Hello all, I am Laura Ruscio. I am the Trauma Performance Improvement Coordinator here at Mercy Hospital St. Louis Level 1 Trauma Center. I am lucky enough to introduce you to our lovely speakers today, who will be talking about the part three of spinal cord injuries in the inpatient care setting. So today I'd like to introduce Nicole Cook. Nicole Cook is a trauma clinical nurse specialist with over 20 years of experience in emergency critical care and trauma nursing. In her current role at Wake Med Health and hospitals in Raleigh, North Carolina, she is responsible for the clinical activities and outcomes of the trauma program, as well as direct care patient consultation on specialty populations to include spinal cord injuries. Nicole is also engaged in education, research and dissemination of knowledge as an author, national and international speaker, TMCC director and ATCN facility. I would also like to introduce Scott Moore. Scott Moore, Dr. Scott Moore is an acute care surgeon at a Level 1 Trauma Center in Raleigh, North Carolina as well. He obtained his specialty training in trauma and acute care surgery care at Denver Health. Dr. Moore has also completed additional certifications in neurocritical care. There's also a specific academic interest in occult shock diagnosis, chest wall injury management and critical care management in spinal cord injury patients. Welcome Nicole Cook and Dr. Moore. Hey y'all, thank you so much. Super excited to be here. Dr. Moore and I have worked together for several years on some of our acute spinal cord injury population projects and best practices. And so we were excited when TCAA reached out to us to share our perspective on what we have done in spinal cords. Make sure we're gonna go here. Our educational statement that's put out always and then neither Scott nor I have any conflicts or disclosures to share with anybody today. So any good lecture starts with objectives. We're gonna talk about trauma patients with spinal cord injuries, talk about the processes you can make within your program to really improve outcomes of this incredibly nuanced and difficult patient population and talk about those best practices and what this looks like. But I think one of the biggest things I wanna remind everybody that's on this is that inpatient care begins in the emergency department. Most of our ERs are boarding heavily and our emergency departments are often our largest inpatient units in our organizations. And so it's incredibly important that any of these inpatient best practices trickle to your emergency department and are integrated because what happens there differentiates your inpatient outcomes and how your patients do. So real quick, I know you guys potentially have seen these other couple of lectures that preceded ours but I do wanna touch on just some really brief A and P that's gonna be really important about the inpatient process and our best practices that we utilize. So number one is the sympathetic versus the parasympathetic system. It's incredibly, incredibly, incredibly important to remember the innervation that occurs. Our sympathetic system comes out of our spinal cord itself and our parasympathetic system pretty much comes out of C1. And so with our acutely injured spinal cord patients it's not just mobility and it's not just neurosensation that's impaired. It is truly a system-wide, body-wide injury when you think about it. Peristalsis, secretion of glucose, adrenaline and noradrenaline, bile release, all of these things are kept kind of where they need to be by our sympathetic system and our parasympathetic system kind of opposing each other and keeping us in homeostasis. And when our sympathetic system is impaired basically our parasympathetic system kind of gets to do whatever it wants. And so dropping that heart rate, bronchial construction, things like that. So if you don't account for that in your care you're gonna be way behind the eight balls. So just, I don't know that there's anybody really that truly loves the endocrine system or the parasympathetic but please don't forget about it, it's so important. Number two, the diaphragm really gets so much credit and really, it really does a small percentage of respiratory effort. Man, our intercostals, both external and internal plus our abdominal muscles really are the workhorses when it comes to inspiration, expiration and cough. The only thing our diaphragm does is drop and initiate inspiration. So without those, you're really, really limited in your ventilatory and pulmonary capacity. I wish I could see y'all's faces because I love doing this in live lectures because I love watching people's faces but I want you all to try to take a deep breath in without expanding your rib cage. And I love watching people do this in live lectures because everyone's face just gets a little red and a little wide-eyed when they realize you can't do that. But this is what our spinal cord patients deal with. No chest wall expansion, inability to take that deep breath or cough. And so just remember, it's not just the diaphragm. Diaphragm's great, love it, it's important but remember the other muscles. The other thing to think about when you're going into these patients is that acute spinal cord injuries are incredibly variable and complex and you must individualize care and that care will need to evolve as the injury evolves. We have an hour to talk about this and we could spend eight really hitting on all of the important concepts because care of a central cord injury is gonna be different than a complete versus an anterior cord injury. And that's not even to bring into effect other trauma that's associated, chest wall injuries, abdominal, thoracic injuries. So truly we're gonna give you guys some guidelines and some oversight, but really it's a huge, huge, huge undertaking to really take good care of these patients. Next little bit of A and P that I just wanna go over real quick is just levels of injury in that respiratory function that I mentioned earlier. If you have a C1 to 2 injury, that's complete paralysis of the diaphragm. That's when I kind of care about the diaphragm is when it stops working. These patients maybe have a vital capacity of five to 10% and no cough. And we are looking at a hundred percent mortality without ventilatory support. So a vast majority of these patients will not even make it into your hospital, but remember injuries can evolve and that cord ischemia and injury can ascend the cord. And so maybe previously there were C3-ish, if that ischemia sends the cord and they lose diaphragmatic innervation, then you're really in trouble there. C3 through five, it depends on the injury, what your diaphragmatic impairment looks like. You could have some, you could have none, but maybe vital capacity of about 20%. High likelihood of respiratory failure within days to weeks. So just because they're okay in the ER, just because they're okay day one in the ICU does not mean they'll be okay down the road. Accessory