Articles: Medical Topics
High Spinal Cord Injury: Respiratory Russian Roulette
 Sooner
or later, a personal injury attorney or legal nurse consultant
with a substantial practice will be asked to handle the
case of a patient who suffered a spinal cord injury. A high
spinal cord injury refers to an injury to the spinal cord
at a level of C4 or higher. Spinal cord injury most commonly
occurs during a motor vehicle crash, but also can result
from a fall, gunshot wound, or sports accident. These are
devastating, costly injuries that affect all aspects of
the person’s health and well-being.
Careful
handling of the injured person may avert some spinal cord
injuries — fracture of the vertebral bodies does not
necessarily injure the spinal cord. However, profound injury
is caused by shattered vertebral bodies, which push fragments
of bone into the cord or a bullet that severs the cord.
The
muscles that control breathing are paralyzed when a spinal
cord injury occurs at the level of C4 or higher - the diaphragm,
the muscles between the ribs, and the abdominal muscles
are all affected. Significant injury to the cord can cause
the victim to stop breathing shortly after the accident.
Some paralyzed individuals who stop breathing at the scene
of the accident are resuscitated in time. If their crisis
is quickly identified, artificial breaths given with an
Ambu bag can sustain them until they reach a hospital when
they can be attached to a ventilator.
A spinal
cord injury is a medical emergency—the time between
the injury and treatment is a critical factor affecting
the eventual outcome of the patient. Steroids may be used
to reduce swelling in the cord, although there is inconclusive
evidence that they are of benefit. The Miami Project at
University of Miami promotes the idea of cooling the body
to 32° to 34° centigrade for 20-24 hours after the
injury slows down inflammation and decreases cell damage.
1 Surgical treatment for acute spinal cord compression
is warranted if the patient has an increasing neurological
deficit. The source of the material pressing on the cord
must be located and removed. The timing of the surgical
intervention is determined by a neurosurgeon who takes into
account the level of the injury and the type - incomplete
or complete. An incomplete neurological deficit is one in
which some neurologic function exists more than three segments
below the level of the injury. This patient has a good prognosis
for at least some functional motor recovery. A complete
injury is marked by no motor or sensory function existing
more than three segments below the injury level. Most authors
agree that in the presence of a progressive neurological
deficit, emergency decompression is indicated. Some authors
advocate delaying surgery for several days to allow resolution
of cord edema in patients with complete spinal cord injuries
or stable incomplete spinal cord injuries. Others argue
that early surgical stabilization should occur. There is
no conclusive evidence that early surgery improves outcome.
2
When
a neurological deficit is associated with spinal cord injury,
the overall survival rate for all levels of injury is 86%
at 10 years. The survival rate drops off for patients injured
after age 29 to about 50% at 10 years. Pneumonia is the
leading cause of death of patients older than 55 years,
nonwhites, and quadriplegics. 3
Since
most high spinal cord injured patients will never be able
to permanently breathe on their own, prevention of pneumonia
is key. Ventilator-associated pneumonia (VAP) is in the
patient safety spotlight right now. It used to affect about
5% of patients in hospitals in 2004, but the incidence is
decreasing. It kills 20% to 70% of affected patients. 4
VAP is diagnosed when these criteria are in place: the patient
was on the ventilator for greater than 48 hours and exhibits
3 of these 5 symptoms: fever, increase in white blood cell
count, change in sputum (color or amount), chest x-ray findings
of new infiltrates and worsening oxygen requirements. 5
| To
Reduce the Incidence of VAP
Elevate
the head of the bed to 30-45 degrees
Provide
frequent mouth care every 2-4 hours
Wash
hands diligently
Prevent
blood clots in the legs
Prevent
stomach ulcers
Stop
sedation every day to evaluate the ability to
extubate |
|
The Institute
for Healthcare Improvement included VAP as one of the 6 patient
safety issues in its initial 100,000 Lives Campaign. The Centers
for Medicare and Medicaid Services is considering denying
payment for VAP that develops in hospitals in 2009. VAP is
now judged to be a primarily preventable infection, if specific
elements of care are delivered. Several proven strategies
reduce the incidence of VAP. Some hospitals have been able
to eliminate VAP from their facilities for two or more years.
See the box.
Clearly,
all of these strategies, except the focus on getting the
patient off the ventilator as quickly as possible, are likely
to be highly successful in preventing VAP in high spinal
cord injured patients. The effects of frequent VAP include
the development of antibiotic-resistant organisms, lung
scarring, and the risk of death.
Because
high spinal cord injury can so massively affect the ability
to breathe, it can create deep anxiety and fear. The treatment
that is needed for patients to survive also contributes
to their pain and suffering. Families and caregivers also
experience this stress. Early in the injury, the vigilance
of the treatment team must be non-stop to ensure the survival
of the patient. As time goes on this never-ending vigilance
must be continued by the family and caregivers. 6
In the
last two months, I have been asked to summarize the pain
and suffering of three high spinal cord injured patients,
all of whom were injured in motor vehicle accidents. Their
ages at the time of the injury: 2-years-old, 18-years-old
and 84-years-old. All three had episodes of VAP. Amazingly,
the two-year-old was able to be completely weaned from the
ventilator several years after her injury. The 18-year-old
died from VAP, and the 84-year-old contracted VAP but died
from unrelated respiratory disease.
Although
these cases were summarized to explain pain and suffering,
we also prepare medical summaries, timelines and chronologies.
Call to discuss your needs.
References
1. www.jems.com/news_and_articles/articles/The_Cold_Truth_about_Spinal_Injury.html
2 “Thoracic and lumbosacral fractures”, in Canale:
Campbell’s Operative Orthopaedics, 10th Ed,
2003, Mosby
3. Rubenstein, L. and Josephson, K, “Falls and their
prevention in elderly people: what does the evidence show?”
Medical Clinics of North America, 90 (5) September
2006
4. www.ihi.org/IHI/Programs/Campaign
5. www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Literature/
TexasHospitalsReduceVAP.htm
6. Fried, G. and Fried, K. “Spinal cord injury”,
in Patricia Iyer (Editor) Medical
Legal Aspects of Pain and Suffering, Lawyers and
Judges Publishing Company, 2003
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