A Scoping Review of Clinical Practice Guidelines for the Acute Care of Patients with Spinal Cord Injury: Respiratory, Hemodynamic and Neuroprotective Management (original) (raw)
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A Systematic Review of Intensive Cardiopulmonary Management after Spinal Cord Injury
Journal of Neurotrauma, 2011
Intensive cardiopulmonary management is frequently undertaken in patients with spinal cord injury (SCI), particularly due to the occurrence of neurogenic shock and ventilatory insufficiency and in an attempt to reduce secondary injury. We undertook a systematic review of the literature to examine the evidence that intensive care management improves outcome after SCI and to attempt to define key parameters for cardiopulmonary support= resuscitation. We review the literature in five areas: management of SCI patients in specialized centers, risk in SCI patients of cardiopulmonary complications, parameters for blood pressure and oxygenation=ventilation support following SCI, risk factors for cardiopulmonary insufficiency requiring ICU care after SCI, and preventative strategies to reduce the risks of cardiopulmonary complications in SCI patients. The literature supports that, in light of the significant incidence of cardiorespiratory complications, SCI patients should be managed in a monitored special care unit. There is weak evidence supporting the maintenance of MAP >85 mmHg for a period extending up to 1 week following SCI.
Journal of Neurotrauma, 2011
An interdisciplinary expert panel of medical and surgical specialists involved in the management of patients with potential spinal cord injuries (SCI) was assembled. Four key questions were created that were of significant interest. These were: (1) what is the optimal type and duration of pre-hospital spinal immobilization in patients with acute SCI?; (2) during airway manipulation in the pre-hospital setting, what is the ideal method of spinal immobilization?; (3) what is the impact of pre-hospital transport time to definitive care on the outcomes of patients with acute spinal cord injury?; and (4) what is the role of pre-hospital care providers in cervical spine clearance and immobilization? A systematic review utilizing multiple databases was performed to determine the current evidence about the specific questions, and each article was independently reviewed and assessed by two reviewers based on inclusion and exclusion criteria. Guidelines were then created related to the questions by a national Canadian expert panel using the Delphi method for reviewing the evidence-based guidelines about each question. Recommendations about the key questions included: the pre-hospital immobilization of patients using a cervical collar, head immobilization, and a spinal board; utilization of padded boards or inflatable bean bag boards to reduce pressure; transfer of patients off of spine boards as soon as feasible, including transfer of patients off spinal boards while awaiting transfer from one hospital institution to another hospital center for definitive care; inclusion of manual in-line cervical spine traction for airway management in patients requiring intubation in the pre-hospital setting; transport of patients with acute traumatic SCI to the definitive hospital center for care within 24 h of injury; and training of emergency medical personnel in the pre-hospital setting to apply criteria to clear patients of cervical spinal injuries, and immobilize patients suspected of having cervical spinal injury.
Critical Care and Perioperative Management in Traumatic Spinal Cord Injury
Journal of Neurosurgical Anesthesiology, 2003
Traumatic spinal cord injury is frequently associated with brain injury and with alterations in respiratory and cardiovascular function that require critical care management. Complications include respiratory failure, atelectasis, pneumonia, neurogenic shock, autonomic dysreflexia, venous thromboembolism, and sepsis. While complications may be managed with supportive care, the goal of ameliorating neurologic outcome has proved elusive. Methylprednisolone, when instituted <8 hours after traumatic spinal cord injury, was associated in two clinical trials with statistically significant improvements in motor scores at 6 months and 1 year; however, critical reappraisal of these data raises questions about their validity and clinical relevance. Until more evidence of clinically effective therapies is available, acute management must be driven by pathophysiologic principles, with emphasis on interventions that attenuate secondary neurologic injury; these include the rational use of immobilization, cautious airway management, and promotion of cord perfusion and oxygenation with the appropriate level of hemodynamic and respiratory support. Clinical trials of pharmacologic neuroprotection have yielded disappointing results, but the ongoing elucidation of spinal cord repair and regenerative mechanisms suggests new therapeutic prospects.
Archives of Iranian Medicine
Background: Proper utilization of high-quality clinical practice guidelines (CPGs) eliminates the dependence of patients’ outcomes on the ability and knowledge of "individual" health care providers and reduces unwarranted variation in care. The aim of this study was to adapt/adopt two CPGs for pharmacologic management of acute spinal cord injury (SCI) using guideline adaptation methods. Methods: This study was conducted based on the ADAPTE process. Following establishment of an organizing committee and choosing the health topics, we appraised the quality of the CPGs using the Appraisal of Clinical Guidelines for Research & Evaluation II (AGREE II). Then, the authors extracted and categorized suggestions according to Population, Intervention, Professions, Outcomes and Health care setting (PIPOH). The decision-making process was based on systemic evaluation of each suggestion, utilizing a combination of AGREE II scores, the quality of supporting evidence for or against each ...
