What is the treatment for spinal shock in the Intensive Care Unit (ICU)?

From the Guidelines

The management of spinal shock in the ICU should prioritize maintaining hemodynamic stability and preventing secondary injury, with initial treatment involving fluid resuscitation and vasopressors as needed, according to the most recent and highest quality study available 1. The goal of treatment is to maintain adequate blood pressure and perfusion of vital organs.

• Initial treatment involves fluid resuscitation with crystalloids like normal saline or lactated Ringer's solution to maintain adequate blood pressure.
• If fluids alone are insufficient, vasopressors are indicated, with norepinephrine (starting at 0.01-0.3 mcg/kg/min) being the first-line agent due to its alpha and mild beta effects, as supported by a narrative review of vasoactive agents in shock 1.
• Alternatively, phenylephrine (40-180 mcg/min) may be used for pure alpha effects.
• For bradycardia, atropine (0.5-1 mg IV) can be administered, with external pacing as a backup.
• Methylprednisolone is no longer routinely recommended due to limited evidence of benefit and potential harm.
• Spinal immobilization is crucial to prevent further injury, and patients should be positioned with the head of bed elevated 30 degrees to optimize cerebral perfusion while reducing intracranial pressure.
• Regular neurological assessments should be performed to monitor for changes in function.
• It is essential to note that the concept of permissive hypotension and restrictive volume resuscitation is contraindicated in patients with spinal injuries, as adequate perfusion pressure is crucial to ensure tissue oxygenation of the injured central nervous system, as highlighted in the European guideline on management of major bleeding and coagulopathy following trauma 1.
• The use of vasoactive drugs in shock requires an individualized approach, with precise therapeutic targets, close monitoring, and titration to the minimal efficacious dose, as emphasized in the narrative review of vasoactive agents in shock 1.

From the Research

Spinal Shock Treatment in ICU

• The treatment of spinal shock in the ICU focuses on minimizing progression of the initial injury and preventing secondary injury 2.
• Therapy for the hyperacute phase of traumatic spinal cord injury involves stabilizing vital signs, following the Advanced Trauma Life Support (ATLS) algorithm, and ensuring spinal stabilization 2.
• ICU admission is recommended for patients with high spinal cord injury or hemodynamic instability, as well as those with other injuries that independently warrant ICU admission 2.
• Avoidance of hypotension and hypoxia is crucial to minimize secondary neurologic injury, and elevating the mean arterial pressure above 85 mmHg for 7 days may be considered to allow for spinal cord perfusion 2, 3.
• The use of intravenous steroids is controversial, and some studies suggest that they may not be beneficial in the treatment of spinal cord injury 2, 4.

Hemodynamic Management

• Hemodynamic management is one of the only available treatment options that likely improves neurologic outcomes in patients with acute traumatic spinal cord injury 5.
• Augmenting mean arterial pressure (MAP) aims to improve blood perfusion and oxygen delivery to the injured spinal cord, and a target range of 75-80 mmHg to 90-95 mmHg is suggested 5.
• The duration of MAP augmentation is recommended to be 3-7 days, although the quality of evidence is very low 5.
• The choice of vasopressor is not well established, but norepinephrine may be associated with less risk of adverse events than dopamine 6.

Monitoring and Support

• Spinal cord perfusion pressure (SCPP) monitoring via intradural catheters at the anatomical site of injury may be associated with increased risks of cerebrospinal fluid leakage requiring revision surgery or pseudomeningocele 6.
• Increased SCPP appears likely to be associated with improved neurological recovery, but the current literature is insufficient to make strong recommendations about interventions to support spinal cord perfusion via MAP or SCPP goals 6.
• Early tracheostomy, aggressive measures to maintain lung recruitment, and intermittent catheterization may be beneficial in the management of patients with spinal cord injury 2.