muscles are impaired, very weak cough, but weaning is possible with these patients that just takes a lot of patience. Side happy note, we, you know, three months and we can get some of these patients off of the ventilator, but it's a long, long process. C6 through eight, diaphragmatic accessory muscles, inspiratory or intact. So you can take that breath in, but cough is not gonna happen very well. Expiration is passive, super high risk for fatigue and secretion accumulation. But even T1 through five and T6, cough impaired, super risky, very, very weak cough depending on risk factors. Absolutely love this image because if you've never taken a look at somebody with a spinal cord injury patient and watched them breathe, their chest wall does not move like a normal patient does. So depending on the level of injury, usually T1 and above, they're gonna present kind of like this. For the rest of us, we take a deep breath in, our chest wall expands. For a patient with an acute SCI who's lacking that intercostal innervation and their abdominal muscle tone is lacking, you actually get a bit of chest wall depression to a degree, but actually no outward movement, but their abdomen will move. They almost belly breathe like an infant or like a child. And so watching that, looking for that is incredibly important. And when you see this once, you will never forget it. And it gets burned into your psyche watching somebody breathe with no chest wall movement. Overall for acute spinal cord injury care, it's optimizing the acute care period. And this absolutely improves overall outcomes and increases rehabilitation potential. So everything you do in the inpatient setting and in the emergency department setting will set the course and trajectory for this patient's overall outcome and life really truly. Inpatient best practices encompass a few things and that's population specific order sets, making sure that you address these important things by order set, patient cohorting, having these patients on a specific unit with specially trained nurses, respiratory therapy, physical therapy, speech and such will absolutely improve your outcomes. Patients or staff on a regular unit may get one of these patients every six months and they may get a central cord one month, six months later, they get a complete spinal cord injury. Having that knowledge and that comfort with this patient population is incredibly important and will improve your outcomes. Having a multidisciplinary approach and incorporating your rehab best practices into your acute inpatient setting will set your patient up for success, will minimize your poor outcomes and will change this patient's overall trajectory. Moving into the critical care phase, really it's three things, it's injury stabilization, it's prevention of secondary injury and it's implementation of early rehab strategies. So I'm gonna step off, I'm going to let Dr. Moore talk about some of our acute inpatient ICU practices. Hi, as Nicole said, I'm Scott Moore, I'm one of the surgical intensivists here in WakeMed and kind of continuing on after Nicole's excellent kind of background and introduction, I wanna talk a little bit about the initial management of these patients. So C1 to four injuries, as Nicole alluded to, these are generally gonna require definitive airway in the acute period, very unusual to manage even a C4 injury without a definitive airway unless it's the very young rare patient that occasionally will get away with that, but most of these are gonna, almost all are gonna require definitive airway below the C4 level, and we're talking about complete injuries, that's really gonna depend on a lot of other factors, the age of the patient, any preexisting comorbidities, other injuries that the patient may have, all those factors are gonna be extremely important. So it's very important that these patients are very closely watched and having a systematic way of examining these patients and certain criteria and things to look for is very helpful, and because the respiratory failure in these patients can be very subtle, it's not, if you're waiting for the oxygen saturation to drop, you're definitely gonna miss your window of opportunity in a lot of these patients, and then maintain a very low threshold for ICU admission, pretty much all of our complete cords, certainly any of the high cervical are all gonna go to the ICU initially, but occasionally you'll get a central cord or partial injury that may be appropriate for floor status initially, but even those patients can tire out and can develop issues with their breathing and just keeping a close eye on those patients and having a low threshold for ICU admission is critically important. And so by what I mean by keeping a close eye, we're looking at their breathing, and it's not just that they're breathing, you wanna know how well they're breathing, and so what is their effort? And it can be subtle in these patients as well, because they only have, especially if it's a C4 injury, you're really gonna be looking at their accessory muscles, really from the clavicles up, and looking at their pattern of breathing, what's the respiratory rate, how much they're using those accessory muscles. Entitled CO2 is a very helpful adjunct, so if your hospital has that available for continuous entitled CO2 monitoring on these patients, that's super helpful, because that can certainly pick up ventilatory problems early on. And then we'll talk a little bit about our pulmonary function tests that we can use at the bedside that can really help catch some of these patients that are starting to struggle when it may not be apparent based on some of our more traditional things we look at in non spinal cord injured patients. Once again, relying on the oxygen saturation is a big time pitfall. That's gonna get you into trouble if you're waiting for the oxygen saturation to drop. So force vital capacity is probably the most studied in the spinal cord injury population, and that's both for determining when a patient is running into trouble early on, and also determining when they may be appropriate for weaning in the more rehabilitation period. The force vital capacity is defined as the volume of air that's excelled after maximal inspiration. So it's easy to conceptualize, but a little bit more difficult to measure. Traditionally, we would use what's called a right spirometer to measure this. These used to be like pretty universal in the hospital. You talk to your respiratory therapist now, they may know where one, we have some random drawer that one of these is in, and we've really struggled to find these in our hospital. And so these, even though force vital capacity is useful, getting your hands on a right spirometer may be a struggle. So one thing that you can try to do instead of that is we all have these, and this is pretty universal in any hospital that's doing surgery on patients and managing trauma. So an incentive spirometer is useful in that it can give you an idea of the patient's