Spinal Cord Injury (SCI)

Question 1

For Acute SCI, what are you thinking for airway? Lesions above ___ usually require?

Answer 1

I’m thinking manual in-line stabilization, with glide or fiberoptic
Lesions above C5 usually require intubation and mechanical ventilation

Question 2

Why would you choose supine positioning over upright in SCI patients?

Answer 2

Supine improves respiration. Abdominal muscle wall tone is decreased, so when sitting up, diaphragm sits lower, actually reducing diaphragmatic excursion and vital capacity

Question 3

Why are SCI patients more prone to hypoxemia and pneumonia? KIM that what could happen?

Answer 3

Atelectasis, unopposed vagal tone, ineffective cough, and KIM that a catecholamine surge could occur after acute trauma

Question 4

Post-op respiratory care in a patient with SCI?

Answer 4

agressive bronchial hygiene, suctioning, positive pressure

Question 5

What is the definition of spinal shock?

Answer 5

Loss or depression of all or most of spinal reflex activity below the level of spinal injury. Can result in flaccid paralysis, paralytic ileus, and loss of sensation below

Question 6

Clinical manifestations of spinal shock, what are they, and they are usually seen when? whats the timeline of spinal shock, and how does it work?

Answer 6

Clinical: usually happens with injuries above T6, but you can have hypotension (loss of activity in T1-T4 cardioacceleratory fibers), decreased preload, decreased PVR
Timeline: 24 hours to 3 mos after injury
The loss of sympathetic tone results in unopposed parasympathetic stimulation

Question 7

Mgmt of spinal shock:

Answer 7

fluids, catechomalmie infusion, MAP should be 80-90

Question 8

What is autonomic dysreflexia? When does it develop? What are symptoms?

Answer 8

Occurs in SCI lesion at T6 or above, (Bladder distention can cause this as well as stimulation below the level of the cord, contractions if preggo, lap chole maybe) sympathetic discharge is unopposed and receptors below level of injury are hypersensitive
Develops in first 6 mos to 1 year after initial SCI
Symptoms: HTN, reflex bradycardia, headache, malaise, sweating and flushing ABOVE level of spinal cord

Question 9

Mgmt of Autonomic dysreflexia:

Answer 9

Sit patient up
Avoid/remove noxious stimuli
Treat HTN-Deepen anesthetic!!!!

Question 10

Avoiding/prevention of Autonomic dysreflexia

Answer 10

Prevent it! give GA, neuraxial despite lack of sensation below level of operation
Avoid SUX at all costs-they can have extra-junctional ACh receptors

Question 11

Pre-operative concerns of patients with SCI:

Intra-op

Answer 11

standard H&P 
Level of injury 
length and time 
baseline BP 
prior autonomic dysreflexia? 

Intra-op: have vasodilators ready

Question 12

Nitroprusside:

Answer 12

Direct release of NO

Question 13

Hydralazine:

Answer 13

increases cGMP and vasodilators arterioles

Question 14

SOB and difficulty breathing in pt with spinal cord injury:

Femur fracture. Injuries at C6-C7 affect what?

Answer 14

Cervical spine injury above level of C6, PTX, PE (fat emboli)
Affect chest wall innervation which can lead to paradoxical respiratory motion and an inability to clear secretions

Question 15

When you want a temp probe:

Answer 15

Esophageal vs nasopharyngeal vs tympanic

Question 16

IN neuro cases, when they ask you which monitors you want, don’t forget about what?

Answer 16

Foley and MEP and SSEPs!!!!!!!!!!

Consider A lines and CVPS!!!!

Question 17

When they ask you about hyperventilation, make sure to say:

Answer 17

make sure to acknowledge that you know it could decrease intracranial pressure, But that it could also cause cerebral ischemia

Question 18

If someone has asthma, just give them a

Answer 18

Beta agonist prior to induction

Question 19

What’s the buzzword for treating the neck right during neuro procedures?

Answer 19

IN LINE STABILIZATION

Question 20

If a patient isn’t a planned procedure, we can count thme as full stomach, whcih means we do what to the bed?

Answer 20

30 degree reverse t berg, making sure that that position can be hadled!!!!

Question 21

What things will you say you’ll do for airway-even if you want?

