Investigations

Routine haematological and biochemical parameter assessment could include estimation of arterial blood gases and whenever possible vital capacity and FEV1.

Radiological assessment initially should be restricted to an AP and lateral view of the suspected area/s of injury/s. These should be reviewed by a Senior Medical Practitioner before additional views are obtained.

Better X rays of the cervico-thoracic junction could be obtained by supervised, sustained and careful pulling of the shoulder. Such a manoeuvre should not result in undue rotation or tilt of the skull/cervical spine. Oblique views of the cervico-thoracic junction often give further details of the facet joints. Swimmers views may be of value in some instances.

Additional imaging including CT scans and MR scans where indicated should be carried out provided spinal movement could be minimised and the patient’s general condition allows.


Nursing
It is difficult to under-estimate the important role played by informed nurses in supporting the multi-system needs of a paralysed individual. Two excellent books published by the Spinal Injuries Association deal with the essential features of nursing a patient with acute traumatic spinal cord injury. BASCIS would strongly recommend the acquisition of these books by every A&E Department, ITU and Acute Wards that may be called upon to deal with patients with spinal cord injury. In many instances admission to ITU/HDU may be a better way of organising the necessary level of nursing expertise.

(a) Blood pressure, pulse, respiratory rate and temperature, should be recorded regularly, the frequency of such recording being determined by the clinical condition.

(b) Neurological charting should include head injury observations (if needed) and a record of presence/absence of sensation/movements (voluntary) in the extremities.

(c) If catheterised, record the time of catheterisation, urine drained and urine output-initially on an hourly basis.

(d) Note and record if there is any faecal soiling during de-robing of the patient.

(e) Record all externally visible signs of injury.

(f) Comfort the patient. Do not confirm the diagnosis even if it is strongly suspected. Remember long term functional/neurological outcome following a spinal cord injury in patients who may have “complete lesion” in the A&E Department is difficult to predict soon after injury.

(g) Learn safe and effective transfer of the paralysed patient from a spinal board on to bed/x-ray table/examining couch using appropriate manpower.

(h) Periodic log-rolling and in cervical spine injuries, pelvic twisting may be essential to avoid the development of pressure sores.

(i) Maintain spinal alignment during all spinal procedures. Remember that the patient may have pre-existing kyphosis/ankylosing spondylitis etc. In these patients, spinal alignment means the return to their pre-injury normal contour of the spine and not supine. Thus there may be a need to use pillows to support the neck of a patient with ankylosing spondylitis and paralysis.

(j) Pain due to spinal cord injury is minimal, but pain due to a spinal column injury may be significant. Associated anxiety and fear will clearly exacerbate perceived pain.

(k)The need to maintain “spinal column alignment” should not compromise access to other system injuries. Informed compromises and repositioning of the patient will be needed in the A&E Department.

(l) Maintain intake/output chart. Avoid oral fluids, if at all possible during the first 24 hours or longer in patients with spinal cord injury.