vital capacity. Now, the difference between incentive spirometers in general, when patients use incentive spirometers, they're sucking in traditionally with a right spirometer, I believe you're blowing out typically. That's not the way an incentive spirometer will typically work. But you can still get a general idea of what that force vital capacity is by having the patient completely exhale all their air and then take as deep of a breath in as they possibly can. So the patient's gonna have to be cooperative and understand exactly what you're asking them to do. But in general, you can use an incentive spirometer to get a rough idea of what their force vital capacity is. If they're not able to take a full breath in for whatever reason, and they just are able to, I'm sorry, full breath out, and they're just able to inhale, then what you're measuring is the inspiratory capacity, which is also a useful number to have. So you can use the incentive spirometers that are pretty universal these days to help. And normally, in a normal person without a spinal cord injury, your force vital capacity is gonna be about 60 to 70 mLs per kilogram. In a patient with a spinal cord injury, as Nicole mentioned earlier, if it's up in the C1 to C2 level, your force vital capacity is gonna be reduced by 90%. And so we're looking at much lower numbers typically in these patients. And a force vital capacity of about 15, if you look at a lot of the rehabilitation literature, that's in general associated with a concern that a patient is having difficulties, or if they're on the ventilator and you're thinking about weaning, they may not be quite ready yet. If you start seeing a force vital capacity less than 10, and this would be on like a non-intubated patient, that's generally gonna be a patient that's failing and is gonna need to be intubated in the majority of cases. The other main pulmonary function test that we utilize is called the negative inspiratory force. And a lot of you guys may be familiar with this in terms of using it to determine when somebody can come off a ventilator and minus 20 was classically kind of used as our number for that. When we're talking about the spinal cord injury patient population though, we're looking at different numbers and it's usually measured with what's called a nymphometer. And it can either be attached directly to the ET tube or in the ventilator circuit, or it can be actually that there's a mouthpiece that the patient can actually use to get you a nymph. Anything that's 40 or higher in terms of the negative, and it gets confusing when we talk about negative but when I mean 40 or a greater number than that, that is reassuring. If it's less than 40, that should start to raise concerns that the patient does not have as strong of a respiratory function. And then if it gets less than 30, that suggests impending respiratory failure and you really need to, those are the patients that need to be transferred to the ICU and at the very least monitored super closely. So secretion. So that was kind of the, some of our pulmonary function tests, but what else? And Nicole had mentioned the unopposed or the loss of sympathetic stimulation that then leaves you with unopposed parasympathetic stimulation. And so in addition to the respiratory muscles being impaired that leads to unopposed vagal activity, which then subsequent to that, you get these excessive and tenacious bronchial secretions. So not only is there a lot of mucus, it's extra thick and difficult to clear. And so it's not just that these patients aren't coughing enough, it's that they're actually making more and more mucus and thicker mucus. And on top of that, the loss of the sympathetic stimulation, if you remember, that can cause bronchoconstriction. And so that also is making it harder for these patients to clear those secretions. They get some vascular congestion and pulmonary edema. That's pretty common in these patients. And then finally decreased mucociliary activity, which is allowing all these secretions to just pool in the distal airways. So as an example of what we do here, and this has been super helpful in allowing us to have a fairly objective way of looking at these patients that are not intubated and determining if they're running into trouble. And this is actually a assessment that our respiratory therapists complete. And they look at the NIF. So they're calculating the NIF. They have orders to notify the MD on call if that NIF is less than 30. They're listening to the breath sounds, making sure those are clear. They're measuring the kind of a semi, more qualitative assessment for secretions, determining if the patient's able to clear those secretions on their own, looking at accessory muscle use, looking for abdominal breathing. And that in and of itself is a much, just having that kind of systematic approach I think really allows you to pick up these patients that may be struggling sooner. And then the patients that we're gonna worry about are those that are clearly having increased work of breathing, inability to clear those secretions on their own. Certainly if they're unable to talk or they're sounding winded, that in and of itself should probably prompt you to go ahead and intubate a patient with a spinal cord injury because they're likely gonna continue to struggle. And it can be tough because sometimes these patients don't wanna talk a lot. So it's just based on the patient. And then using those PFTs not really as your primary determinant, but as an adjunct. And so if your PFTs are also suggesting the patient's tiring out, then all those things can help you make a decision early on to at least, at the very least, get those patients transferred to the ICU. A lot of times what we run into is patients are initially in the ICU, they do okay for a little while, they're transferred up to the floor. And those are the patients that sometimes don't in hindsight get as much attention as we'd like. And so that's when a lot of times these serial exams will help us pick up those patients and get them bounced back to the ICU where they need to be. Any patient that's got a lot of other injuries, whether that be abdominal trauma and has had a laparotomy, or if they've got pelvic fractures, certainly a brain injury on top of a spinal cord injury can be a very difficult combination. All of those things are gonna increase the risk of failure. And then anytime you wanna transport a patient, if they're gonna be going into a truck or a helicopter or something to transport between facilities, you really need every spinal cord injury patient, you really should think long and hard about whether that patient should have a definitive airway placed before they go. So what this has led to in our institution is trying to develop patients that do get intubated, trying to come up with a ventilator strategy that helps to optimize outcomes. And we know that patients with spinal cord injuries are unique. They are different than the rest of the patients we take care