Acute Management and Medical Complications of Spinal Cord Injury
Priorities in the first hours
Questions test resuscitation before rehabilitation. Maintain spinal precautions during extrication, then prioritize airway, breathing, and circulation. Hypotension in a trauma patient is hemorrhagic until proven otherwise; volume loss, not neurogenic shock, is the commonest cause. Once bleeding is excluded, current guidance supports elevating mean arterial pressure to roughly 85-90 mmHg for about 5-7 days to protect cord perfusion.
Distinguish neurogenic shock from spinal shock. Neurogenic shock is a hemodynamic state from loss of sympathetic outflow above T6: hypotension with bradycardia, warm dry skin, and temperature dysregulation. Spinal shock is the transient loss of reflexes and flaccidity below the lesion, resolving over days to weeks. Bradycardia may require atropine or pacing if symptomatic; avoid unnecessary vagal stimuli such as tracheal suctioning without pretreatment.
Pulmonary and other early complications
High cervical injuries impair diaphragm and intercostal function. Track vital capacity and negative inspiratory force; falling trends herald respiratory failure. Ileus and gastric atony are common - place a nasogastric tube, avoid early enteral overload, and monitor for distension. Start venous thromboembolism prophylaxis once bleeding risk allows, use mechanical prophylaxis and sequential compression devices, provide pressure-redistributing surfaces, and monitor temperature.
Steroids and surgery
High-dose methylprednisolone is not recommended for routine use; it remains controversial and is not a standard of care. Early decompressive surgery within about 24 hours is reasonable for many patients.
Traps
Giving pressors for hypotension without excluding hemorrhage; confusing spinal shock with neurogenic shock; assuming steroids are mandatory; and attributing bradycardia to head injury.
Rule of thumb
MAP 85-90 for about a week, and treat bradycardia only when symptomatic.