Spinal cord injury (acute

management)
Note: This guideline is currently under review.

Introduction
Spinal cord injury (SCI) in children is a rare injury that can result in permanent loss of motor and sensory
function, and dysfunction of the bowel and bladder. Impairment of these functions result in significant social and
psychological consequences for the child and their family. SCI is often associated with a traumatic brain injury.
In children and adolescents SCI is most commonly a result of road traffic accidents, falls or diving into water.

Children with SCI experience multiple health care problems including autonomic instability, complications of
immobility and bowel or bladder dysfunction. Management in the acute phase is aimed at preventing further
spinal cord injury, maintaining physiological stability, and commencing routine care of the skin and establishing
good bladder and bowel care.

Aim
This guideline is aimed at the acute management of children with injury to the spinal cord.

Definition of terms
AIS: ASIA (American Spinal Injury Association) Impairment Scale. An international classification system
for level of impairment as a result of spinal cord injury. There are five classifications for traumatic spinal
cord injury: A-E.

Quadriplegia (also referred to as tetraplegia): dysfunction of arms, legs, bowel & bladder due to SCI in
the cervical region

Paraplegia: dysfunction of lower body, bowel & bladder due to SCI in the thoracic, lumbar or sacral
region

Spinal shock: Temporary areflexic state with loss of autonomic control, and muscle tone below the level
of the injury which lasts up to six weeks after injury. It usually occurs in spinal cord injury to cervical &
upper thoracic spinal cord. Functional recovery may improve after spinal shock resolves.

Neurogenic shock: hypotension as a result of bradycardia and vasodilation due to loss of thoracic
sympathetic innervation following SCI. Profound effects are noted if injury is at level of T6 or above. Most
 dramatic effects noted in the first few weeks with most patients stabilizing in 7-10 days

SCI pathophysiology & presentation

Complete/incomplete injury
A complete SCI results in loss of all motor and sensory function below the level of injury (AIS A).

An incomplete SCI results in preservation of sensory function below the level of injury (AIS B), or a
combination of varying degrees of sensory and motor preservation below the level of injury (AIS C or D).

Cause of injury
The spinal cord can be injured by transection, distraction, compression, bruising, haemorrhage or
ischaemia of the cord or by injury to blood vessels supplying it. These injuries can all result in permanent
cord injury and may be complete or incomplete.

Concussion of the spinal cord can result in temporary loss of function for hours to weeks

Pathophysiology
Injury results from primary & secondary insults

Primary injury occurs at the time of the traumatic insult

Secondary injury occurs over hours to days as a result of a complex inflammatory process, vascular
changes and intracellular calcium changes leading to oedema and ischemia of the spinal cord.
Irreversible damage occurs to nerve cells leading to permanent disability

Spinal cord injury may occur without evidence of bony injury on Xray or CT. Paediatric injuries are more
commonly associated with injury to ligaments discs and growth plates and often require a MRI to define
the injury pattern.

Signs & symptoms of acute SCI

Flaccid paralysis below level of injury

Loss of spinal reflexes below level of injury

Loss of sensation (pain, touch, proprioception, temperature) below level of injury

Loss of sweating below level of injury

Loss of sphincter tone and bowel & bladder dysfunction

Management
Initial assessment
See major trauma-primary survey guideline (link)
(http://www.rch.org.au/clinicalguide/guideline_index/Major_paediatric_trauma_The_primary_survey/) and
cervical spine injury guideline (link) for initial assessment
(http://www.rch.org.au/clinicalguide/guideline_index/Cervical_Spine_Assessment/)

Be aware the loss of thoracic sympathetic innervation (T1-T5) may inhibit tachycardia and
vasoconstriction as signs of hypovolaemia. Thus haemorraghic injuries may not be indicated by the
usual signs.