of in terms of their pulmonary mechanics, and they're different from the rest of our patients in terms of the ways that they will decompensate. So I'm sure most of you are familiar with the ARDSNet study that was published back in 2000. It really did revolutionize ventilator management in the world. And it really, it's defined, the biggest thing that came out of that was using low tidal volumes. And when I was in training, we would routinely get up to 10 mLs per kilogram. That was kind of our starting tidal volume setting. And then as, starting in 2000, and then progressing through the 2000s, we saw more and more of this use of low tidal volume. And it's associated with lower rates of acute lung injury and actually improves mortality in critically ill patients. And so this is really the standard of care for ventilator management for the majority of our patients that are in the ICU. However, the problem about applying this study to all of our patients, and specifically the spinal cord injury patient population, is that this study didn't actually include those patients. They actually excluded patients with high cervical cord injuries. They also, you know, interestingly, excluded a lot of our TBI patients. A lot of our surgical patients actually were excluded from the ARDSNet study. It's always something important to keep in mind. So we know anecdotally that high tidal volumes do tend to help prevent some of the complications that we see in critically ill spinal cord injury patients that are on the ventilator. And this was studied, it's been studied a few times, but never in a very robust, large randomized control trial. It's always been either retrospective studies or very small trials. The probably the most famous study that looked at this was in 1999 by Peterson et al. And this was actually done in a rehab setting. So these patients had already been out of the acute phase and were in the rehab phase, the subacute phase. And most of them were about three months or so out from their injury. So these, and these patients were all on the ventilator and they compared a high tidal volume strategy, which would be 20 mLs per kilogram, which keep in mind that the ARDSNet says six to eight. So this is about, you know, three times as high, if not more than what the ARDSNet would recommend versus a low tidal volume, which is defined as anything less than 20. They found that those patients were weaned faster, about 21 days faster than the small tidal volumes. And they had significantly less atelectasis when they compared, when they looked at x-rays on these patients. And they didn't really have any issues with peak pressures on those patients that have the high tidal volumes. And that's the main concern is barotrauma. If we're using such high tidal volumes, are we going to destroy the lungs? And so these spinal cord injury patients in general are going to have very, very high compliance in their lungs, meaning that they're, in general, they're going to tolerate high tidal volumes for the most part. And so that's why I think you can, you can sort of get away with these high tidal volumes a lot of times. Another study that was published in 2016 was an RCT, but very, very small, not powered to really find, you know, significant differences. They compared a low tidal volume strategy, which was still high compared to what we do now, which is 10 mLs per kilogram, compared to a high tidal volume strategy, which is, you know, once again, 20 mLs per kilogram. They did find that the days to wean on these patients was about the same, but importantly, they did not find any increased adverse pulmonary events in these patients. So in other words, they weren't, you know, dropping lungs, they weren't getting acute lung injury, they weren't getting increased pneumonias with these high tidal volumes, but they didn't also show any real benefit to it either. So if we look at what other centers are doing, these are rehab centers for the most part. They are, for the most part, a lot of these centers are using high tidal volumes in their spinal cord injury patients. Santa Clara Valley Medical Center uses a 12 mLs per kilogram starting tidal volume, and they will go up from there, up to 20 mLs per kilogram, and then they gradually try to get the PEEP down to zero. Now you're, of course, probably wondering what happens to the PCO2 when you're using these high tidal volumes, if the patient's got, you know, a respiratory rate of 10 or above, they're gonna start to run into issues, and they do sometimes. And so one thing you can do to help deal with that is you basically just increase their dead space ventilation by increasing, by adding some tubing, that sort of thing to your circuit, and that can actually fix that problem. Shepherd Center wasn't able to find specifically what they're doing, but they do say, you know, in the research I was able to find, they do recommend high volume ventilation to prevent atelectasis. They try to keep the PEEP pressures less than 35. They are keeping track of vital capacities and negative inspiratory force, and that's mostly in the context of when to try to figure out when to wean patients. Another center in Arkansas is also using high tidal volumes, and they're generally targeting a tidal volume of 20 mLs per kilogram. They try to minimize the use of high PEEP. So there's not great data on using high tidal volumes, but it is anecdotally being used, and it makes sense from a physiologic standpoint that these patients would benefit from it. And the reason is because it helps to keep those distal airways from collapsing, and there's some data actually that it actually will stimulate surfactant production. That's been mostly in animal models. So what are we doing? So based on kind of our experience here, we were having a lot of issues a few years ago with these patients on, when they were being placed on lung protective ventilation modes, like that six to eight mLs per kilogram. We were having a lot of issues with atelectasis. Patients were needing lots of emergent broncs to try to clear these mucus plugs and that sort of thing. So Nicole and I thought a lot about this and felt like we could do better. And so looking at the limited amount of literature out there, we came up with this protocol. And at least early on, we're really only trying to utilize it for the most part in our complete cervical cord injuries, but we are selectively using it in lower cord injuries, complete, and then a partial high cervical cord. So even some of our central cords that are higher up, we are using the high tidal volumes that patients look like they can benefit from it. We do generally exclude patients that have major chest wall injuries. It can be, that's a little bit nebulous and it requires a lot of patient, a lot of discretion on the intensivist part, which patients you would exclude from this, because a lot of our patients are gonna have rib fractures, but not all rib fractures are the same. And so a massive flail chest with horrible pulmonary