What is the initial management for a patient with paraplegia?

Initial Management of Paraplegia

Immediately immobilize the spine and initiate aggressive hemodynamic support targeting mean arterial pressure ≥70 mmHg while simultaneously assessing for compressive spinal cord lesions requiring urgent decompression. 1, 2

Immediate Spinal Stabilization

• Apply manual in-line stabilization combined with a rigid cervical collar for any suspected spinal cord injury to prevent onset or worsening of neurological deficit 1, 2
• Transport on a rigid backboard with vacuum mattress maintaining head-neck-chest alignment throughout 2
• Avoid multiple transfers between facilities, as this historically caused deteriorated neurological levels in many patients 3

Hemodynamic Resuscitation

Maintaining adequate spinal cord perfusion is the single most critical intervention to prevent secondary injury and improve neurological outcomes. 1, 2

• Target mean arterial pressure (MAP) ≥70 mmHg during the first 7 days post-injury, as time spent below MAP 65-70 mmHg directly correlates with worse neurological recovery 2
• Maintain systolic blood pressure >110 mmHg before complete injury assessment to reduce mortality 2
• Use vasopressors as needed to achieve hemodynamic targets rather than accepting hypotension 1
• Avoid excessive fluid administration; use blood products rather than crystalloid for volume resuscitation when indicated 1

Urgent Diagnostic Evaluation

Rule out compressive spinal cord lesions immediately, as early surgical decompression may preserve neurological function. 4

• Obtain MRI and CT scan to precisely assess extent of spinal cord damage and guide surgical decision-making 3
• Perform thorough neurological examination documenting motor, sensory, and reflex function to establish injury level 1
• Assess for polytrauma, as most paraplegic patients from road-traffic accidents have severe associated injuries requiring multidisciplinary management 3
• Evaluate for alternative diagnoses including Guillain-Barré syndrome, functional paralysis (normal bowel/bladder function with complete motor/sensory loss, shifting sensory findings, normal reflexes), and iatrogenic causes 1, 5

Respiratory Management

• Assess respiratory function immediately, particularly for injuries at T6 and above which may compromise intercostal muscle function 1
• Consider early tracheostomy if prolonged ventilatory support is anticipated, particularly when residual vital capacity is significantly decreased 1
• Early tracheostomy (<7 days) reduces ICU hospitalization times and laryngeal complications from prolonged intubation 1, 2

Prevention of Secondary Complications

Begin aggressive complication prevention from the acute phase, as these determine long-term morbidity and quality of life. 1, 2

Pressure Ulcer Prevention

• Implement 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

Bladder Management

• Initiate intermittent urinary catheterization as soon as daily diuresis volume is adequate to reduce urological complications 1, 2
• Remove indwelling catheters as soon as medically stable to minimize infection risk 1
• Self-intermittent urethral catheterization is the gold standard once patient is capable 1, 2

Thromboprophylaxis

• Implement prophylactic anticoagulation immediately given high thromboembolism risk 3

Gastrointestinal Protection

• Provide gastrointestinal cytoprotection to prevent stress ulceration 3

Pain Management

• Implement 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 1, 2

Early Rehabilitation

Begin rehabilitation immediately after spinal stabilization to maximize neurological recovery through neurotrophic factor elaboration. 1, 2

• Initiate stretching techniques for at least 20 minutes per zone, complemented by simple posture orthosis and proper bed/chair positioning 1, 2
• For incomplete injuries, implement gravity-assisted ambulation or body weight support with treadmill training 1

Critical Pitfalls to Avoid

• Delaying spinal immobilization worsens neurological outcomes 1, 2
• Inadequate blood pressure support below MAP 70 mmHg increases secondary spinal cord injury 2
• Missing compressive lesions requiring urgent surgical decompression results in preventable permanent disability 4
• Neglecting early pressure ulcer prevention leads to significant morbidity affecting long-term quality of life 1, 2
• Inadequate pain management creates chronic pain syndromes that are difficult to treat later 1, 2