Referrals
Neurosurgical, orthopaedics & trauma service should be notified prior to or on admission to the
Emergency department

Rehabilitation service to be notified within 24 hours of admission

Admission location
These patients will usually require admission to PICU (Rosella)

If not requiring PICU admission, then this will usually be Cockatoo (Neurosurgical ward) unless multiple
abdominal injuries are present, in which case the child will be admitted to Platypus (General surgical
ward)

Spinal immobilisation
See cervical spine injury guideline (link)
(http://www.rch.org.au/clinicalguide/guideline_index/Cervical_Spine_Assessment/)

Initial care - immobilisation:

Immobilize the entire spine of any patient with known or potential SCI

Immobilize neck with a hard collar. See guideline for cervical spine assessment (link)
(http://www.rch.org.au/clinicalguide/guideline_index/Cervical_Spine_Assessment/)

Use log roll with adequate personnel to turn patient while maintaining spine alignment

For children < 8 years of age use an airway pad to promote neutral cervical spine position (link to
resource) (www.rch.org.au/clinicalguide/guideline_index/Cervical_Spine_Injury/)

Remove from spinal board on arrival in ED or as soon as resuscitation allows

Maintain neck in neutral position by use of a hard collar, but change to two-piece collar for
comfort and avoidance of complications (e.g. pressure area, venous obstruction, aspiration)
within 6 hours of admission.

Early surgery:
Surgery may be required in the situation of a reversible compression injury, or deteriorating
neurology with a spinal injury amenable to some form of reduction and or fixation.

Halo & Orthotic devices:

Some patients may have Halo devices applied by surgeons, or a brace made by orthotics to
maintain correct alignment of the spine. These devices are fixed to the child’s chest.
 Ensure you know how to open devices to perform chest compressions in the event of a cardiac
arrest, and that spinal immobilisation is maintained manually throughout any resuscitation

Move patient using slide sheets or pat slide with adequate number of personnel to maintain spinal
alignment

No pharmacological agent has been proven to limit damage and optimize recovery of function. If steroids
have already been given, cease them when resuscitation completed. Aim for normal perfusion pressure
and oxygenation of SC.

Once the extent and stability of the injury has been determined a documented plan should be formulated
to ensure immobilisation and stabilisation.

Imaging
Multiple levels of injury in the spine are common. In the under 8 age group especially, there is a high
proportion of missed craniocervical injuries with/ without associated cranial nerve involvement.
plain film imaging of the entire cervical, thoracic and lumbar spines

Further early imaging will at least involve an urgent MRI of the entire spine looking for remediable
lesions

CT scan may be used to further identify the extent of bony injury

Neurological assessment
Neurological assessment and documentation in the EMR including:
Sensory level

Motor function
After 72 hours, the ASIA guide should be completed documenting sensory and motor
levels. Contact the rehabilitation registrar to assist with this assessment

Glasgow coma score

Pupil response

Perform hourly for 1st 24 hours then decrease to 4 hourly if condition stabilised

Note evidence of brain injury as well as spinal cord injury

Vital signs (and autonomic control)

Vital signs can be quite abnormal following SCI. In addition to the usual causes in trauma such as pain,
bleeding and distress, this can be due to loss of autonomic control, which occurs particularly in cervical
or high thoracic injuries. The autonomic nervous system controls our HR, BP temperature etc.
Autonomic instability is most acute in the first few days to weeks of the injury.

Particular implications of autonomic instability to be aware of are:

Heart rate
 Bradycardia can easily occur , for example on endotracheal tube or tracheostomy suction, due to
unopposed vagal activity (Thoracic sympathetic input may have been damaged)

Patient needs continuous HR monitoring in PICU or ward

Treatment with anticholinergic medication is often required

Blood pressure
Loss of autonomic control results in loss of vasomotor tone. Patient may be quite vasodilated and
hypotensive. This phase of neurogenic shock can last up to several weeks. Hypotension should be
treated to prevent secondary poor perfusion of the spinal cord.