contusions, probably not a patient, at least early on, you're gonna wanna give super high volumes to, but down the road, once they heal some, that probably would be a possibility. Any patient that has evidence for acute lung injury, I mean, by that, I mean ARDS or the starting signs of ARDS. And that would be, you could tell that based on just poor lung compliance. Those are gonna be the patients you really don't wanna use these high tidal volumes on, because you're gonna end up causing more barotrauma. Any patient that's really had a massive transfusion, at least in the first few days after that massive transfusion, you probably wanna avoid this, because those patients are also gonna be at risk for acute lung injury, just from that massive transfusion. Septic patients, same thing. Septic in and of itself is a risk factor for acute lung injury, and I would generally probably avoid it in the patient that's septic. Chronic lung disease, we're generally gonna, I wouldn't say we avoid it, but we're gonna get our pulmonology colleagues on board, typically for those patients, just to make sure that they're on the optimal settings. And the specific protocol we use is a, we start at eight mLs per kilogram. And we decided on that number because it's at the upper end of the lung protective ventilation settings. And so we can really see how that patient's doing on that 80 mLs per kilogram. We can measure their peak pressures. We can measure their plateau pressures. And if those are less than, if the peak is less than 40, and the plateau is less than 30, that's generally an indication that we can start going up on our tidal volumes. And then every 24 hours, we're going up by 100 milliliters, up to a target tidal volume of 12 mLs per kilogram, which is way less than what we saw in some of those other studies. But what we're really trying to do here is balance the excellent data on lung protective ventilation with what we think would be beneficial ventilatory modes for spinal cord injuries. We do, if the patients are continuing to have issues with atelectasis, we can go up to 15 mLs per kilogram, obviously keeping track of those peak pressures and plateau pressures. And even beyond that, if the patient's continuing to have issues. In general, you're gonna want your PEEP around five to eight. In terms of secretion clearance, cough assist is available, and that's an insufflation, desufflation type device that basically simulates a cough in patients. And that definitely helps with secretion clearance. And we're doing that Q6 hours. You want your PEEP less than 10, because that's gonna, that negative pressure that that device generates is going to affect your PEEP. And so if a patient's having issues with PEEP, number one, if they're requiring a lot of PEEP, that's probably a sign that they may not be a good candidate for the high tidal volume. But number two, if you still think they are, you're not gonna wanna do cough assist on those patients. And instead we're doing, we give side breaths to these patients. And that's defined as one and a half the tidal volume, 10 times every six hours. And it was, this was critical. So we had this protocol for a while, but until we got an order set in Epic, it was very spotty in terms of how well it was, it was how consistently it was being followed. But once we got the, you know, the orders in Epic, which it can take some time, at least at our institution, it takes time to do that. It really helped with the consistency and the application of the protocol. And so this is basically what our order set looks like. So to conclude my sort of portion of this talk, and I'm gonna hand it back over to Nicole here, but, you know, high tidal volumes, you know, are helpful, chest percussion, bronchodilators, we have, you know, a lot of this is in our order sets, sort of consistent mobility and turning the patient, cough assist devices, quad cough, and patients that are good candidates for that. Hypertonic saline, you gotta be careful with hypertonic saline. Sometimes it can make your secretions even harder to clear, but in the patients that are a good candidate for that, those are appropriate. And then, and I'm not gonna talk a lot about early tracheostomy, but in general, I'm a big advocate of this. I think it helps a lot of patients and it allows patients to be more awake, less sedated, taking, you know, as much of breaths on their own. And it really does facilitate, in my opinion, even though the literature on this is a little mixed, in my opinion, it really helps facilitate the weaning process. Great. Awesome. So lots and lots about pulmonary. We basically got through the A, B, and now we'll hit C and a couple of other things now, but going back to the sympathetic and parasympathetic system in our acute spinal cord injury patients, the next big issue that we come across is neurogenic shock. And neurogenic shock can be incredibly insidious. You can absolutely have a patient roll into the trauma bay with a heart rate of 45 and a pressure of 70, or we have had patients that it took six to 12 hours or even more post admission before it really started to declare itself. And so this all goes into, you know, optimizing that care, avoiding that secondary injury, that drop in blood pressure and oxygenation. Just one episode of either of those is absolutely shown to alter your outcomes. And so when you get somebody with an acute spinal cord injury, and this is usually T6 and above, we lose that ability to accelerate heart rates. The vagus nerve gets to do whatever it wants and we get bradycardic, but we also lose that ability to secrete epi and norepi, or adrenaline and noradrenaline. And this really can be confounding in our trauma patients because yeah, we will absolutely get patients that are just an isolated spinal cord injury and the neurogenic shock is very obvious and we treat it. But don't forget, these patients are also at incredibly high risk for hemorrhagic shock. You want to make sure that you are identifying and ruling that out very quickly. We follow blood pressure guidelines on this, but remember at the crux of this, this is decreased tissue perfusion, and this is going to affect your patient globally. Not only the cord itself, but if you have patients with coexisting heart disease or kidney disease, those organs are now malperfused. And so watching that incredibly closely. Absolutely make sure there are no other sources of bleeding, that this is true neurogenic shock. We all run around a little dehydrated. So judicious use of fluids is not, you know, in trauma, we really try to hit the blood heavy, but I mean, we all probably could use a 500 mil bolus of saline on a daily basis. We're all a little dry. So yeah, they may need some fluid in the pipes, but the end of the day, this is a pipe problem. They are vasodilated. They are going to roll in pink warm and dry potentially, which that's the one time that skin is normal that we actually should be worried about. Bradycardia from a symptomatic