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