Emergency War Surgery NATO Handbook: Part IV: Regional Wounds and Injuries: Chapter XXXIII: Wounds and Injuries of the Spinal Column and Cord
United States Department of Defense
Peer Review Status: Internally Peer
Reviewed
Traumatically-induced sympathectomy seen with injuries to the vertebral column above T-6 produce bradycardia, hypotension, and hypothermia. Ringer's lactate may be required to maintain adequate vascular volume and maintain a reasonable blood pressure Atropine (0.4-0.6 mg every four hours) may improve blood pressure levels by maintaining the cardiac rate above 40/min. Hypotension in the complete spinal cord injury is to be anticipated, due to marked decrease in peripheral vascular resistance.
The use of a nasogastric tube is always indicated in the acute spine-injured patient. Its use reduces the chance of emesis, and allows earlier diagnosis of stress ulcer hemorrhage Cimetidine (300 gm by IV infusion every six hours) is utilized during the first 7-10 days post injury, along with the installation of aluminum hydroxide gel (Amphogel, 30 cc) and a magnesium hydroxide (Mylanta II, 15 cc) into the nasogastric tube every two hours to prevent stress ulceration. The use of this combination tends to counteract the diarrhea caused by one and the constipation brought on by the other. The use of a nasogastric tube, connected to low suction, also reduces the effects of paralytic ileus, which often follows injury of the thoracic and lumbar spine.
A major concern following spine and spinal cord injury is the occurrence of deep venous thrombosis. The most appropriate prophylactic measures include: (a) awareness, (b) adequate fluid hydration, (c) thigh-length compression hose (changed two to three times daily to evaluate the skin and check for edema), and (d) subcutaneous heparin (5,000 units twice a day). This dose of subcutaneous heparin during the immediate post-trauma period is not likely to cause intraspinal bleeding.
The bladder is emptied by intermittent catherization. Frequently, for the female patient, this is not possible and an indwelling catheter is required. In the combat situation, for logistics reasons, it may be necessary to leave an indwelling catheter in place. Failure to decompress the bladder can lead to a hypertensive crisis severe enough to cause bleeding into the brain (autonomic hyperreflexia). The use of prophylactic urinary antibiotics is not advised. Liberal fluid intake (2,000 cc daily) and the use of an acidifying agent (e.g., cranberry juice) to reduce the occurrence of urinary calculi is recommended. Bowel training includes the use of suppositories.
Decubitus ulcers must be prevented. Patients are instructed in prevention techniques. Where self care is not appropriate, patient care and turning must be provided by attendants. For the recumbent patient, all pressure points are carefully padded and frequently observed. The skin is kept dry and powered. All bony prominences are inspected daily. Physical therapy is started immediately to minimize contracture and disuse atrophy. All joints incapable of being actively mobilized by the patient require daily ranging through their full arc of motion. Foot supports prevent contractures of the ankle and pressure decubiti of the heel.
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