standpoint, we treat it. Not every patient that rolls in with a heart rate of 47 needs atropine. It's going to depend on your global picture. So what does the literature say? So best practice guidelines, and it's level three evidence that we have. And it basically says keeping a map of 85 to 90 for the first five to seven days post injury is going to probably make things better and most likely not make things worse. That's basically paraphrasing the literature. Depending on the paper you look at, NOREPI is your first line agent. There's some guidelines that differentiate between NOREPI and other vasopressors, depending on if it's a lower injury versus an upper injury. For us here, we've gone with NOREPI as our first line agent and a map greater than 85 for the first five to seven, at least five to seven days, depending on the injury and our specialty consults and what it looks like with this injury. But we also do some other things to help us support this patient transition off of pressors because our ICU space is precious. And having a patient on seven days of NOREPI simply for map goals can feel like we're kind of clogging up the bed flow. And so adding in Midodrine, which many of these patients are on long-term and even to home to assist to orthostatic hypotension because this sympathetic issue, this is lifelong for these patients. They're going to be chronically a little bradycardic, chronically slightly hypotensive and chronically orthostatic. And so Midodrine is a long-term medication many of these patients will end up on for the rest of their lives. But there's some other adjuncts in the literature that you can use for bradycardia, which will in turn then help your cardiac output. And that's albuterol and then theophylline. We have opted to go at our facility with albuterol simply for ease of use. And the fact that we then don't have to check lab levels and worry about that. And we truly have had, we feel some great outcomes and we were having lots of issues with profound bradycardia. That would occur when we would suction patients or turn them and it was really inhibiting care. And we don't have enough numbers to do a decent study on yet, but it truly feels like we are having much less neurogenic episodes, but they absolutely can still happen. We've had them happen up to a month out and they can come out of nowhere. So you can absolutely still have bradycardia, cardiac pauses and arrest. They still can occur despite medication. You may need cardiology involvement for pacer wires or pacer placement. It's gonna be very patient dependent. But remember, so many of these interventions that we're doing for these patients are vagus nerve stimulating, suctioning, coughing, turning, anything to do with catheterization or the bowels can all potentiate this happening. But these are all life-saving interventions too. If you think about it, if we don't suction or turn this patient pulmonary ventilatory wise, they're going to fail. Preventing ileus and urinary issues are all life-saving as well. And so finding that fine line of optimizing their cardiac output, preventing cardiac arrest and bradycardic arrest while avoiding all of these other complications. And so we found adding albuterol on top of that can help mitigate some of that, but getting cardiology involved is incredibly important. Moving on from cardiac, the other two things that always come up are urinary management and bowel management. These patients will absolutely require a Foley in the resuscitative phase. They're going to get fluid and potentially blood resuscitation. There's that element of third spacing, and then there's some diuresis that happens after that. But once stabilized, most are going to require scheduled I and O catheterization depending on the patient, depending on the level of injury, but it's fairly safe to assume in most of your spinal cord injury patients, there's going to be some element of neurogenic bladder in the acute inpatient phase that's going to transition as the patient's injury transitions. What the best practice is, is to start scheduled I and O catheterization. Once that Foley comes out, don't wait for them to not have adequate urine output and have these massive retention injuries. Your patient pees just a little bit and then you throw a bladder scanner on them and they have a leader in their bladder. That's bladder stretching injury and all sorts of problems. So by starting scheduled in and out catheterization, we start ours in the ICU once the Foley comes out, if appropriate. That improves your bladder rehabilitation outcomes. It decreases your CAUTIs. This mirrors rehabilitation and long-term strategies. Avoid suction devices if you can in a patient who has an insensate perineal area. I feel like that just needs to be said. Our order set, as you can see below, is a volume based in and out catheterization. We have a rehabilitation hospital on our campus that we partner with and use their rehab strategies in our inpatients. And so this is a volume based if nursing caths the patient and they get 500 out, the next cath is going to be in four hours. If they cath the patient and it's less than 500, the next one is in six hours. This mirrors rehab and this mirrors what these patients may be doing at home. Our patients can get to a point where they have, they're on a bladder schedule and can kind of work their lives around this. Further out in the rehabilitation phase, then they start talking about different procedures and testing. But for acute inpatient, this is what we have found is works the best. From a bowel perspective, these patients are incredibly high risk for ileus, not only due to trauma, but also due to spinal cord injury and decreased and slowed peristalsis of the bowel. These patients will likely have constipation, retention issues and potentially impaction. They will likely require daily scheduled digital stimulation with suppository. And this is usually T12 and above, but making sure your lumbar injured below patients don't also have impaction is incredibly important. Oral agents alone are not usually adequate. Colace by itself, no, please no. Other oral agents don't. Generally they require suppository as well, but that digital stimulation by triggering those reflex receptors in the rectum itself can help trigger some of that peristalsis. And the goal is to do this at the same time every day, regardless of if that patient has already had a bowel movement that day. These patients, as they move through the rehab and go home can actually train their bowels to move almost the same time on a daily basis, which can be an incredible life changer. If they know what time they're going to have a bowel movement every day, they can schedule. I have to go to the grocery store at this time. Well, I'm gonna have a bowel movement at this time. I know how to, how to work my life. Obviously, you know, watching out for bradycardia and vagal response, but down in the bottom corner, this is what our order looks like for nursing. And just