What is the initial management for a patient with paraplegia?

Initial Management of Paraplegia

Immediately immobilize the spine and initiate hemodynamic support targeting mean arterial pressure ≥70 mmHg while simultaneously securing the airway if cervical injury is suspected. 1

Immediate Prehospital Stabilization

• Apply manual in-line stabilization (MILS) combined with a rigid cervical collar to prevent onset or worsening of neurological deficit in any patient with suspected spinal cord injury. 1
• Transport on a rigid backboard with vacuum mattress while maintaining head-neck-chest stabilization throughout. 1
• Critical pitfall: Delaying immobilization leads to worsening neurological outcomes and increased secondary injury. 1, 2

Airway Management (If Cervical Injury Suspected)

• Remove only the anterior portion of the cervical collar during intubation to improve mouth opening and glottic exposure while maintaining posterior stabilization. 1, 2
• Perform rapid sequence induction with direct laryngoscopy using a gum elastic bougie to increase first-attempt success rate. 1, 2
• Maintain cervical spine in neutral axis without Sellick maneuver. 1, 2
• Use succinylcholine ONLY within the first 48 hours after spinal cord injury; after 48 hours it causes life-threatening hyperkalemia due to denervation hypersensitivity. 1, 2

Hemodynamic Management

• Maintain systolic blood pressure >110 mmHg before injury assessment to reduce mortality. 1
• Target mean arterial pressure (MAP) ≥70 mmHg during the first 7 days to limit worsening of neurological deficit and prevent secondary injury. 1, 2
• Use vasopressors as necessary to achieve hemodynamic stability; avoid fluid overload by preferring blood products over crystalloids for volume resuscitation. 2
• Critical pitfall: Time spent with MAP <65-70 mmHg directly correlates with worse neurological outcomes. 1

Corticosteroid Administration (If Spinal Cord Compression Suspected)

• Administer high-dose dexamethasone (96 mg/day IV) prior to radiographic confirmation if clinical suspicion of spinal cord compression exists. 3
• Be aware that this high-dose regimen carries 11-29% toxicity risk including GI perforation, ulcers, and bleeding. 3
• De-escalate rapidly if MRI is negative. 3

Respiratory Management

• Perform early tracheostomy within the first 7 days for high cervical injuries (C2-C5) to accelerate ventilatory weaning and reduce ICU hospitalization times. 1, 2
• Immediate intubation is mandatory for high cervical cord injuries affecting diaphragmatic function (above C5). 1, 2

Prevention of Secondary Complications (Begin Immediately)

Pressure Ulcer Prevention

• Implement aggressive prevention from the acute phase with visual and tactile checks of all at-risk areas at least once daily. 1, 2
• Reposition every 2-4 hours. 1, 2
• Begin early mobilization once spine is stabilized. 1, 2

Urological Management

• Initiate intermittent urinary catheterization as soon as daily diuresis volume is adequate. 1, 2
• Self-intermittent urethral catheterization is the gold standard. 1, 2
• Remove indwelling catheters as soon as medically stable to minimize urological risks. 2

Pain Management

• Use multimodal analgesia combining non-opioid analgesics, antihyperalgesic drugs (ketamine), and opioids during acute management. 1, 2
• For neuropathic pain developing later: prescribe oral gabapentinoids for more than 6 months, adding tricyclic antidepressants or serotonin reuptake inhibitors if monotherapy fails. 2

Surgical Considerations

• Surgery is indicated when spinal cord instability or bony retropulsion causes cord compression. 3
• Surgery is suggested in patients with paralysis for <48 hours based on prospective trial data. 3
• Note: Surgical stabilization may decrease initial rehabilitation days by 21-39 days but is associated with twice as many complications compared to nonoperative management. 4, 5

Early Rehabilitation

• Begin rehabilitation immediately after stabilization to maximize neurological recovery through neurotrophic factor elaboration. 1, 2
• Perform stretching techniques for at least 20 minutes per zone. 1, 2
• For incomplete injuries, use gravity-assisted ambulation or body weight support with treadmill training. 2
• Critical pitfall: Neglecting early rehabilitation results in preventable complications and poorer functional outcomes. 1, 2

Diagnostic Evaluation

• Obtain sagittal T1-weighted MRI of the entire spine for new onset back pain with paraplegia to rule out spinal cord compression. 3
• Evaluate for alternative diagnoses including Guillain-Barré syndrome which requires different management. 2