 1
• Use familiar and available supraglottic airway devices as no specific device is clearly superior in reducing cervical spine movement 1

Hemodynamic Management

• Maintain systolic blood pressure >110 mmHg to reduce mortality in spinal cord injury patients 3
• Implement measures to prevent pressure ulcers, including frequent repositioning and pressure zone checks 3

Timing of Surgical Intervention

• Early surgical decompression (within 24 hours of injury) is recommended to improve long-term neurological recovery 3, 4
• In specialized centers, ultra-early surgery (<8 hours) may further improve outcomes and reduce respiratory complications 3

Special Considerations

• Cervical spine injuries, particularly those affecting upper cervical levels, can compromise neural pathways that innervate the larynx, leading to sensory deficits and increased aspiration risk 5
• Patients with cervical spine injuries often demonstrate reduced ability to generate adequate expiratory pressures needed for effective cough 5
• Multidisciplinary planning, preparation, and optimization of human factors should be considered before airway management 1
• In pre-hospital and military settings, airway management should follow standard algorithms relevant to those particular clinical settings 1

Common Pitfalls to Avoid

• Avoid delaying airway management due to concerns about cervical spine movement, as maintaining a patent airway is the priority 1
• Don't rely solely on cervical collars for immobilization during airway management, as they can worsen intubation conditions and may not effectively limit cervical spine movement 1
• Avoid excessive ventilation during CPR as it can cause gastric inflation and resultant complications 1
• Don't delay surgical decompression beyond 24 hours if indicated, as early intervention improves outcomes 3, 4