making sure that they actually document the size and consistency that these are full bowel movements, not smears, not impaction, things like that. From a skin perspective, please make sure these patients are being turned. We're always very nervous to turn a patient with instability, but if it's going to be a couple of days until they go to the OR, get a good team together and make sure we're doing very careful log rolls. The presence of one stage, one decubitus injury in a spinal cord injury patient absolutely increases overall morbidity and mortality levels. So please make sure that you're being very careful. Frequent turns, but padding, those bony prominences, lots and lots of nutritional support and making sure you have specialty devices on their heels, on their coccyx, things like that. Because this, I know we all worry about it from a numbers perspective, but truly from a patient outcome perspective, these are life-changing for these patients. Next topic is VTE prevention. I'm going to let Scott talk about that. Yeah. So venous thromboembolism is something we worry about in all of our trauma patients, but spinal cord injury patients we know are probably the highest risk for developing these complications. If you don't give these patients any type of chemoprophylaxis, about 62% of them will go on to develop a VTE complication. And that comes from an older study back from 1994. If you do give pharmacoprophylaxis, and this is looking at, I think probably most of those patients in that study were probably getting single dose daily, either Levinox or Heparin, still about 9% will develop a VTE complication. So very much a relevant issue for these patients. And a recent study that just came out this year in the Journal of Trauma found that delays greater than 48 hours after the injury missed doses. And that's most commonly going to be from going to the operating room. And so for various other injuries, whether it's other orthopedic injuries or it's for the spinal fixation itself, those are probably the most common reasons why patients will miss doses. And use of unfractionated Heparin rather than low molecular weight Heparin or Levinox were all shown to increase the risk of VTE complications. So what we do here is we have a weight-based protocol that utilizes Noxeparin twice daily. And to try to keep it as simple as possible, we basically just said cutoffs at 80 and 120. So if you're less than 80, you get 30 milligrams of Levinox twice a day or every 12 hours, 80 to 120 range, you get 40 milligrams every 12 hours, and then greater than 120 or up to 50 every 12 hours. And this is actually the same protocol we use on all of our trauma patients and our surgical patients just to try to keep things as simple as possible. In patients that you may have a question about dosing, it's certainly a good idea to check a 10A level. And then that would be specifically in patients that are morbidly obese that can very much affect what your dose would be in order to achieve a prophylactic level of Levinox. We're typically shooting for 0.2 to 0.4 on our 10A levels. And then the use of unfractionated heparin really should be reserved only for patients whose creatinine clearance is less than 30. And if you're going to use unfractionated heparin, make sure you're doing it every eight hours, not every 12 hours. And try to start that VTE chemoprophylaxis as soon as possible. And ideally, less than 24 hours after injury. That can be hard because these patients oftentimes are going to the operating room for other things, and surgeons are going to want it held. In general, for our orthopedic procedures here, if we're done twice daily, Levinox will only hold that dose right before they're going to the operating room. That's the only dose they get held, ideally. Now, there's always going to be some variations, but that's, in general, the practice pattern. SCDs are great. They're simple to use, but you should never feel comfortable that your patient is adequately covered if they only have SCDs on. That's not enough, really, in trauma patients as a whole, but especially in spinal cord injury patients. You really need to be thinking about getting chemoprophylaxis on as soon as possible. In terms of the duration of VTE chemoprophylaxis, that's a little bit controversial. It's not well studied in spinal cord injury patients. We do know that spinal cord injury patients, once they get out of the acute phase, are relatively protected from forming deep venous thrombosis compared to a similarly immobilized human. So, we think that that probably occurs somewhere in the eight to 12-week time frame where that transition occurs, where even though the patient is still immobilized, there's a relative protection against forming DVTs, but it's, once again, not super well studied. We actually recently had a patient who was, gosh, I think three or four months out from their initial injury, and they had a massive saddle PE. Thankfully, we were able to save them, but these patients, even when they get months and months out, can still have VTE complications. We're actually in the process of looking at aspirin 325BID for indefinite use once that patient completes either the eight to 12-week time frame of Lovenox. I'm going to turn it back over to Nicole to talk about some last issues. Hey, y'all. These patients are going to have pain, surgical pain and physical pain and neuropathic pain. It's incredibly important to assess for pain type and treat accordingly because there can be multiple different types of pain ongoing. You can absolutely have nociceptive pain, musculoskeletal post-op, muscle use, spasms. If you have a patient that is a new, you know, complete paraplegic that is now relying on their upper extremities and their shoulders to bear their body weight, our shoulders aren't usually used to bearing our entire body weight, and so they're high risk for shoulder overuse and injuries. So making sure we're treating for and anticipating that pain, but also neuropathic pain, and neuropathic pain is tough to treat. Remember, these patients can have aledinia and hyperalgesia. Aledinia is where things that previously didn't normally hurt us hurt a lot. Just the sensation of touching them gently can sometimes just absolutely trigger this intense neuropathic pain, or, you know, things that before didn't hurt so much hurt a whole lot right now. And so considering things like, you know, gabapentin and other drugs and adjuncts like that and titrating them up, using a pain service, if you have one can be incredibly important. And just because there is a spinal cord injury does not mean they don't have pain. It actually means their pain can be much worse. And there's a lot of stigma and sometimes misunderstanding associated with that. And so making sure that we just really truly understand that and take care of it, you know, baclofen, things like that for spasticity, other things for muscle spasms, it really truly can be three to four or five different drugs, making sure that we