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Anesthetic Management of Acute and Chronic Spinal Cord Injuries

Types of Spinal Cord Injuries. Traumatic: MVA, assault, falls, sporting injuriesNon-traumatic: infection, tumor, vascular malformationsMechanism of injury: direct, compression, interruption of blood supply10,000 new cases per year in the U.S., ~50% cervical spine injury30-40/million in America/

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Anesthetic Management of Acute and Chronic Spinal Cord Injuries

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    1. Anesthetic Management of Acute and Chronic Spinal Cord Injuries Jun Lin, M.D., Ph.D. Attending Physician Department of Anesthesiology Long Island College Hospital 339 Hicks Street Brooklyn, NY 11201 Associate Professor Department of Anesthesiology State University of New York - Downstate Medical Center 450 Clarkson Avenue, Box 6 Brooklyn, New York 11203

    2. Types of Spinal Cord Injuries Traumatic: MVA, assault, falls, sporting injuries Non-traumatic: infection, tumor, vascular malformations Mechanism of injury: direct, compression, interruption of blood supply 10,000+ new cases per year in the U.S., ~50% cervical spine injury 30-40/million in America/year 250,000+ people living with Spinal Cord Injury in the U.S. Reference/Further reading: Wyndaele M and Wyndaele J-J . Incidence, prevalence and epidemiology of spinal cord injury: what learns a worldwide literature survey? Incidence and prevalence of SCI. Spinal Cord 2006; 44:523-529

    3. Hypothesized Case for Education Purpose Only An unknown age patient brought to emergency room, suffered from an automobile accident. Awake, in acute stress, unable to move four extremities. BP 80/40 mmHg, P 49/min, RR 34/min, O2 saturation 88% on supplemental O2. Patient is scheduled for emergent cervical decompression. What are your concerns? How will you secure patient’s airway? Is succinylcholine safe to use?

    4. Functional Anatomy of Spinal Cord Corticospinal tracts (descending motor pathways): precentral gyrus of the frontal lobe (upper motor neurons) ? internal capsule ? medulla oblongata: 80-90% axons cross - lateral corticospinal tract, 10-20% ventral corticospinal tract synapse with lower motor neurons?ventral root?peripheral nerves Dorsal columns: light touch touch, vibration, propriopreception Spinothalamic tracts: pain, temperature, light touch Autonomic nerve system: sympatheic (C7-L1) parathpathetic (S2-4, cranial nerves)

    5. Physiology of Acute Spinal Cord Injury Neuromuscular Respiratory Cardiovascular Metabolic and Nutritional

    6. Acute Spinal Cord Injury: Respiratory Consequence Nerve Innervations: C3-5 phrenic nerve; C5 intercostal muscle; C7 upper extremity paresis and sensory loss Injury at C2: immediate ventilation support C4 or above affect diaphragm and require permanent ventilatory assistance 40% Cervical injury need assisted ventilation, 2% need long term mechanical ventilation One third of paraplegic patients need airway management for respiratory distress Functional electrical stimulation: phrenic and diaphragmatic pacing, no effect on coughing mechanism, still need secretion management

    7. Respiratory Physiology of Acute Spinal Cord Injury Restrictive lung pathology Loss of expiratory reserve Loss of accessory muscle function: ?expiratory volume, ?cough, ?secretion ? Vital Capacity 10 cm3/kg ? ? ? cough, ? ? ? secretion, atelectasis, pneumonia

    8. Cardiovascular Physiology of Acute Spinal Cord Injury Neurogenic shock: high cardiac output and low systemic vascular resistance Cardioaccelerator center T1-T4 Sympathectomy: bradycardia, vasodilation, hypotension, spinal shock Bradycardia, HR<50 BPM, asystole , during tracheal intubation (oxygen, atropine) Pulmonary edema may occur from catecholamine surge and fluid overload Fluid and vasopressor to maintain systolic BP 85-90 mmHg for the first 7 days Reference/Further Reading: Guly HR, Bouamra O, lecky FE. The incidence of neurogenic shock in patients with isolated spinal cord injury in the emergency department. Resuscitation. 2008; 76:57-62. Furlan JC and Fehlings MG. Cardiovascular Complications After Acute Spinal Cord Injury: Pathophysiology, Diagnosis, and Management. Neurosurg Focus. 2008;25(5):E13 

    9. Hemodynamic Management Hypotension and bradycadia common Brdaycardia: vagolitics, pacemaker Dopamine (ß,a) good choice for hypotension accompanied with bradycardia Volume resuscitation: best fluid not known, albumin?risk of death, avoid hypotonic fluids CVP line or pulmonary artery catheter CVP or PCWP 18 recommended Left ventricular dysfunction to monitor

    10. Initial Resuscitation of Trauma Patient Rapid Overview Primary Survey Airway Breathing Circulation Neurologic Function Examination, Lab and Radiology tests Secondary Survey Emergent Surgery Specific X-rays Observation

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