What are the feeding recommendations for a patient with a cervical crush fracture?

Feeding Recommendations for Cervical Crush Fracture

Initiate early enteral nutrition within 24-48 hours via nasogastric or nasojejunal tube, targeting 25 kcal/kg/day with protein >1.2 g/kg/day, as part of a multidisciplinary care protocol that prioritizes prevention of complications from prolonged immobilization. 1

Timing and Route of Nutrition

• Start enteral feeding within 24-48 hours of injury to reduce infectious complications, length of hospital stay, and mortality compared to delayed feeding or parenteral nutrition. 1

• Use nasogastric or nasojejunal tube feeding as the primary route, as enteral nutrition is superior to parenteral nutrition in trauma patients, reducing infection rates and hospital length of stay. 1

• Postpyloric (jejunal) feeding may be preferred if gastric emptying is delayed or aspiration risk is high, though gastric feeding is acceptable with appropriate monitoring. 1

Nutritional Targets

• Provide 25 kcal/kg/day as the energy target, with protein intake >1.2 g/kg/day to support wound healing and prevent muscle wasting during immobilization. 1

• Start tube feeding at 20-50 ml/hour and advance by 20 ml/hour daily as tolerated until nutritional goals are met. 1

• Monitor tolerance carefully, as trauma patients may experience gastric stasis, reflux, and delayed gastric emptying, particularly in the supine immobilized position. 1

Critical Rationale: Complications of Prolonged Immobilization

The urgency of early feeding stems from the severe complications of cervical spine immobilization that escalate rapidly after 48-72 hours:

• Pressure ulcers develop commonly after 48-72 hours of immobilization, requiring skin grafting and serving as sources of sepsis. 1

• Respiratory complications are the leading cause of death in elderly cervical spine injury patients (26.8% mortality), with ventilator-associated pneumonia promoted by supine positioning and gastric stasis. 1

• Failed enteral nutrition occurs at higher rates in immobilized patients who fail to reach nutritional targets, necessitating more expensive and complication-prone parenteral nutrition. 1

• Increased intracranial pressure from cervical collars worsens outcomes in patients with co-existing head injury (present in one-third of cases). 1

Airway Management Considerations

• If airway management is required before feeding tube placement, use videolaryngoscopy with manual in-line stabilization and remove only the anterior portion of the cervical collar. 1, 2, 3

• The actual risk of secondary spinal cord injury from airway procedures is extremely low (0.34% in meta-analysis of 1177 patients), so necessary procedures should not be delayed. 2

Multidisciplinary Integration

• Embed nutritional interventions within a comprehensive, individualized care plan that includes geriatric assessment (if applicable), staff education, active complication prevention, and early rehabilitation planning. 1

• Implement comprehensive pressure ulcer prevention protocols from admission, as these complications significantly increase morbidity and healthcare costs ($30,000 per ulcer). 1, 2

• Consider early tracheostomy (<7 days) if prolonged airway support is anticipated, as this facilitates better oral care, reduces aspiration risk, and improves feeding tolerance. 2

Monitoring and Adjustment

• Assess nutritional status and dietary intake daily, with dietitian involvement for patients at risk of malnutrition or failing to meet nutritional targets. 1

• Use prokinetic agents (metoclopramide, erythromycin) if gastric emptying is delayed and feeding intolerance develops. 1

• Maintain mean arterial pressure ≥70 mmHg continuously during the first week post-injury to limit neurological deterioration, as hemodynamic instability can compromise both spinal cord perfusion and gastrointestinal function. 2

Common Pitfalls to Avoid

• Do not delay enteral nutrition waiting for complete spinal clearance or definitive surgical management, as complications from malnutrition and immobilization escalate rapidly. 1

• Avoid exclusive parenteral nutrition unless enteral access is impossible, as it increases infection risk and costs without improving outcomes in trauma patients. 1

• Do not use traction during airway or feeding tube placement, as it causes clinically significant cervical distraction; use manual in-line stabilization instead. 4