address their pain adequately. Don't forget the scheduled Tylenol. We are huge fans of scheduled Tylenol in addition to everything else. From a psychosocial and emotional perspective, these are absolutely life-changing, devastating diagnoses, not only for the patient, but for the family. And there's a lot of thoughts and feelings that go along and associated with this. And it really truly is stages and shades of grieving and change. If you think about it, these patients are often very autonomous, living their lives, breadwinners, doing just everything. And within a moment's notice, they are now completely dependent on strangers for the most basic of bodily needs. And it leads to a lot of grief and anger and embarrassment and fear and a loss of control. And that can all be verbalized or shared in a number of ways that can be really unhealthy and really can make some communication and relationships with caregivers very, very difficult. And we battle this all the time with our patients and work with them. And it's really just, you must acknowledge how devastating this is for the patient, give them real information and real understanding of their injury, but also truly allowing for hope. We don't know for six months to a year often what these patients are going to have an outcome of. And so offering truth with hope is incredibly important. The way we kind of term it is that we plan for the worst, but we hope for the best for these patients. We act as if they're going to regain no, you know, no function back, but we hope they do. And so I was talking with a patient recently and something I hadn't even thought about was this patient shared with me just how embarrassing it was to be put into a lift, a Hoyer lift, to be put into their wheelchair and carried around in their words, like a baby. And I'd never, ever thought of it that way, but this was why the patient never wanted to get out of bed into the wheelchair. And that's because they were embarrassed to be carried in their, in their words. And so putting ourselves in their place is important to understand that and how we support them is, you know, through this is early engagement with support services, really good education and time with them, spiritual care, mental health providers, anything that you can offer, find that community network and peer support, whatever you can do for them and spend time with them. Last couple of slides, cause I know we're running out of time. As you transition from critical care to inpatient, it really, truly is a continuation of your inpatient therapies, spasticity, continue those early physical therapy, occupational speech, and recreational therapies, start teaching the patient how to provide their own self-care and start thinking early about your disposition. And really, truly at the end of all of this, what your successful inpatient care looks like is this, and this slide is not on your handout. So get out your camera phone and take a picture if you need to, but this is what successful inpatient care looks like. Optimizing ventilatory outcomes, neurogenic instability taken care of, skilled therapies, early bowel and bladder training, absolutely avoiding skin breakdown, DVT prophy, education and support, and appropriate disposition. We did want to include our contact information on this. You guys are welcome to reach out to us at any point. Scott, if you want to kind of talk about what we're looking at doing. We are, because there's such a lack of literature on use of tidal volume specifically, we are interested in trying to study that a little bit more systematically. It's a challenge because we do see a lot of spinal cord injury patients here, but not probably enough to really have a robust study on our use. We anecdotally, you know, looking back at the, since we implemented this protocol probably two years ago or so, definitely it seems like we're seeing less atelectasis, less plug-in events and that sort of thing, but we'd like to study that systematically. If anybody out there in the audience is interested in collaborating, this is our contact information. We'd love to hear from you and try to, you know, collaborate and try to figure out more about, you know, how to ideally manage these patients on the ventilator. Or if you just have questions about spinal cord injury management in general, we're both happy to hear from you. And with that, we are done. Thank you guys. Um, we are kind of at time, but I was going to ask a few questions. We didn't have any chat questions throughout. Um, or no, I lied. We have one last minute. Um, Beth said, what are your thoughts on diaphragm stimulators for patients with failure to wean? I think they're, I mean, they have shown a lot of promise and we actually have, I think one of our medical intensivists is, is, is interested in, um, starting that here, not just for spinal cord injury patients, but for other, um, patients that are failing to wean. So it's definitely something that, um, deserves looking at. Um, uh, the first step for us, you know, a lot of that is, you know, I think being, um, you know, really seeing these patients more in the acute phase, we're not, that that's probably a little early to be doing diaphragm stimulation. It's probably more applicable to the patients that are, um, you know, a month or two months out, but, and who have already kind of failed, um, you know, wean, but, um, definitely hugely interesting. I think it, it, it potentially has a lot of promise. In another question, Jen had asked, are you starting DVT prophylaxis on post-op, even when there is a drain place? Um, and I'm assuming that's like a, um, like a drain, like a, like a surgical drain in the, from a spinal fixation. Um, yeah, so that drains are always, uh, are always tricky and that, that becomes very surgeon specific. And so that's probably the biggest reason why we have, um, you know, we'd go outside of our DVT prophylaxis algorithm is first based on surgeon preference. It's hard to argue with a surgeon who is nervous about bleeding because they were in the operating room and they, they saw it. So we generally defer to the surgeon, but, um, but we don't, but drains in place is not a reason to hold prophylaxis in our algorithm. There are a couple, any, any concerns for active bleeding certainly would be, uh, you know, a coagulopathy, those sorts of things are, but drains in and of themselves are not in our, in our guideline. But if a surgeon prefers that we hold it for that reason, we will. All right. Sounds good. Well, um, thank you so much for your time and everyone's, um, active participation. Everyone said it was a great presentation. So thank you so much, Nicole and Dr. Moore for, um, taking time out of your busy days and giving us a great presentation. Absolutely. Thanks y'all. Thank you.

spinal cord injuries

inpatient care setting

autonomic nervous system

respiratory function

cardiovascular management

bowel and bladder management

pain management

psychosocial support

multidisciplinary approach