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Guideline Title: Management of the Acute Spinal Injured Patient


Campus:
Category:
Responsibility for Review:

Date Approved:

Alfred
Infection Control
Program Director,
Cardiorespiratory and
Intensive Care
April 2010

Control No.:
Related Policy No.:
Rev.:

Review Date:

AH0410
001

April 2013

GUIDELINES
These guidelines should be read in conjunction with the Clinical care guidelines, and the following
ICU guidelines. Management of ICU trauma patients, ICU bowel management, Sedation in ICU,
Spinal clearance management and the ICU enteral nutrition.

PURPOSE
This guideline provides an outline of the nursing requirements of spinal injured patients in the
intensive care unit (ICU). The guideline has been devised from a review of relevant literature and
related guidelines. The guideline relates to the care of patients whilst in ICU and does not replace
the spinal clearance guideline. The aim is to optimise nursing care using standardised practice for
the care of patients with acute spinal injuries. The specific precautions necessary for spinal patients
are explicitly stated.

1.0

Spinal immobilisation

1.1

Aim

To reduce the risk of further injury to patients through effective communication of spinal
precautions required for individual patients.

To reduce the risk of pressure sore development.

To promote safe work practice and reduce the risk of injury to staff.

To prevent limb contractures as a result of reduced mobility.

1.2

Standard

The specific spinal immobilisation precautions for patients with confirmed or suspected
injury will be documented on the Spinal Assessment Chart MR R-69 by a relevant
medical officer within 24 hours of admission to ICU.

Patients will be positioned according to the instructions of the Spinal Clearance


management protocol and as documented on the Spinal assessment chart.

Management of the Acute Spinal Injured Patient


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1.3

Method

1.3.1 The medical team responsible for the management of the patients spinal injury (either
neurosurgery or orthopaedics) is required to complete the Spinal Assessment Chart. The
form should be filed with the patients notes. The order should be reviewed by the relevant
medical team and the ICU team during medical rounds and recharted at intervals not
exceeding 5 days.
1.3.2 Until the form is completed patients with confirmed or suspected spinal injury must wear a
Philadelphia or Aspen collar (the stiffneck collar should remain in situ for the shortest
possible time) and be log rolled using a minimum of 4 persons in order to maintain spinal
alignment. Patients require log rolling a minimum of every 3 hours for pressure area relief.
There is no requirement to use the Jordan frame unless specified on the Spinal Assessment
Chart or there is other significant injury that warrants its use e.g. unstable pelvic fractures.
1.3.3 Patients may be nursed on a regular ICU bed with clear signage stating NO BEND and
with the knee bend/backrest mechanism locked and taped over where appropriate. Patients
must be placed on a standard mattress until it is deemed safe to use a pressure relieving
mattress and this is documented on the Spinal Assessment Chart. Patients should be
cared for on a pressure relieving mattress whenever possible if there is no evidence of
vertebral body injury or the injury has been surgically fixed.
1.3.4 During normal business hours (0800 1700) the Orthotics Department (ext. 63182) are
available to fit Philadelphia and Aspen collars. The emergency Stiffneck collar should be
replaced by a Philadelphia collar as soon as possible. Patients admitted after 1700 should
have there Stiffneck collar replaced with a Philadelphia collar by a Registered Nurse
accredited to fit collars as soon as possible. This should be assessed the following business
day by an Orthotist.
1.3.5 Reposition and perform limb stretches according to the physiotherapy instructions for each
individual patient.

2.0

Haemodynamic monitoring

2.1

Aim

To monitor haemodynamic status in spinal injured patients.


To prevent spinal cord ischemia by maintaining haemodynamic stability.
To identify and treat hypotension that follows spinal cord injury due to loss of vascular tone
and unopposed parasympathetic output (Greenberg, 2001).
To reduce the risk of Autonomic Dysreflexia (AD).
To detect signs of Autonomic Dysreflexia early.
2.2

Standard

The mean arterial pressure (MAP) is maintained within the limits prescribed by the ICU
team in consultation with the medical team treating the spine. Hypotension is avoided
(AANS, 2002). Target MAP should be documented on the flow chart (MR E-10) by the
ICU team.

Management of the Acute Spinal Injured Patient


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Adequate hydration is maintained and the patient is carefully monitored for signs of
pulmonary oedema (Greenberg, 2001).
Bowel and Bladder care is provided according to this guideline.
Sustained increases in blood pressure are reported to the ICU medical team.
2.3

Method

Monitor the MAP via an arterial line for a minimum of 7 days (while in the ICU) following
acute spinal cord injury. Notify the ICU medical officer if there is a deviation from
acceptable MAP parameters so that appropriate treatment can be commenced.
Provide bowel and bladder care according to the guidelines. Ensure creases in the
bedclothes are removed and be vigilant about other possible sources of noxious stimuli (to
prevent AD).
Report sustained increases in blood pressure (that is > 30minutes) to the ICU medical team.
Instigate treatment for autonomic dysreflexia using aggressive antihypertensive therapy.
Other vital signs such as heart rate, central venous pressure and temperature should be
monitored according to the patients status as for any ICU patient.

