Failure of Mean Arterial Pressure Goals to Improve Outcomes Following Penetrating Spinal Cord Injury

Readdy, William J; Saigal, Rajiv; Whetstone, William D.; Mefford, Anthony; Ferguson, Adam R.; Talbott, Jason F.; Inoue, Tomoo; Bresnahan, Jacqueline C.; Beattie, Michael S.; Pan, Jonathan Z.; Manley, Geoffrey T.; Dhall, Sanjay S.

doi:10.1227/neu.0000000000001249

Cited by 28 publications

(27 citation statements)

References 28 publications

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“…66 Aggressive cardiopulmonary management following multisystem trauma involving the spinal cord should weigh equipoise between expected risk of complications and relatively lower likelihoods of recovery.…”

Section: Spinal Cord Perfusion and Vasopressor Supportmentioning

confidence: 99%

Update on critical care for acute spinal cord injury in the setting of polytrauma

Yue

Winkler

Rick

et al. 2017

Neurosurgical Focus

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Traumatic spinal cord injury (SCI) often occurs in patients with concurrent traumatic injuries in other body systems. These patients with polytrauma pose unique challenges to clinicians. The current review evaluates existing guidelines and updates the evidence for prehospital transport, immobilization, initial resuscitation, critical care, hemodynamic stability, diagnostic imaging, surgical techniques, and timing appropriate for the patient with SCI who has multisystem trauma. Initial management should be systematic, with focus on spinal immobilization, timely transport, and optimizing perfusion to the spinal cord. There is general evidence for the maintenance of mean arterial pressure of > 85 mm Hg during immediate and acute care to optimize neurological outcome; however, the selection of vasopressor type and duration should be judicious, with considerations for level of injury and risks of increased cardiogenic complications in the elderly. Level II recommendations exist for early decompression, and additional time points of neurological assessment within the first 24 hours and during acute care are warranted to determine the temporality of benefits attributable to early surgery. Venous thromboembolism prophylaxis using low-molecular-weight heparin is recommended by current guidelines for SCI. For these patients, titration of tidal volumes is important to balance the association of earlier weaning off the ventilator, with its risk of atelectasis, against the risk for lung damage from mechanical overinflation that can occur with prolonged ventilation. Careful evaluation of infection risk is a priority following multisystem trauma for patients with relative immunosuppression or compromise. Although patients with polytrauma may experience longer rehabilitation courses, long-term neurological recovery is generally comparable to that in patients with isolated SCI after controlling for demographics. Bowel and bladder disorders are common following SCI, significantly reduce quality of life, and constitute a focus of targeted therapies. Emerging biomarkers including glial fibrillary acidic protein, S100β, and microRNAs for traumatic SCIs are presented. Systematic management approaches to minimize sources of secondary injury are discussed, and areas requiring further research, implementation, and validation are identified.

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Section: Spinal Cord Perfusion and Vasopressor Supportmentioning

confidence: 99%

Update on critical care for acute spinal cord injury in the setting of polytrauma

Yue

Winkler

Rick

et al. 2017

Neurosurgical Focus

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“…4 In comparison to blunt SCI, a study by Readdy et al showed that vasopressor use did not improve neurological outcomes. 20 We also did not find any significant improvement in neurological outcome in patients who sustained penetrating injuries and were treated with vasopressors. The existing literature provides some guidance on surgical indication, reserving surgical intervention for progressive neurological deficit, spinal instability, or infection control.…”

Section: Discussionmentioning

confidence: 51%

“…Consequently, there is significant variability in penetrating spinal trauma management practices with most trauma centers relying on blunt spine trauma guidelines, which may be ill-equipped for the distinct patient population and mechanism of penetrating injury. 11,13,20 Our institution is an academic level 1 trauma center and safety-net hospital in the southeastern United States with a relatively high rate of penetrating spine injuries. 27 The goal of this study was to examine the epidemiology of penetrating spine injuries compared with blunt injuries.…”

mentioning

confidence: 99%

A case series of penetrating spinal trauma: comparisons to blunt trauma, surgical indications, and outcomes