Blood pressure monitoring should be:

Continuous in PICU

At least hourly in the ward

Ensure patient is adequately fluid resuscitated but not overloaded

Patient may need vasopressor drugs such as nor-adrenaline or intravenous fluids to maintain BP (but
excessive fluids will cause pulmonary oedema). Patients requiring vasopressors should be managed in
PICU

Temperature
The loss of temperature control e.g. ability to sweat, shiver, vasodilate, vasoconstrict or position self to
maintain temperature. Consequently, the child will take on the temperature of the environment

Hypothermia is common

Temperature measurement should be preformed 4hrly in the acute stage of admission

Ensure adequate clothing or bedding in cool environment

Ensure artificial cooling in a hot environment

Breathing
Respiratory difficulty is common in the early stages of spinal shock but will ultimately depend on injury
level
C1-C4: paralysis of diaphragm and intercostal muscles: will need mechanical ventilation via
endotracheal intubation or tracheostomy. May need long-term ventilation of phrenic/diaphragm
pacing

C5-T6: paralysis of intercostals, diaphragm OK – may need some form of respiratory support

T6-12: abdominal muscles paralysed, may have some decreased function

Asses respiratory status including pattern, effort, ability to cough, auscultate chest, Monitor SpO2
ETCO2, ABG

Intubate & ventilate if respiration is inadequate

 Maintain strict ventilator associated pneumonia (VAP) prevention strategies

Nurse head up, but tilt entire bed so that spine remains in line & immobilised-do not just simply raise
head of bed up
Note at later stage of admission when patient is allowed to sit up, that if abdominal muscles are
paralysed, breathing difficulty may be worsened when sitting up and eased when semi-
recumbent

Give O2 as required

Ensure abdomen not distended (NG should be inserted)

Refer to physiotherapist to establish a regimen of chest physiotherapy, assisted coughing and BiPAP.

Skin
See Pressure injury prevention guideline (link)
(http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Pressure_Injury_Prevention_and_Management/)

A patient who has a SCI is at high risk of damage to their skin integrity. The SCI causes loss of sensation of
pain, pressure & temperature. The patient may also have lost motor control and have poor autonomic nervous
system function. The end result is a lack of sensory warning mechanisms, an inability to move and circulatory
changes all impacting on skin integrity.

High risk for pressure areas, measures need to be implemented to assess and prevent skin breakdown:
A baseline skin assessment should be completed on admission

For all patients a Pressure Injury Prevention Plan must be commenced

Pressure mattress (low air loss or alternating pressure) or gel mat if approved
Air or alternating pressure mattresses should not be used for unstable spines

Reposition 2 hourly
This should occur from the time of admission

Reduce friction and shear during repositioning and transfers

If skin breakdown occurs it can progress rapidly. Pressure must be kept off this area. Refer to
stomal therapy for advice on appropriate dressing

Take care with water temperature for washes, and use of hot or cold devices against skin
The patient will not feel the temperature extreme, or be able to withdraw from it

Hygiene
Daily wash to keep skin clean
Dry thoroughly after washing

Do not leave patient in damp/wet bed

Commence bowel regime as outlined below

Hard collar needs to be removed & skin underneath checked & washed daily
Manually immobilised head whenever the hard collar is off
 Collar fit & position to be checked each shift

Inspect the skin of the occiput each shift

Refer to surgeons & orthotics for advice on access to skin under halo jackets and braces

Adequate nutrition is important for good skin integrity. Enteral nutrition is preferred.

Skin should be fully inspected once per shift

Bladder
Urinary bladder function may be affected by SCI. The muscles and sphincters of the bladder are normally
controlled by neurological input and spinal reflexes. Loss of this normal neurological control of the bladder is
commonly referred to as a neurogenic bladder. The aim of bladder care is to prevent infections, minimise and
contain incontinence and find an appropriate way to empty the bladder. This will need to be related to the child’s
developmental level, lifestyle, and family needs. For the adolescent patient sexual function also needs to be
considered.
Bladder dysfunction depends on the level of spinal cord injury
Some patients will have a contractile/reflex bladder which contracts when the bladder muscle
(detrusor) is under a certain amount of pressure. Depending on the urethral sphincter function
these patients will leak in between catheters.

Some patients will have an acontractile/flaccid bladder that stretches and holds a large volume of
urine but the bladder muscle (detrusor) does not contract and bladder emptying occurs usually
by overflow

Some patients will have a combination bladder

In the early acute phase of the SCI an indwelling urinary catheter will be used. Always use lignocaine
lubricant to insert catheter.

