CONCISE GUIDANCE TO GOOD PRACTICE

A series of evidence-based guidelines for clinical management

NUMBER 9

Chronic spinal cord injur y: management of patients in acute hospital settings

NATIONAL GUIDELINES

Fe bru ar y 2008

BASCIS

Clinical Standards Department

Th e aim of t h e C li n ical St a nd ards De p art me n t of t h e Royal Coll ege of Physicia ns is to improve p at i e n t care a nd h e al t hcare provision by sett i ng cli n ical st a nd ards a nd mon i tori ng t h e ir use . We h ave expert ise i n t h e de ve lopme n t of e vide nce-b ase d gu ide li n es a nd t h e orga n isat ion a nd report i ng of mu l t ice n tre comp arat ive perform a nce d at a . Th e de p art me n t h as t hree core strategic ob j ect ives: to def ine st a nd ards around t h e cli n ical work of physicia ns, to measure a nd e val u ate t h e imp l e me n t at ion of st a nd ards a nd i ts imp act on p at i e n t care a nd to e ff ect ive ly implement t h ese st a nd ards. Our programme i nvolves collaborat ion wi t h specialist soci et i es, p at i e n t groups a nd n at ion al bod i es i ncl ud i ng t h e Nat ion al Inst i t u te for He al t h a nd C li n ical Exce ll e nce (NICE), t h e He al t hcare Comm ission a nd t h e He al t h Found at ion .

Guideline Development Group

Ange la Gall MRCP(UK ) a nd Lynn e Turn erStokes FRCP pre p are d t h is gu id a nce on be h al f of t h e mu l t id iscip li n ar y Gu ide li n e De ve lopme n t Group conve n e d by t h e Bri t ish Soci ety of Re h ab ili t at ion Me d ici n e, t h e Mu l t id iscip li n ar y Associat ion of Sp i n al Cord In j ur y Prof ession als a nd t h e Bri t ish Associat ion of Sp i n al Cord In j ur y Specialists i n associat ion wi t h t h e C li n ical St a nd ards De p art me n t of t h e Royal Coll ege of Physicia ns. Th e gu id a nce h as bee n e ndorse d by t h e Sp i n al Cord In j ur y Associat ion . Dr Angela Gall Consu l t a n t i n Re h ab ili t at ion Me d ici n e, Royal Nat ion al Ort hop a e d ic Hosp i t al, St a nmore Mrs Debbie Horne Occup at ion al Th erap ist, Sp i n al Cord In j ur y C e n tre, Midd l esbrough Professor Paul Kennedy Prof essor of C li n ical Psychology a nd Acade m ic Director, Un iversi ty of Oxford Professor Lynne Turner-Stokes Director, Region al Re h ab ili t at ion Un i t, Nort hwick Park Hosp i t al Mrs Dot Tussler Physiot h erap ist, Nat ion al Sp i n al Cord In j ur y C e n tre, Stoke Ma nde vill e

Concise Guidance to Good Practice series

Th e concise gu ide li n es i n t h is seri es are i n te nde d to i n form t hose aspects of physicia ns cli n ical pract ice wh ich m ay be ou tside t h e ir own specialist are a . In m a ny i nst a nces, t h e gu id a nce will also be use f u l for ot h er cli n icia ns i ncl ud i ng GPs, a nd ot h er h e al t hcare prof ession als. Th e gu ide li n es are design e d to allow cli n icia ns to m ake rap id, i n forme d decisions b ase d wh ere ver possib l e on syn t h esis of t h e best availab l e e vide nce a nd expert conse nsus gat h ere d from pract isi ng cli n icia ns a nd service users. A ke y f e at ure of t h e seri es is to provide bot h recomme nd at ions for best pract ice, a nd wh ere possib l e pract ical tools wi t h wh ich to imp l e me n t i t . Series Editors : Lynne Turner-Stokes FRCP a nd Bernard Higgins FRCP

Citation: Royal Coll ege of Physicia ns, Bri t ish Soci ety of Re h ab ili t at ion Me d ici n e, Mu l t id iscip li n ar y Associat ion of Sp i n al Cord In j ur y Prof ession als, Bri t ish Associat ion of Sp i n al Cord In j ur y Specialists, Sp i n al In j uri es Associat ion . Chronic spin a l cord injury: ma n agement of pa tients in acute hospit a l settings: na tiona l guidelines. Concise Gu ida nce to Good Pract ice seri es, No 9. London: RCP, 2008. Copyright: All righ ts reserve d. No p art of t h is pub licat ion m ay be reproduce d i n a ny form (i ncl ud i ng photocopyi ng or stori ng i t i n a ny me d i um by e l ectron ic me a ns a nd wh et h er or not tra nsi e n t ly or i ncide n t ally to some ot h er use of t h is pub licat ion) wi t hou t t h e wri tte n perm ission of t h e copyrigh t own er. App licat ions for t h e copyrigh t own ers perm ission shou ld be addresse d to t h e pub lish er.
Copyright 2008 Royal College of Physicians