2007 SAE-P: Spinal Cord Injury Medicine
2000
Educational Activity 1.1 1. According to the Standards for Neurological Classification of Spinal Cord Injury published by the American Spinal Injury Association (ASIA) (a) shoulder abductors are 1 of the 5 key upper-extremity muscle groups. (b) the zone of partial preservation is only pertinent in complete spinal cord injury. (c) if half the key muscles below the neurologic level of injury have a muscle grade less than 3, the ASIA grade is D. (d) the patient should be examined in a seated position. Ref: American Spinal Injury Association. International standards for neurological classifications of spinal cord injury (revised 2000). Chicago: ASIA; 2002. Educational Activity 1.1 2. The only cause of spinal cord injury that has steadily increased over the last 3 decades is (a) violence. (b) falls. (c) motor vehicle crashes. (d) sports. Ref: Jackson AB, Dijkers M, DeVivo MJ, Paczatek RB. A demographic profile of new traumatic spinal cord injuries: change and stability over 30 years. Arch Phys Med Rehabil 2004;85:1740-8. Educational Activity 1.3 3. Compared with traumatic spinal cord injury (SCI), nontraumatic SCI is more likely to be associated with (a) an incomplete lesion. (b) a higher incidence of spasticity. (c) a higher rate of home discharge. (d) a shorter time between diagnosis and rehabilitation. Ref: Chapman J. Comparing medical complications from nontraumatic and traumatic spinal cord injury [abstract]. Arch Phys Med Rehabil 2000;81:1264. Educational Activity 1.3 4. Transverse myelitis (a) results in paraplegia 70% of the time. (b) progresses in more than 1 week and less than 4 weeks. (c) is associated with a poor recovery if there is a rapid progression. (d) is rarely associated with sensory symptoms. Ref: Transverse Myelitis Consortium Working Group. Proposed diagnostic criteria and nosology of acute transverse myelitis. Neurology 2002;59:499-505. Educational Activity 1.4 5. In people with myelomeningocele, (a) the majority have below-normal intelligence. (b) posterior fossa decompression is frequently required. (c) hydrosyringomyelia (syrinx) is uncommon. (d) hydrocephalus is seen in approximately 90% of patients. Clinical Activity 2.1 6. Which treatment is NOT standard management for acute care of spinal cord injury? (a) Prophylaxis for venous thromboembolism within 72 hours (b) Volume resuscitation to optimize spinal cord perfusion (c) High-dose methylprednisolone as a neuroprotective agent (d) Assessment and treatment of spinal and neurogenic shock Ref: (a) Consortium for Spinal Cord Medicine. Early acute management in adults with spinal cord injury: a clinical practice guideline for health-care providers. Washington (DC): Paralyzed Veterans of America; 2007. (b) Qian T, Guo X, Levi AD, Vanni S, Shebert RT, Sipski MS. High-dose methylprednisolone may cause myopathy in acute spinal cord injury patients. Spinal Cord 2004;43:199-203. Clinical Activity 2.1 7. Which statement is TRUE concerning autonomic dysfunction? (a) It is associated with injury below T9. (b) It is common in the acute period. (c) Bradycardia occurs in response to blood pressure elevations. (d) Hypothermia is common because of poor thermoregulation. Ref: (a) Bilello JF, Davis JW, Cunningham MA, Groom TF, Lemaster D, Sue LP. Cervical spinal cord injury and the need for cardiovascular intervention. Arch Surg 2003;138:1127-9. (b) Krassioukov AV, Furlan JC, Fehlings MG. Autonomic dysreflexia in acute spinal cord injury: an underrecognized clinical entity. Clinical Activity 2.2 8. Which statement is TRUE concerning bladder management considerations in acute spinal cord injury? (a) Increased urine volumes occur with immobilization. (b) Intermittent catheterization may begin once intravenous fluids are discontinued and strict urine outputs are not needed.
BMJ Open
IntroductionThe upsurge in the use of clinical prediction models in general medical practice is a result of evidence-based practice. However, the total number of clinical prediction rules (CPRs) currently being used or undergoing impact analysis in the management of patients who have sustained spinal cord injuries (SCIs) is unknown. This scoping review protocol will describe the current CPRs being used and highlight their possible strengths and weaknesses in SCI management.Methods and analysisArksey and O’Malley’s scoping review framework will be used. The following databases will be searched to identify relevant literature relating to the use of CPRs in the management of patients who have sustained an SCI: PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL), ScienceDirect, EBSCOhost, Medline, OvidMedline and Google Scholar. Grey literature as well as reference lists of included studies will be searched. All studies relating to the use of CPRs in the management...
Specialized Respiratory Management for Acute Cervical Spinal Cord Injury: A Retrospective Analysis
Topics in Spinal Cord Injury Rehabilitation, 2012
Background: In individuals with cervical spinal cord injury (SCI), respiratory complications arise within hours to days of injury. Paralysis of the respiratory muscles predisposes the patient toward respiratory failure. Respiratory complications after cervical SCI include hypoventilation, hypercapnea, reduction in surfactant production, mucus plugging, atelectasis, and pneumonia. Ultimately, the patient must use increased work to breathe, which results in respiratory fatigue and may eventually require intubation for mechanical ventilation. Without specialized respiratory management for individuals with tetraplegia, recurrent pneumonias, bronchoscopies, and difficulty in maintaining a stable respiratory status will persist. Objective: This retrospective analysis examined the effectiveness of specialized respiratory management utilized in a regional SCI center. Methods: Individuals with C1-C4 SCI (N = 24) were the focus of this study as these neurological levels present with the most complicated respiratory status. Results: All of the study patients' respiratory status improved with the specialized respiratory management administered in the SCI specialty unit. For a majority of these patients, respiratory improvements were noted within 1 week of admission to our SCI unit. Conclusion: Utilization of high tidal volume ventilation, high frequency percussive ventilation, and mechanical insufflationexsufflation have demonstrated efficacy in stabilizing the respiratory status of these individuals. Optimizing respiratory status enables the patients to participate in rehabilitation therapies, allows for the opportunity to vocalize, and results in fewer days on mechanical ventilation for patients who are weanable.