Answer 21

If pt having awake fiberoptic-you can say airway block, nebulized lidocaine-have to mention the sedation that you’ll give (ketamine and glyco, precedex (titrate precedex to effect) 6 mg boluses
don’t ventilate with facial fractures

Question 22

Pt having PVCs-

Answer 22

although relatively common (especially in setting of cardiac disease) they do sometimes requrire treatment. IF more than 3 per minute,-assess cause such as hypoxemia, myocardial ischemia, hypokalemia, mechanical irritation (central venous catheter).

I would also ensure presence of a defibrillator should V tach or v fib develop. If so i would cardiovert if unstable or administer amiodarone if stable

Question 23

ACE inhibitors and intra-op hypotension:

Answer 23

They increase the risk of intaoperative hypotension

Question 24

Cricoid and c collar:

Answer 24

Make sure you say that you don’t give cricoid to pts with spinal injury

Question 25

As per UBP, they seem to think that hypotension and RSI go together:

Answer 25

Yes.

Question 26

When to give sux in spinal cord pts?

Answer 26

only in first 24-48 hours when there are no extra-junctional receptors

Question 27

Having difficulty intubating, what would you do with c collar?

Answer 27

You could theoretically remove the front part-MAKE SURE YOU MAINTAIN IN LINE STABILIZATION
You can change blades, patient positioning (reverse t berg if tolerated)
If still a prob, pt may have to do a trach

Question 28

Positioning in prone patients:

Answer 28

Addidtional spinal cord injury in those patients, pressure induced injury to eyes, breasts, genitals, knees, and toes
position related obstruction of venous drainage leading to increased intracranial and intraocular pressure
brachial plexus injury

Question 29

What happens if someone spills a large amount of vapor gas?

Answer 29

immediately suction spilled agent into plastic container
seal and label container
transport it to appropriate waste disoposal site
verify patient securely postioned, sedation and block good, and prepare pt for transport to nearest anesthetizing location (with 100% O2, rescue drugs, appropriate monitoring)

Question 30

Don’t forget about all of the conditions that they named-for example-pt on plavix-for how long? this will affect future surgeries and when they can happen, it can affect your neuraxial anesthetic

Answer 30

Freebie

Question 31

In pts with bare metal stents, how long before they can go with elective cases?
What about with drug eluding stents?

Answer 31

Bare metal stents: bare minimum of 30 days
DES: 6 mos - 1 year, but can be considered after 3 mos if risks of further delay are believed to be greater than the risks of stent thrombosis.

Question 32

Elective procedures should be delayed for ______ following baloon angioplasty to allow for complete healing of any vessel injury.

Answer 32

14 days

Question 33

Baclofen-if they mention it, what do you need to say?

Answer 33

Continue therapy thoughout the perioperati ve period (abrupt cessation can lead to seizures)

Question 34

Would you do sedation in a pt with spinal cord injury? why or why not?

Answer 34

No-due to risks of pulmonary aspiration and autonomic hyperreflexia. Also, GI paralysis associated with high spinal cord injury can increase risk of pulmonary aspiration.

In these patients, assuming you have no reason to not, you can place an orogastric tube to decompress the stomach after they are intubated.

Question 35

How long does plavix have to be d/c before you can do a spinal?

Answer 35

s e v e n d a y s

Question 36

OH NO! Your central oxygen supply has just been compromised-what are you going to do?
Why is disconnecting from something important?

Answer 36

Immediately switch to backup oxygen cylinders
disconnect main pipeline supply This is improtant in order to prevent machine from preferrentially using the main pipeline supply rather than the lower pressure backup oxygen cylinder.
hand ventilate with low flow gas rates
calculate the amount of time before Oxygen cylinders are depleted and call for additional oxygen cylinders

Question 37

When you’re seeing signs of AH-you want to do what?

Answer 37

Ask surgeon to d/c stimulation
deepen anesthetic
administer direct acting vasodilator (sodium nitroprusside)
ENSURE THAT THE BLADDER IS EMPTYING APPROPRIATELY
PLACE A line
MONITOR PT CLOSELY FOR COMPLICATIONS-CEREBRAL OR RETIANL HEMORRHAGE, PULMONARY EDEMA

Question 38

In other words, tell me what is the pathophysiology of AH?

Answer 38

pain or visceral stimulus below level of spinal cord injury results in reflex symp discharge. Area below lesion is neurologically isolated, and sypmp activity in this area is not modulated by inhibitory impulses from higher cNs centers.

vasoconstriction below, reflex vasodilation above
when lesion is above T7, vasodilation above lesion is insufficent to prevent systemic hypertension which then stimulates carotid sinus receptors, leadign to reflex bradycardia