What is the management of spinal shock?

Management of Spinal Shock

The management of spinal shock requires immediate spinal immobilization, aggressive hemodynamic support targeting systolic blood pressure >110 mmHg initially and mean arterial pressure ≥70 mmHg during the first week, respiratory support as needed, and early prevention of secondary complications including pressure ulcers and urological issues. 1, 2

Immediate Stabilization and Immobilization

Early spinal immobilization is critical for any trauma patient with suspected spinal cord injury to prevent onset or worsening of neurological deficits. 1

• Apply manual in-line stabilization (MILS) during all airway management procedures, combined with removal of the anterior cervical collar portion during intubation to improve glottic exposure while maintaining cervical spine protection 1
• For pre-hospital intubation, use rapid sequence induction with direct laryngoscopy, gum elastic bougie, and maintain cervical spine axis without Sellick maneuver to maximize first-attempt success 1
• Transport patients on rigid backboard with head fixation and vacuum mattress 1

Hemodynamic Management

Maintaining adequate spinal cord perfusion is the cornerstone of preventing secondary injury and requires aggressive blood pressure targets that exceed typical trauma resuscitation goals. 1, 2

Blood Pressure Targets:

• Maintain systolic blood pressure >110 mmHg during the initial pre-assessment phase to reduce mortality 1
• Target mean arterial pressure ≥70 mmHg continuously during the first week post-injury to limit neurological deterioration 1
• Use fluid resuscitation and vasopressors as needed to achieve these targets 2, 3

Vasopressor Selection:

• Phenylephrine demonstrates lower complication rates compared to dopamine in both complete and incomplete spinal cord injuries 3
• Norepinephrine provides approximately 2 mmHg increase in spinal cord perfusion pressure without differential MAP effects versus dopamine 3
• Dopamine carries higher rates of complications, particularly in elderly patients with spinal cord injury 3
• Consider oral pseudoephedrine as adjunctive therapy to facilitate weaning from intravenous vasopressors 3

Common pitfall: Neurogenic shock incidence varies dramatically (reported 19-100%) depending on diagnostic criteria used; ensure you distinguish true neurogenic shock from hypovolemic shock, as hypovolemia is frequently the primary factor causing hypotension 4

Respiratory Management

High cervical injuries (above C5) commonly affect diaphragmatic function and require early aggressive respiratory support. 2, 5

• Identify respiratory complications immediately, as they are life-threatening in high cervical injuries 2, 5
• Consider early tracheostomy (<7 days) when prolonged airway support is anticipated or when residual vital capacity is significantly decreased 2, 5
• Early tracheostomy reduces ICU hospitalization times and decreases laryngeal complications from prolonged intubation 2, 5

Prevention of Secondary Complications

Pressure Ulcer Prevention (prevalence can reach 26%):

Implement comprehensive pressure ulcer prevention from the acute phase, as these complications cause significant morbidity with common locations being sacrum (39%), heels (13%), ischium (8%), and occiput (6%). 1, 2

• Begin early mobilization immediately once spine is stabilized 1, 2
• Perform visual and tactile checks of all at-risk areas at least once daily 1, 2
• Reposition patient every 2-4 hours with pressure zone checks 1, 2
• Use discharge tools (cushions, foam, pillows) to avoid interosseous contact, particularly at knees 1
• Utilize high-level prevention supports including air-loss mattress and dynamic mattress systems 1, 2

Urological Management:

Intermittent urinary catheterization is the reference method and should replace indwelling catheters as soon as daily diuresis volume is adequate. 1, 2

• Remove indwelling catheters as soon as patient is medically stable to minimize urological risks (urinary tract infections, urolithiasis) 1, 2, 5
• Transition to self-intermittent urethral catheterization, which is recommended by national and international neuro-urology societies 1, 2, 5
• Use micturition calendar to adapt frequency and schedule of intermittent catheterization 1

Pain Management

Implement multimodal analgesia combining non-opioid analgesics, antihyperalgesic drugs (ketamine), and opioids during surgical management to prevent prolonged pain syndromes. 2, 5

• For neuropathic pain, prescribe oral gabapentinoids for more than 6 months 2, 5
• Add tricyclic antidepressants or serotonin reuptake inhibitors when gabapentinoid monotherapy is inefficient 2, 5

Common pitfall: Inadequate pain management leads to chronic pain syndromes that become extremely difficult to treat later 2, 5

Early Rehabilitation

Begin rehabilitation immediately after spinal stabilization to maximize neurological recovery, as physical exercise enhances CNS regeneration through neurotrophic factor elaboration. 2, 5

• Perform stretching techniques for at least 20 minutes per zone, completed by simple posture orthosis and proper bed/chair positioning 2, 5
• For incomplete injuries, implement gravity-assisted ambulation or body weight support with treadmill training to improve walking outcomes 2, 5

Direct Admission to Level 1 Trauma Centers

Transport patients directly to Level 1 trauma centers within the first hours after trauma, as this reduces morbidity and mortality, enables earlier surgical procedures, reduces ICU length of stay, and improves neurological outcomes. 1

Critical Pitfalls to Avoid

• Delaying immobilization worsens neurological outcomes 2, 5
• Neglecting early rehabilitation results in preventable complications and poorer functional outcomes 2, 5
• Blood pressure characteristically declines after the first week post-injury; maintain vigilance beyond initial resuscitation period 4
• Fluid management is often inadequate; avoid treating all patients at net fluid intake ≤ zero 4