What is the management plan for a patient with quadruplegia (quadriplegia)?

Management of Quadriplegia

Immediate Stabilization and Acute Care

In patients with quadriplegia, implement immediate spinal immobilization, maintain mean arterial pressure (MAP) 85-90 mmHg for 5-7 days, ensure direct admission to a Level 1 trauma center, and initiate early respiratory support with a comprehensive ventilatory weaning protocol to optimize neurological outcomes and prevent secondary complications. 1, 2

Hemodynamic Management

• Maintain MAP between 85-90 mmHg for the first 5-7 days post-injury to ensure adequate spinal cord perfusion and prevent secondary ischemic injury 2
• Keep systolic blood pressure (SBP) > 110 mmHg before injury assessment to reduce mortality 1, 2
• Avoid all episodes of hypotension (SBP < 90 mmHg) during the acute phase, as this is an independent mortality risk factor 1
• Use continuous arterial line monitoring, as MAP targets are difficult to maintain 25% of the time without it 1, 2

Spinal Immobilization and Transport

• Implement immediate rigid cervical collar with head-neck-chest stabilization for all suspected spinal cord injuries 1, 2
• Use manual in-line stabilization (MILS) during any airway manipulation to limit cervical spine mobilization 1
• Transport directly to Level 1 trauma centers, which reduces ICU length of stay and improves neurological outcomes 1, 2

Respiratory Management

Respiratory complications are the leading cause of morbidity and mortality in quadriplegia, particularly with high cervical injuries (C2-C5). 1

Ventilatory Weaning Protocol

Implement a comprehensive bundle approach that includes: 1

• Abdominal contention belt during spontaneous breathing periods and sitting positions to compensate for diaphragmatic weakness 1
• Active physiotherapy with mechanically-assisted insufflation/exsufflation devices (Cough-Assist) to remove bronchial secretions 1
• Aerosol therapy combining beta-2 mimetics and anticholinergics 1
• Maintain supine positioning when possible, as lying down is often better tolerated than sitting due to gravity effects on abdominal contents and inspiratory capacity 1

Tracheostomy Timing

• For upper cervical injuries (C2-C5): Perform early tracheostomy within 7 days to accelerate ventilatory weaning and reduce laryngeal complications 1
• For lower cervical injuries (C6-C7): Perform tracheostomy only after one or more extubation failures 1
• Early tracheostomy (< 7 days) reduces ICU hospitalization times and has been associated with better neurological recovery at 1 year 1
• Main risk factors for weaning failure include injury above C5 and complete spinal cord injury (ASIA Impairment Scale A) 1

Respiratory Muscle Training

• In patients with neuromuscular weakness, implement expiratory muscle training to improve peak expiratory pressure and cough effectiveness 1
• Expiratory muscle training in quadriplegic patients can increase expiratory reserve volume by 46% through isometric training of the clavicular portion of the pectoralis major over 6 weeks 1

Pain Management

Neuropathic Pain Control

• Introduce multimodal analgesia during surgical management, combining non-opioid analgesics, antihyperalgesic drugs (ketamine), and opioids to prevent prolonged pain 1, 2
• Initiate oral gabapentinoid treatment for more than 6 months to control neuropathic pain 1
• Add tricyclic antidepressants or serotonin reuptake inhibitors when gabapentinoid monotherapy is insufficient 1

Prevention of Secondary Complications

Pressure Ulcer Prevention

Implement the following measures immediately upon ICU admission: 1

• Early mobilization as soon as the spine is stabilized 1, 2
• Visual and tactile checks of all at-risk areas at least once daily 1, 2
• Repositioning every 2-4 hours with pressure zone checks 1, 2
• Use high-level prevention supports including air-loss mattresses, dynamic mattresses, cushions, and foam pillows 1, 2

Urological Management

• Transition to intermittent urinary catheterization as soon as the patient is medically stable, as this is the reference method that reduces long-term risk of urinary tract infections and urolithiasis 1, 2
• Remove indwelling catheters as soon as possible to minimize urological risks 1
• Use a micturition calendar to adapt the frequency and schedule of intermittent catheterization 1

Early Rehabilitation

Begin the following interventions immediately upon ICU arrival: 1

• Stretching techniques for at least 20 minutes per zone to maintain joint amplitudes and prevent contractures 1
• Simple posture orthoses (elbow extension, flexion-torsion of metacarpophalangeal joint, opening of thumb-index commissure) 1
• Proper bed and chair positioning to correct and prevent predictable deformities 1
• Spasticity prevention and treatment protocols 1

Functional Prognosis

The presence of triceps function is a critical determinant for functional independence in self-care tasks. 3

• Patients with triceps as the lowest functioning muscle have significantly greater independence in self-care activities compared to those with only wrist extensors 3
• Most functional gains occur in bowel and bladder care, dressing, and mobility activities during the first 3-12 months post-discharge 3
• Vigorous medical support and maximal weaning efforts improve long-term survival: 90% at one year, 56% at three years for initially ventilator-dependent patients 4

Critical Pitfalls to Avoid

• Never delay spinal immobilization, as this worsens neurological outcomes 1, 2
• Do not rely on intermittent blood pressure measurements—use continuous arterial line monitoring, as targets fail 25% of the time without it 1, 2
• Avoid excessive crystalloid resuscitation, which causes pulmonary edema and worsens outcomes 2
• Do not delay tracheostomy in high cervical injuries (C2-C5) beyond 7 days, as early tracheostomy improves neurological recovery 1