What are the key considerations in managing a patient with a cervical spine injury, particularly those with spinal cord injuries at or above the T6 level?

Key Considerations in Managing Cervical Spine Injury

Immediately immobilize the spine of any patient with suspected cervical spine injury using a rigid cervical collar with head-neck-chest stabilization to prevent onset or worsening of neurological deficit. 1

Initial Stabilization and Immobilization

• Apply rigid cervical collar immediately with manual in-line stabilization (MILS) for all patients with suspected cervical spine injury, as this significantly reduces complications despite low-quality evidence. 1
• Maintain systolic blood pressure >110 mmHg before injury assessment is completed to reduce mortality. 1
• Target mean arterial pressure (MAP) of 85-90 mmHg for at least 5-7 days post-injury to ensure adequate spinal cord perfusion and prevent secondary ischemic injury. 2, 3, 4
• Use continuous arterial line monitoring as maintaining these hemodynamic targets is challenging. 5
• Transport directly to Level 1 trauma centers within the first hours, as this reduces morbidity, mortality, and improves neurological outcomes through earlier surgical intervention. 1, 5

Common Pitfall

Prolonged rigid cervical collar immobilization carries significant risks, with most complications appearing and rapidly escalating after 48-72 hours. 6 Balance the need for protection against complications of prolonged immobilization.

Airway Management in Cervical Spine Injury

Use rapid sequence induction with direct laryngoscopy and a gum elastic bougie without Sellick maneuver, while maintaining manual in-line stabilization. 1, 2

Specific Intubation Technique:

• Remove the anterior portion of the cervical collar during intubation attempts to improve mouth opening and glottic exposure while maintaining MILS. 1, 6, 2
• Apply manual in-line stabilization throughout the procedure, though this increases difficulty of intubation due to reduced glottic exposure. 1
• Avoid Sellick maneuver to minimize cervical spine movement. 1, 2
• Videolaryngoscopy is NOT recommended as first-line in the prehospital setting based on prospective randomized data. 1
• Succinylcholine can be safely used within 48 hours of injury; after 48 hours, switch to rocuronium to avoid hyperkalemia risk from denervation. 1, 2

Critical Airway Decision Points:

• Patients with high cervical cord injury (C4 or higher) should be intubated immediately. 3
• Lower cervical injuries require case-by-case evaluation, but any spinal cord lesion above T11 will disrupt respiratory mechanics in the acute setting. 3

Respiratory Management and Ventilator Weaning

Implement a comprehensive respiratory bundle for cervical spinal cord injury patients to facilitate weaning and reduce complications. 1

Ventilator Weaning Bundle:

• Abdominal contention belt during spontaneous breathing periods or raising procedures (tetraplegic patients tolerate lying down better than sitting due to gravity effects on abdominal contents). 1
• Active physiotherapy with mechanically-assisted insufflation/exsufflator device (Cough-Assist) for bronchial secretion removal. 1
• Aerosol therapy combining beta-2 mimetics and anticholinergics. 1

Tracheostomy Timing:

• **Perform early tracheostomy (<7 days) for upper cervical injuries (C2-C5)**, as these patients have >50% reduction in vital capacity and high risk of ventilator weaning failure. 1
• For lower cervical injuries (C6-C7), perform tracheostomy only after one or more failed extubation attempts. 1
• Wait at least 7 days if anterior cervical surgical approach was used; earlier tracheostomy possible with posterior approach. 1
• Early tracheostomy reduces ICU length of stay and laryngeal complications from prolonged intubation. 1

Pain Management

Introduce multimodal analgesia combining non-opioid analgesics, ketamine, and opioids during surgical management to prevent prolonged pain. 1

Neuropathic Pain Protocol:

• Initiate oral gabapentinoid treatment for >6 months to control neuropathic pain. 1
• Add tricyclic antidepressants or serotonin reuptake inhibitors when gabapentinoid monotherapy is insufficient. 1

Temperature Management

Prevent hypothermia aggressively, as each 1°C drop reduces coagulation factor function by 10%, and temperatures <34°C are associated with >80% mortality. 5

Specific Interventions:

• Remove all wet clothing immediately and cover the patient. 5
• Increase ambient temperature in treatment area. 5
• Apply forced air warming devices as first-line active warming. 5
• Administer only warm intravenous fluids; never use cold IV fluids. 5
• Target normothermia: core temperature 36-37°C. 5

Early Rehabilitation Considerations

Begin joint range-of-motion exercises and positioning immediately upon ICU admission to prevent contractures and deformities. 1

• Perform stretching for at least 20 minutes per zone. 1
• Apply simple posture orthoses (elbow extension, metacarpophalangeal joint flexion-torsion, thumb-index commissure opening). 1
• Use proper bed and chair positioning to correct and prevent predictable deformities. 1

Monitoring and Assessment

• Grade patients daily using ASIA classification, with the first prognostic score at 72 hours post-injury. 3
• Maintain continuous hemodynamic monitoring with arterial line for accurate MAP measurement. 2
• Perform hourly vital signs and neurological assessments. 2
• Assess for associated injuries with low threshold, as there is high incidence of visceral, pelvic, and long bone injuries. 3