3.0

Respiratory

3.1

Aim

To maintain adequate gas exchange by ensuring optimal ventilation and oxygenation.


To detect respiratory difficulty early
To prevent and manage atelectasis
3.2

Standard

Maintain optimal respiratory function and commence weaning from ventilator as early as
possible.
Maintain Sa02 95% (or patients normal level) at all times\
3.3

Method

Measure the vital capacity for all non-ventilated patients using spirometry every 2 hours
(Parsons et al, 2005). Notify the ICU medical team if measurement less than 10ml/kg or if
there is a significant reduction of 500mls.
Implement non-invasive ventilation modes if advised by the ICU medical team

Management of the Acute Spinal Injured Patient


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4.0

Sedation and Analgesia

4.1

Aim

To reduce pain and anxiety to levels acceptable to the patient.


To monitor changes in haemodynamic status indicating pain, in the absence of sensation
4.2

Standard

The patients level of comfort is assessed on admission and every four hours during daylight
hours during their stay in ICU
Provide adequate and appropriate analgesia and sedation without delay
Reduce likelihood of autonomic dysreflexia caused by untreated pain.
4.3

Method

Refer to ICU sedation guideline


Consult with ICU medical team regarding the requirement for antispasmodic medications.
Monitor for increases in blood pressure and changes in heart rate which may be the only
indicators of pain in patients who cannot feel pain but have intact nociception.
Refer to the pain team early if pain is unrelieved.
5.0

Bowel care

5.1

Aim

To empty the bowel at regular intervals in order to prevent incontinence and associated
complications such as skin breakdown
To maintain patient dignity
To establish a bowel regime to prevent complications such as constipation and diarrhoea and
minimise the use of laxatives and aperients that can irritate the bowel.
5.2

Standard

Commence the bowel regime stipulated below on admission. The only exception to this rule
is for patients with known previous spinal injury.
Patients who have an existing spinal injury should continue on the regime they are familiar
with. These patients should be questioned about their usual bowel regime. This should be
documented and adhered to as long as it remains effective.
Regular bowel action (at least every two days) of a formed stool is achieved.
Constipation does not occur.

Management of the Acute Spinal Injured Patient


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5.3

Method

Fybogel 1tsp and lactulose 20mls BD are prescribed on the medication chart.
NB. If the patient is not receiving adequate fluid input, Fybogel will cause
constipation very rapidly.
Daily bowel care consists of one Microlax enema, preferably administered with the patient
on their left side, followed by a 20minute wait. The time for the enema to take effect can
vary between patients.
If no bowel motion occurs, gentle digital stimulation is performed by inserting a finger just
inside the rectum. If there is still no bowel motion then the same procedure is repeated the
next day. Ensure that the enemas or manual stimulation are performed with sufficient
lubrication. The administration of aperients and bowel care at the same time each day aids
the bowels ability to respond and empty more completely and avoids incontinence.
If the patient does not have a bowel motion for 3 days it is important to review treatment to
prevent impaction.
Bowel routines take time to establish. It is recommended that a minimum of 5 days
treatment be continued before a change to bowel medication is considered. Once a change is
made it should also be continued for 5 days before further changes. Only one change to
bowel medication should be made at a time, as multiple changes can lead to the bowel
responding erratically and the carer will be unsure of which medication suits the patient.
The simultaneous use of several medications is not recommended in acute spinal cord
injury; it is best to adhere to the Fybogel and lactulose regime. Movicol one sachet may
be added to treat constipation. Use of any aperients containing Senna is not recommended
for spinal injured patients (SIU, 2001).
A full abdominal examination should be performed to assist with determining underlying
causes for absence in bowel movements and an abdominal X-ray should be considered.
Bowel activity must be recorded on the patients Bowel Chart Worksheet each day.

6.0
6.1

Bladder care
Aim

Management of the Acute Spinal Injured Patient


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To prevent urinary tract infection (UTI)


To detect UTI early
6.2

Standard

UTIs will not occur


Patients will not experience urinary tract discomfort and bladder distension
6.3

Method

Ensure the urinary catheter tubing is strapped to the patients leg and supported when ever
the patient is repositioned.
Report low (1ml/kg/hr) or high urine output states to the ICU medical team.
Perform daily urine analysis
Send a sterile sample of urine for microbiology analysis if protein or blood is detected.

7.0

Nutrition

7.1

Aim

To provide adequate nutritional supplements as appropriate. Patients with spinal cord injury
are susceptible to large nitrogen losses, losses of lean body mass, reduced protein synthesis,
loss of gastrointestinal mucosal integrity and ultimately compromise of immune competence
(AANS, 2002).
7.2

Standard

Enteral feeding is started early according to ICU enteral nutritional guidelines.