Once patient has stabilised and opioids reduced consider change to intermittent catheter 4-6/24.
Refer to Urology to enable Stomal therapy involvement to assist in establishing a routine

Long term management can include clean intermittent catheterisation (by carer or child if able); condom
drainage or other options used more for adults dependant on care, such as bladder tapping or use of a
suprapubic catheter

Occasionally if clean intermittent catheterisation is difficult or impractical a mitrofonoff stoma might be

considered

Some patients will be prescribed Oxybutin to reduce bladder spasm & thus increase holding capacity &
continence between catheters

Complications:
Recurrent UTI

Renal & bladder calculi

Vesico ureteric reflux

Latex allergy development due to increased latex exposure: use latex free catheters
 Prevention of complications:
Maintain good hydration to reduce the risk of UTI & Kidney stones

Good hand hygiene by carers, and ensuring goog hygiene of the patients perineal area to reduce
infection

Priaprism (erection) may occur in boys and is usually self-limiting & not a contraindication to
catheterisation. Referral to urology if priaprism prolonged

Bowels
Bowel function will be affected by loss of neurological control of its function (neurogenic bowel). In addition,
medications such as antibiotics and opioids, immobility, alterations is food, fibre and fluid intake may affect
function. Patients are at risk of constipation, impaction and diarrhoea. It is important to achieve regular bowel
emptying. Constipation is not only troublesome but can also trigger major complications such as autonomic
hyper-reflexia (dysreflexia).

Commence bowel management as soon as bowel sounds are present and enteral/oral feeds begin
In the acute phase of spinal shock:
Aperients should be commenced with enteral feeding

Refer to Dietician early to ensure adequate nutrition, fluid & fibre in the feeds

When spinal shock has resolved (and helpful if patient able to sit)
Refer to stomal therapy for assistance in establishing a bowel routine if the
ward/rehabilitation routine is not satisfactory in the early phase; or when discharge is
being discussed.

Routine will depend on age, bowel function, level of injury, pre injury function &
family/carer support

Bowel dysfunction:
Some patients may have a ‘reflex’ bowel. Although peristalsis will move stool through bowel, the
anal sphincter may not relax. It may need stimulation to relax & allow passage of stool

Some patients may have a ‘flaccid’ bowel. Reflexes that move stool through the bowel are
impaired and the anal sphincter is relaxed preventing stool being held in the rectum

Some patients have a combination of bowel function problems

Constipation
Caused by: insufficient fluid & fibre intake, insufficient aperients, ineffective evacuation of stool,
medications (anticholenergics, opioids), immobility

Treatment: increase fluids & fibre, increase aperients

Impaction
Caused by: chronic constipation. Will often have liquid overflow

Treatment: contact stimulant, movicol or osmotic laxative; Assisted evacuation only if necessary
(e.g. microlax, large volume enema, manual disimpaction)

Diarrhoea
 Change in diet, antibiotics, bacteria, excess aperients, high impaction

Treatment: adjust diet, reduce aperients, stool specimen, abdominal x-ray if impaction suspected;
possibly consider probiotics

Type of bowel management aperients:

Contact stimulants help to move faeces through the bowel (peristalsis) e.g., senokot.

Bulking agents regulate bowel by increasing water content e.g. metamucil

Softeners increase water penetration of stool e.g. coloxyl very good for children

Iso-osmotic laxative e.g. Movicol,

Osmotic laxative e.g. lactulose

Suppositories & enemas can stimulate bowel action & lubricate faeces for easier evacuation e.g.
microlax, glycerol suppositories

Other: if above management suggestions are ineffective discuss with stomal therapy to consider
peristeen bowel washout system or Malone stoma-bowel washouts

Nutrition
Insert naso/oro gastric tube early to limit risk of vomiting and aspiration as patient will often have
paralytic ileus initially. NG placement also allows for enteral feeding to commence

Refer to Dietician early to ensure adequate nutrition, fluid & fibre in the feeds

Consider gastric ulcer prophylaxis

Re-introduce oral feeding after ensuring ability to swallow and protect airway

Gastrostomy may be required

Thromboprophylaxis
Refer to the Clinical Haematology Department for consideration of thrombotic risk and development of
an individualised thromboprophylaxis plan