Morrow¹,

Podet²,

Spinelli

et al. 2019

Neurosurgical Focus

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OBJECTIVEWhile blunt spinal trauma accounts for the majority of spine trauma, penetrating injuries affect a substantial number of patients. The goal of this study was to examine the epidemiology of penetrating spine injuries compared with blunt injuries and review the operative interventions and outcomes in the penetrating spine injury group.METHODSThe prospectively maintained trauma database was queried for spinal fractures from 2012 to 2018. Charts from patients with penetrating spine trauma were reviewed.RESULTSA total of 1130 patients were evaluated for traumatic spinal fractures; 154 injuries (13.6%) were secondary to penetrating injuries. Patients with penetrating injuries were significantly younger (29.2 years vs 44.1 years, p < 0.001), more likely male (87.7% vs 69.2%, p < 0.001), and more commonly African American (80.5% vs 33.3%, p < 0.05). When comparing primary insurers, the penetrating group had a significantly higher percentage of patients covered by Medicaid (60.4% vs 32.6%, p < 0.05) or prison (3.9% vs 0.1%, p < 0.05) or being uninsured (17.5% vs 10.3%, p < 0.05). The penetrating group had a higher Injury Severity Score on admission (20.2 vs 15.6, p < 0.001) and longer hospital length of stay (20.1 days vs 10.3 days, p < 0.001) and were less likely to be discharged home (51.3% vs 65.1%, p < 0.05). Of the penetrating injuries, 142 (92.2%) were due to firearms. Sixty-three patients (40.9%) with penetrating injuries had a concomitant spinal cord or cauda equina injury. Of those, 44 (69.8%) had an American Spinal Injury Association Impairment Scale (AIS) grade of A. Ten patients (15.9%) improved at least 1 AIS grade, while 2 patients (3.2%) declined at least 1 AIS grade. Nine patients with penetrating injuries underwent neurosurgical intervention: 5 for spinal instability, 4 for compressive lesions with declining neurological examination results, and 2 for infectious concerns, with some patients having multiple indications. Patients undergoing neurosurgical intervention did not show a significantly greater change in AIS grade than those who did not. No patient experienced a complication directly related to neurosurgical intervention.CONCLUSIONSPenetrating spinal trauma affects a younger, more publicly funded cohort than blunt spinal trauma. These patients utilize more healthcare resources and are more severely injured. Surgery is undertaken for limiting progression of neurological deficit, stabilization, or infection control.

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“…Additionally, maintenance for 5-7 days may be insufficient because certain individuals benefit from longer management [4]. One study has shown that vasopressor therapy achieving the MAP goal is more likely to cause complications than to improve neurological outcomes, with dopamine leading in complications [20]. As such, the risk of vasopressors should be balanced against their benefits in each individual patient, and there should be clear goals for use in regard to improvement of the sensory and motor deficits vs. cardiovascular stabilization.…”

Section: Patient Managementmentioning

confidence: 99%

Neurogenic Shock

Volski¹,

Ackerman²

2020

Clinical Management of Shock - The Science and Art of Physiological Restoration

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Neurogenic shock is a state characterized by hypotension, bradycardia, and other evidence of autonomic dysfunction. The most common cause is acute spinal cord injury (SCI), which will be the subject of our focus. Because the typical autonomic reflexes may be either abolished or dysregulated, appropriate treatment requires an understanding of the neuroanatomic substrate for the change. In this chapter, we will explore the root cause for neurogenic shock, differentiating it from spinal shock, and discuss those patients at risk and generally accepted treatment paradigms. The timeframe for manifestation of neurogenic shock is variable and it can quickly progress to cause secondary injury or death, so appropriate monitoring requires a high level of suspicion and diligence.

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Failure of Mean Arterial Pressure Goals to Improve Outcomes Following Penetrating Spinal Cord Injury

Abstract: ASIA, American Spinal Injury AssociationMAP, mean arterial pressureSCI, spinal cord injury.

Cited by 28 publications

References 28 publications

Update on critical care for acute spinal cord injury in the setting of polytrauma

Update on critical care for acute spinal cord injury in the setting of polytrauma

A case series of penetrating spinal trauma: comparisons to blunt trauma, surgical indications, and outcomes

Neurogenic Shock

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