Primary Survey

Use a systematic approach based on the ABCDE survey to assess and treat acutely ill patients. The goal is to manage any life-threatening conditions and identify any emergent concerns, especially in an SCI patient who may present with other complications of trauma.

All patients with a mechanism of injury likely to have induced SCI must have an appropriately fitted and sized collar placed and inline immobilisation implemented.

Regular assessment is crucial in SCI trauma patients as developing cord oedema may cause significant changes in neurological function.

 Airway with cervical spine protection

Early and safe airway management in the SCI patient can make a crucial impact to long-­‐term patient outcomes and functional deficits.

Assess for airway stability

Attempt to elicit a response from the patient.

Look for signs of airway obstruction (use of accessory muscles, paradoxical chest movements and see-saw respirations).

Listen for any upper-airway noises and breath sounds. Are they absent, diminished or noisy?

Spinal patients are at particular risk of passive regurgitation and subsequent aspiration. High cervical injuries potentiate loss or compromise of both gag and cough responses.
(Nasogastric tube insertion is highly recommended although consideration of intubation and inherent airway protection should be considered prior to insertion.)

Attempt simple airway manoeuvres if required

Open the airway using a chin lift or jaw thrust.

Suction the airway if excessive secretions are noted or if the patient is unable to clear it themselves.

Insert an oropharyngeal airway (OPA)/nasopharyngeal airway (NPA) if required.

Secure the airway if necessary (treat airway obstruction as a medical emergency)

Consider early intubation if there are any signs of:
·         Decreased level of consciousness, unprotected airway, an uncooperative/combative patient leading to distress and further risk of injury.
·         Pending airway obstruction: stridor, hoarse voice.
·         Apnoea or respiratory failure due to paralysis.

Intubation of the patient while maintaining full spinal precautions requires skill and a high level of teamwork.

Manoeuvres to open the airway that mobilise the cervical spine, such as a neck tilt are contraindicated. Only jaw thrust and chin lift should be utilised.

RSI with cricoid and in line stabilisation
Image used with permission from Jeffery Rosenfeld, Practical management of head and neck injury, 2012, Sydney, Elsevier Australia

Manual in-line cervical stabilisation must be maintained while the cervical collar is removed to facilitate intubation. A second assistant may apply cricoid pressure over the cricoid cartilage ring while intubation is performed. The use of external laryngeal manipulation may be an effective procedure to mobilise the airway and to facilitate vocal cord identification11.
Prophylactic, pre-­‐treatment of quadriplegic and high-paraplegic patients with atropine is indicated prior to airway management due to unopposed vagal tone and the risk of bradycardia during pharyngeal stimulation12.

 Breathing and ventilation

Patients with a spinal injury may have respiratory compromise relative to the level of injury and spinal cord compromise, remembering that the diaphragm is innervated by cervical nerves 3, 4 and 5. Breathing and ventilation may be compromised by direct pulmonary injury or aspiration. They may present with an inadequate cough reflex, hypoventilation and apnoea. Rising spinal cord oedema may result in progressive loss of diaphragmatic function.
Paradoxical breathing, a sign of high spinal injury, results from activation of the diaphragm while thoracic muscles remain paralysed, causing the thorax to cave in (respiratory movements in which the chest wall moves in on inspiration and out on expiration, in reverse of the normal movements)12.

Assess the chest

Assess the patient’s ventilation by monitoring their respiratory rate and oxygen saturation. Auscultate to identify abnormal breath sounds and assess their bilateral air entry. 

 Circulation with haemorrhage control

Intravenous access should be obtained early to permit fluid administration.

Management of volume resuscitation is important in spinal patients and hypotension should be avoided; a general guide is to maintain a systolic blood pressure of above 90 mmHg. It is important not to assume that hypotension in a patient with SCI is solely as a result of their cord injury without excluding other causes such as haemorrhage.

Inspect for any signs of haemorrhage and apply direct pressure to any external wounds. Consider the potential for significant internal bleeding related to the mechanism of injury, which may lead to signs and symptoms of shock.

Expect hypotension and bradycardia associated with spinal shock in those with lesions above the sixth thoracic vertebrae.

Additionally, neurogenic shock may cause a bradycardia, contributing to hypotension, and may require treatment with medication such as atropine. Pulse commonly falls to 55 bpm or less. 

A heart rate less than 45 bpm and blood pressure under 90 mmHg require treatment in consultation with ARV and the receiving unit. If necessary, perform a FAST scan.

Consider the need for FAST (Focused Assessment with Sonography in Trauma) if available and if staff are trained in its use. FAST is used primarily to detect pericardial and intraperitoneal blood, and it is more accurate than any physical examination finding for detecting an intra-abdominal injury13.

If the patient is haemodynamically stable and there are no signs of significant internal bleeding then FAST may be delayed until the secondary survey.

 Disability: neurological status

Perform an initial AVPU assessment (Alert, responds to Voice, responds to Pain, Unresponsive); check the patient’s pupillary response.

Until ruled out by appropriately qualified clinical personnel (and where necessary with supportive radiological examination), major trauma patients should be considered at risk of spinal injury.

Identifying a cervical spinal injury in primary assessment is important. Priapism, diaphragmatic breathing and loss of anal tone are key signs of high spinal cord compromise.

Combative patients should not be physically restrained due to the increase in leverage and potential for further injury. Sedation, intubation and ventilation may be indicated to manage severe agitation.

 Exposure/environmental control

Remove the patient’s clothing to allow a complete examination.

An SCI patient can become hypothermic due to the loss of autonomic regulation, so it is important to monitor their temperature and keep them in a warm environment.