Consider the use of antiembolic stockings or sequential calf compression devices (SCCD) (Link:
http://www.rch.org.au/picu_intranet/guidelines/Sequential_Compression_Devices/
(http://www.rch.org.au/picu_intranet/guidelines/Sequential_Compression_Devices/))

Postural hypotension
Patients with SCI are at risk for postural hypotension when moving from supine to sitting upright. This is due to
loss of sympathetic autonomic nervous system innervation and include an inability to regulate BP normally with
vasoconstriction. Do not attempt to start sitting patient up until medical approval given.
To avoid problems with postural hypotension:

Anti embolic stockings and/or SCCD’s will encourage venous return from the legs
Abdominal binders encourage venous return through the IVC
Orthotics can make these to fit
 Slowly increase bed angle to sitting position, rather than in one quick move. It may take weeks for the
patient to tolerate sitting upright.
Involve physiotherapy team in this process

Joint contractures
Abnormal muscle tone and lack of movement can result in joint contractures. Referrals should be made to
Physiotherapy, Occupational Therapy and Orthotics within 1-2 days of admission:

Physiotherapy: for range of movement exercises & positioning patient in good alignment
Orthotics: splints for ankles
Occupational Therapy: splints for hands

Autonomic hyperreflexia (Dysreflexia)

Autonomic Dysreflexia is a MEDICAL EMERGENCY that needs immediate recognition and action
Usually it affects those with injuries T6 or higher and generally won’t occur until a few weeks post injury
(After spinal shock has subsided).
Autonomic dysreflexia is a condition where the autonomic nervous system has an abnormal excessive
response to noxious stimuli below the level of the injury
Common causes of stimuli include full bladder or bowel (ineffective emptying or constipation), pressure
sores, tight clothing, fractures, surgery, pain
Signs & symptoms include:
Hypertension
Sudden and severe nature which requires immediate recognition and treatment
Hypertension may be the only manifestation of dysreflexia.
Note: BP for children with a SCI is normally low, so a BP that is in the high end of normal
range for age is actually elevated for them
Bradycardia
Severe pounding headache
Skin rash (flushed, blotchy, transient)
Vasodilation above the level of the injury or sweating
Vasoconstriction below level of injury: pale, cool skin with, goosebumps and/or piloerection
Blurred vision/ pupillary dilation
Anxiety
Nasal congestion
Nausea
Note: for very young children symptoms may be vague & hard to recognise due to verbal &
developmental stages
Manage by:
Remove noxious stimuli where possible
loosen clothing, remove compression stockings, abdominal binder
perform urinary catheterisation using lignocaine gel, ensure catheter not blocked
 bowel disimpaction using lignocaine gel
look for pressure areas, ingrown toenails, evidence of fracture
Position child sitting upright or with head of bed elevated
Monitor BP & HR 5 minutely
Antihypertensive agents may be prescribed if not responding to above measures within a few
minutes, or cause cannot be found

Sexual function
Sexual function can be of great concern to families even in very young children
Important topic for adolescents with SCI
Topic needs to be discussed with family & child in age appropriate manner so that they understand
implications for the child’s lifetime
Puberty will occur as for other children; for females pregnancy is possible, and for males treatment may
be required for erection, ejaculation & fertility

Psychological
A diagnosis of spinal cord injury is often devastating for children and their families. There are frequently
preconceptions about spinal cord injury that need addressing and there may also be pre-existing issues
for the child or family.

Make appropriate referrals:

Social work
Clinical psychology
Victorian Paediatric Rehabilitation Service (http://www.health.vic.gov.au/vprs/)
Link to support groups or other children with similar injury

Potential complications and management

The following are the most common complications seen for these children. The prevention and management is
described above under the relevant headings

Pressure sores
Autonomic Hyperreflexia (Dysreflexia)
Pneumonia and retained secretions
Urinary tract infections
Constipation
Deep venous thrombosis
Bone demineralisation/ hypercalcaemia
Latex allergy
Spasticity – deformities/pain
Family centred care
Incorporate child’s developmental level when planning care
The child who is unable to perform care may be able to direct it enabling a sense of control
Enable family to work with the multi disciplinary care team to develop culturally sensitive care
Provide as much information as possible regarding the child’s plan of care for the next few days/weeks
Involve Nursing Care Coordinator early