Adequate nutritional support is provided according to ICU enteral nutritional guidelines.
7.3

Method

Refer to Nutrition Guidelines for ICU


Refer to ICU Dieticians

8.0

Skin care

8.1

Aim

To prevent pressure ulcers


Management of the Acute Spinal Injured Patient
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To detect the signs of pressure ulcers early


8.2

Standard

A pressure ulcer risk score (modified Sunderland score) is calculated and recorded on the
ICU chart (MR E-10) every 24hours or when the patients condition changes.
A Spinal assessment chart (MR R-69) is completed within 24hours of admission and
reviewed every 5 days thereafter.
Pressure ulcers are recognised, documented and reported immediately
8.3

Method

Follow the instructions in the Alfred Pressure ulcer prevention policy and Pressure ulcer
prevention management guideline
Wherever possible the patient should be nursed on a pressure relieving mattress. Refer to
Spinal assessment chart (MR R-69) for restrictions.
Ensure the legs are positioned on pillows lengthways with the heels elevated off the bed
surface.
When patients have a cervical collar in situ a skin check of the area under the collar should
be performed at each pressure area care episode (at least every 3hours). Pressure relieving
gel pads may be placed under the patients head in order to evenly distribute pressure from
the collar.
Contact orthotics department for fitting advice.
9.0

Psychosocial care

9.1

Aim

To meet the specific psychosocial needs of the spinal injured patient and their family
9.2

Standard

All patients with significant spinal cord injury and their families will be offered the services
of social work and pastoral care.
Patients will be offered counselling and assistance specific to their needs by the most
suitably qualified person.
Patients and their families will be encouraged to be involved in care

9.3

Method

Offer to refer the patient/family to the ICU social worker


Offer to refer the patient/family to the ICU Chaplain

Management of the Acute Spinal Injured Patient


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Encourage family and friends to provide photographs and small keep sakes to personalise
the bedside.
Organise the provision of a TV and radio.
When the patient is well enough ask the family to provide loose fitting clothes and easily
fitted training shoes for comfort when sitting out in chair.

RELATED DOCUMENTATION
Sedation in ICU Guideline

Intranet

ICU Enteral Nutrition Guideline

Intranet

Spinal Clearance Management

Intranet

ICU Bowel Management Guideline

Intranet

ACKNOWLEDGEMENT
Thank you to The Royal North Shore Hospital ICU for sharing their work with us.

REFERENCES
American Association of Neurosurgical Surgeons (AANS). 2002 Joint section on disorders of the
spine and peripheral nerves of the American Association of Neurological Surgeons and the
Congress of Neurological Surgeons: Guidelines for the management of acute cervical spine and
spinal cord injuries. Neurosurgery. 50 (Suppl).
Coats-Bennett, U. 2002 Use of support surfaces in the ICU, Critical Care Nursing Quarterly, 25(1):
22-32
Greenberg, M. 2001 Handbook of Neurosurgery, Fifth edition, Thieme, NY.
Gutierrez, C.J., Harrow, J. and Haines, F. 2003 Using an evidence-based protocol to guide
rehabilitation and weaning of ventilator-dependant cervical spinal cord injury patients, Journal of
Rehabilitation Research and Development, 40(5): 99-110, (Suppl 2).
Larcher Caliri, M. H. 2005 Spinal cord injury and pressure ulcers, Nursing Clinics of North
America, 40: 337-347.
Nelson, A. (Ed.) 2001 Nursing practice related to spinal cord injury and disorders: a core
curriculum, Eastern Paralysed Veterans Association, NY.
Parsons, K. C. (Chair) et al 2005 Respiratory management following spinal cord injury. A clinical
practice guideline for health-care professionals, The Journal of Spinal Cord Medicine, 28(3): 260292.
Rowan, C.J., Gillanders, L.K., Paice, R.L. and Judson, J.A. 2004 Is early enteral feeding safe in
patients who have suffered spinal cord injury? International Journal of the Care of the Injured, 35:
238-242.

Management of the Acute Spinal Injured Patient


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Sidall, P.J. and Middleon, J.W. 2006 A Proposed algorithm for the management of pain following
spinal cord injury, Spinal Cord, 44: 66-77.
Spinal Injuries Unit (SIU) (ND/A) Management of Neurogenic Bowel: Clinical Practice Guidelines.
RNSH.
Spinal Injuries Unit (ND/B) Caring for the Neurogenic Bowel. RNSH.
Spinal Injuries Unit (ND/C) Changes to Bowel Regimen. RNSH
Winslow, C. and Rozovsky, J. 2003 Effect of spinal cord injury on the respiratory system,
American Journal of Physical Medical Rehabilitation, 82(100): 803-814.

Contact person:

Jason Watterson

Email:

j.watterson@alfred.org.au

Position:
Phone:

Clinical Nurse Educator (ICU)


9076 0700

Management of the Acute Spinal Injured Patient


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