Cervical Spine Injury Management Guidelines

Guidelines for the Treatment of Cervical Fractures with or without Spinal Cord Injury

1. Admission Guidelines:
All patients with the following clinical conditions MUST be admitted to the ICU for close respiratory and neurological monitoring. The pre-printed Spinal Cord Injury Orders will be used on all patients.

• Radiographic evidence of unstable cervical fracture or dislocation (i.e. atlantococciptal dislocation, bilateral subaxial facet dislocation,..) and/or

• Clinical or radiographic evidence of spinal cord injury

All field collars should be changed out to a permanent rigid collar (Aspen or Miami-J) within 6 hours of admission.
Admission location and monitoring criteria for patients with documented cervical fractures without radiographic evidence of dislocation (i.e. transverse foramen fractures, spinous process fractures,.. ) and without clinical or radiographic evidence of spinal cord injury is left to the discretion of the admitting Attending Physician.

2. Immobilization Guidelines:
Unstable Cervical Fracture or Dislocation, with/without Spinal Cord Injury:

• All patients will be maintained in a rigid cervical collar with strict cervical and log roll precautions until temporary stabilization using halo traction or halo vest is applied (Note: If the patient will be maintained in halo traction for >24 hours he/she should be placed on a rotorest bed to promote respiratory toileting, to be discontinued after surgical fixation)

• Definitive operative stabilization of such fracture dislocations should occur within the first 24-48 hours of hospitalization

Stable Cervical Fracture without Dislocation, without Spinal Cord Injury:

• All patients will be maintained in a rigid cervical collar, unless otherwise determined by the Attending Physician.

• Log roll precautions, operative intervention and length of collar use to be determined by the Attending Physician.

3. Neurological Examination:

• Every 1-2 hours until definitive stabilization is achieved and for at least 24 hours post-operatively, unless otherwise determined by the Attending Physician.

• After 24 hours, the frequency of neurological examination may be progressively weaned as determined by the Attending Physician.

• Evaluation should be based upon the ASIA scoring system, unless otherwise determined by the Attending Physcian.

4. Steroids Administration:

• Steroids can be administered in all patients with evidence of spinal cord injury (excluding penetrating injury and/or nerve root injury) unless contraindicated by co-morbidities or injuries as determined by the Attending Physician.

• Load: Methylprednisolone 30mg/kg IV over 15 minutes

• Infusion: (Begin 45 minutes after bolus)
  • Within 0-3 hours of injury: Methylprednisolone 5.4mg/kg/hr IV for 23 hours
  • Within 3-8 hours of injury: Methylprednisolone 5.4mg/kg/hr IV for 47 hours

• All patients receiving steroids must also have the following ordered
  • Pepcid 20mg IV/PO/FT Q12 or Prevacid 30mg PO/FT Daily
  • Routine finger stick blood sugar monitoring with institution of and insulin sliding scale or insulin gtt for BS >140

5. Blood Pressure Management:

• To promote spinal cord perfusion MAPs will be maintained >85 mm Hg for 7 days post injury
• Pressures should be maintained using the following:
  • Dopamine 2-10 mcg/kg/min IV
  • Phenylephrine 5-200mcg/min IV
  • When able to take PO’s institute one of the following oral agents and begin weaning gtt
  • Ephedrine 25mg PO Q6 (maximum dose 150mg/24 hours)
  • NaCl tablets 1-2gms PO TID (maximum dose 4gms TID
  • Florinef 0.2mg PO Daily (maximum 1mg/24 hours)
  • Midodrine 10mg 30 min before sitting up or TID (do not use in combination with ephedrine)

• Institute abdominal binding and elastic (ACE) bandages to lower extremities when placed in the sitting position or cleared for OOB activity

6. Respiratory Management:

• All patients must receive continuous oxygen saturation monitoring (Maintain a low threshold for intubation in high cervical injury C5 or above)
• Initiate quad cough and suctioning Q2 hours when appropriate
• Incentive spirometer Q2 hours when appropriate
• Albuterol 2.5mg in 3cc NS per nebulizer, every 6 hours in the intubated and high cervical (C5 or above) non-intubated patient

7. DVT Prophylaxis:

• Upon admit all patients will received SCS with antiembolic stockings unless contraindicated by lower extremity injuries
• Non-operative cases will receive enoxaparin 30mg SQ BID within 48 hours of admission, unless otherwise determined by the Attending Physician.
• Operative cases will have enoxaparin 30mg SQ BID started within 48 hours of surgery regardless of drain placement.
• DVT prophylaxis in patients with traumatic brain injury, in addition to their spinal injury, will be evaluated on a case by case basis by the Attending Neurosurgeon.

8. Additional Treatment Guidelines:

• All patients not on a rotorest bed will be turned every 2 hours
• All patients will initially receive an indwelling foley catheter with Q2 I&O Monitoring
  • The patient will intitally be allowed an attempt at self evacuation, this will be followed up with a bladder scan or straight catheterization if results provide proof of retention (> 100cc unless history significant for BPH then may liberalize to 150cc) a routine catheterization program will be instituted
  • I&0 catherterization will begin once urine output is <2 liters in 24 hours and will be ordered in the following manner
    • I&O cathererization Q6 hours if >400cc change frequency to Q4 hours
• All patients will have the following consults within 48 hours of admission unless contraindicated secondary to instability (emphasis on early mobilization
  
  • Physical Therapy
  • Occupational Therapy
  • Speech Therapy for Swallow evaluation
    • If unable to pass or participate in swallow evaluation; a feeding tube will be placed and nutritional support initiated within 48 hours of admission
  • Physical Medicine and Rehabilitation

• All patients with evidence of altered rectal tone, pernineal sensation, or with evidence of lack of bowel function will be started on the following bowel regimen within 24-48 hours of admission
  • Colace 100mg PO/FT BID
  • Bisacodyl Suppository 10mg PR with digital stimulation administered at the same time daily