Special considerations
Referral must be made to the rehabilitation team in the first 24 hours
If long term mechanical ventilation is required, phrenic nerve/diaphragm pacing may be considered

Companion documents
Medical management of spinal cord injury
Acute traumatic spinal cord injury admission process

Links
Victorian Paediatric Rehabilitation Service (http://www.health.vic.gov.au/vprs/)
Victorian spinal cord service (Austin Hospital) (http://www.austin.org.au/page/539)
The Queensland Spinal Cord Injuries Service: www.health.qld.gov.au/qscis
(http://www.health.qld.gov.au/qscis/)

References
Alexander M, Matthews D (Eds). Pediatric Rehabilitation Principles and Practice 4th Edition. Chapter 11
Spinal Cord Injuries
Brown, A & Carmuciano,K. (2003). Introduction to skin management in SCI. Education handout.
Victorian Spinal Cord Service
Brown, A & Carmuciano,K. (2003). Introduction to the neurogenic bowel. Education handout. Victorian
Spinal Cord Service
Brown, A & Carmuciano,K. (2003). Introduction to autonomic dysryflexia. Education handout. Victorian
Spinal Cord Service
Brown, A & Carmuciano,K. (2006). Postural hypotension. Education handout. Victorian Spinal Cord
Service
Burke D, & Murray D. (1992) Handbook of spinal cord medicine. Macmillan. London.
Consortium for Spinal Cord Medicine.(2008) Early Acute Management in Adults with Spinal Cord Injury:
A Clinical Practice Guideline for Health-Care Professionals. Washington DC. Parayzed Veterens of
America
Early acute management in adults with spinal cord injury. A clinical practice guideline for health-care
professionals. J spinal Cord Med 2008; 31(4): 408-479.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2582434/
 Hickey, J. (2009). The clinical practice of neurological and neurosurgical Nursing. Sixth Edition. Wolter
Kluwer/Lippincott Williams & Wilkins. Philadelphia
Fries,J. (2005). Critical rehabilitation of the patient with spinal cord injury. Critical Care Nurse Quarterly.
28(2):179-187.
Jones, T; Ugalde, V; Franks, P; Zhou, H; White, R. (2005). Venous Thromboembolism After Spinal Cord
Injury: Incidence, Time Course, and Associated Risk Factors in 16,240 Adults and Children. Archives of
Physical Medicine and Rehabilitation. 86(12) Dec:2240-2247.
Kirshblum S, Burns S, Biering-Sorensen F, Donovan W, Graves D, Jha A, Johansen M, Jones L,
Krassioukov A, Mulcahey M, Schmidt-Read M, Waring W. (2011). International standards for
Neurological classification of spinal cord injury (Revised 2011). The Journal of Spinal Cord Medicine.
34(6): 535-546
The Queensland spinal cord injuries service (2013) Management of autonomic dysreflexia: Information
for health professionals.
The Queensland spinal cord injuries service (2012) Bowel management following spinal cord injury:
Information for health professionals
The Queensland spinal cord injuries service (2012) Bladder management following spinal cord injury:
Information for health professionals
The Queensland spinal cord injuries service (2013) Management of pressure areas following spinal cord
injury: Information for health professionals
Vogel, L; Hickey, K; Klaas,S; and Anderson,C. (2004). Unique issues in pediatric spinal cord injury.
Orthopaedic Nursing. 23(5):300-308

Evidence table
Spinal Cord Injury (Acute Management) evidence table
(www.rch.org.au/uploadedFiles/Main/Content/rchcpg/hospital_clinical_guideline_index/Evidence
table(SCI)2015.doc)

Please remember to read the disclaimer

(http://www.rch.org.au/rchcpg/about_hospital_clinical_guidelines/Disclaimer/)

The development of this nursing guideline was coordinated by Janine Evans, Rosella - PICU, and approved by
the Nursing Clinical Effectiveness Committee. Updated April 2015.