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Clinical Hub,References,Level I Adult Trauma Center Manual,Spine

Traumatic Non-Penetrating Tetraplegia or Paraplegia

Traumatic Non-Penetrating Tetraplegia or Paraplegia - Clinical Hub, References, Level I Adult Trauma Center Manual, Spine

Focus

Objectives

  1. To define diagnostic approaches to non-penetrating spinal cord injuries.
  2. To define early therapeutic intervention strategies for spinal cord injuries.

Definitions

  1. Traumatic tetraplegia: Any non-penetrating complete spinal cord injury associated with a spinal cord or nerve root deficit not involving the cranial nerves above and including C8, T1 roots.
  2. Traumatic paraplegia: Any non-penetrating complete spinal cord injury associated with a spinal cord or nerve root deficit below and including T2.
  3. Complete: Any spinal cord injury associated with a complete motor and sensory deficit below the level of the injury.
  4. Incomplete: Any sensory or motor sparing below the level of injury including perianal sensation.

Guidelines

  1. Follow the ABC’s.
  2. Perform a complete neurologic exam looking for neurologic deficit and the level of the deficit.
  3. Maintain spine precautions.
  4. Obtain X-rays according to the C-spine and thoracic and lumbo-sacral injury protocols.
  5. If quadraplegia or paraplegia are noted, perform a bulbocavernosus reflex test:
    1. Male: pull on penis while examining for an increase in rectal tone.
    2. Female: pull on Foley catheter while examining for an increase in rectal tone
    3. If this reflex is present, then spinal shock is not occurring and injury will usually not improve.
    4. If this reflex is absent, then spinal shock may be occurring and ultimate outcome of injury is masked.
    5. Document presence/absence of bulbocavernosus reflex.
  6. Consult the orthopedic or neurosurgery spine service immediately.
  7. Neurogenic shock may occur with Cerebral or Spinal injuries down to T4-6.
    1. Place Foley and monitor urine output.
    2. Follow frequent blood pressures.
    3. If patient has SBP <90 mmHg or MAP <65 mmHg and urine output <30 ml/hr and hemorrhagic shock has been ruled out (by CXR, DPL, FAST, or CT scan of the abdomen), follow the following steps until improvement occurs:
      1. Start dopamine at 5mcg/kg/min; continue fluid resuscitation as necessary.
      2. If no response, increase dopamine to 10mcg/kg/min
      3. Consider phenylephrine starting at 30mcg/min if filling pressures and cardiac index are satisfactory.
  8. For quadraplegics with potential pulmonary problems:
    1. Nearly all patients with a C-5 or higher neurologic deficit will require intubation.
    2. Assess vital capacity: if less than 1000mL (or 10 ml/kg) consider intubation
    3. Assess ability to clear secretions: consider intubation if secretions cannot be cleared spontaneously or with quad cough maneuver.
    4. Closely monitor in ICU or IMC for the first 24 hours, with good pulmonary toilet.
    5. If there is question about retention of secretions or development of atelectasis in the first 24 hours, intubate to prevent emergent intubation.
  9. Provide DVT prophylaxis when indicated
  10. Consult acute rehabilitation service early to assist with planning

Major Motor Levels

Level

Muscle Group

Action

DTR

C5

Deltoid, spinati

Abduction of shoulder; external rotation of arm

 

C6

Biceps brachialis

Flexion of elbow

Biceps/jerk

C7

Triceps, wrist extensors

Extension of elbow, wrist

Triceps/jerk

C8

Intrinsic hand muscles

Abduction, adduction of fingers

 

L2, L3

Iliopsoas

Hip Flexion

 

L4

Quadriceps

Extension of knee

 

L5

Tibialis anterior and posterior, extensor halluces longus

Dorsiflexion of foot and big toe

Ankle

S1

Gastrocnemius

Plantar flexion of foot

Ankle

S4-5

Anal sphincter

Voluntary contractions of anal sphincter

 

 

Major sensory levels Segmental reflexes

C4

Clavicle

C5

Deltoid region

C6

Radial forearm and thumb

C7

Middle finger

C8

Fifth finger

T1

Medial, proximal arm

T5

Nipples

T7

Costal margins

T10

Umbilicus

T12

Inguinal ligament

L3

Anterior thigh

L4

Medial aspect of knee

L5

Lateral calf, dorsum of foot, big toe

S1

Lateral foot, fifth toe

S2

Posterior thighs

S3,4

Buttocks, perianal region

Reflex

Level

Biceps

C6

Triceps

C7

Upper abdominal

T7-T10

Lower abdominal

T10-T12

Cremasteric

L2

Knee Jerk

L4

Posterior tibial jerk

L5

Ankle Jerk

S1

Bulbocave4rnosus

S2-4

Anocutaneous

S4-5

Resources