Useful sources of information

Bri t ish Soci ety of Re h ab ili t at ion Me d ici n e : www.bsrm.co. u k Mu l t id iscip li n ar y Associat ion of Sp i n al Cord In j ur y Prof ession als: www.m ascip.co. u k Bri t ish Associat ion of Sp i n al Cord In j ur y Specialists: www.b ascis.pwp.b l u e yonder.co. u k Sp i n al In j uri es Associat ion: www.sp i n al .co. u k

Contents
Guideline Development Group Useful sources of information ii ii 1

Spinal cord injur y (SCI) is a life long condition affecting over 40,000 people in the UK. When an individual with established SCI is admitted to hospital for a procedure or because of illness, hospital teams need to manage both the acute condition and the spinal cord injur y. These guidelines aim to assist teams in assessing and managing this potentially vulnerable group of people to avoid the common problems of hospital-acquired morbidity. Key steps are:

Introduction and aim of the guidelines Pathophysiological consequences of SCI

Resp irator y Ne urological 2 2 4 C ard iovascu lar

References

4 4

7 8 9

Further reading THE GUIDELINES

an understanding of the common pathophysiological consequences of SCI listening to the patient and members of their family who are often expert in managing the condition maintaining close contact with the individual's regular team/specialist spinal cord injur y centre.

A St a ff aware n ess a nd trai n i ng

B Assessme n t of p at i e n ts wi t h sp i n al cord i n j ur y C Ma n age me n t of p at i e n ts wi t h sp i n al cord i n j ur y

Appendices
1 2 3 4 Gu ide li n e de ve lopme n t process Le ve ls of e vide nce

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Ch ecklist for assessme n t a nd m a n age me n t of i nd ividu als wi t h est ab lish e d SCI 12 Sp i n al cord i n j ur y ce n tres 13

Introduction and aim of the guidelines

Traumatic spinal cord injury (SCI) in the UK affects an estimated 1015 people per million population per year1 so there are around 40,000 individuals in the UK living with a traumatic SCI.2 Most injuries are in young men but the mean age of injury is increasing, including those injured over the age of 60 years. The majority of injuries now result in tetraplegia and are predominantly incomplete injuries. The prevalence of other conditions causing SCI such as inflammatory, neoplastic and infective conditions is currently unknown. The life expectancy for people with SCI is less than for the general population although it continues to increase. These individuals are therefore at risk from age-related diseases that affect the general population, including cardiovascular disease, infection and malignancies. Also, the multisystem impairments resulting from SCI can lead to several complications, particularly infections, respiratory complications and pressure sores. Those with SCI are

Royal College of Physicians of London 11 St Andrews Place, London NW1 4LE www.rcplondon.ac .uk Registered Charity No 210508 ISBN 978-1-86016-324-1

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Chron ic sp i n al cord i n j ur y: m a n age me n t of p at i e n ts i n acu te hosp i t al sett i ngs 1

at greater risk of hospital admission every year following their injury compared with the general population. As a result, general physicians are likely to find themselves caring for individuals with SCI in acute hospital settings. These guidelines aim to assist in their assessment and management to avoid the common problems of hospital-acquired morbidity in this potentially vulnerable group of people. Although the guidance is based on evidence in those with traumatic SCI, much of it will apply to people with non-traumatic causes of SCI. The guideline development process is shown in Appendix 1 (p 10). Lack of pain or touch sensation below the level of the lesion in a person with complete SCI may confound diagnosis, for example a severe lower limb fracture or cellulitis may provoke only a slight sensation of nausea. But perhaps more importantly, complications related to the SCI itself (as opposed to the reason for admission) are very common in hospitals where SCI patients are rarely seen and their specialist needs are not addressed. Many people are maintained on finely tuned management routines, eg pressure sore prevention or bladder/bowel management which, if disturbed, can take weeks to re-establish. Quality Requirement 11 of the National Service Framework for Long-term (Neurological) Conditions3 emphasises the importance of listening

to the person and their family, who are often expert in the management of the condition, and of maintaining close contact with the individual's regular team/specialist spinal injuries centre. (Appendix 4 lists spinal centres which offer telephone advice.) Finally, many people with SCI need an accessible environment, their usual equipment, eg a wheelchair, and/or nursing staff familiar with SCI, to optimise their management during intercurrent illness.

Pathophysiological consequences of spinal cord injury

Respirator y system
People with SCI are at risk of chest complications because of a number of factors which include:

paralysis of ventilatory muscles affecting breathing and coughing capability relative bronchoconstriction excess secretions due to relative parasympathetic system dominance (from reduced sympathetic function in tetraplegics) ventilation/perfusion mismatch from reduced mobility that may exacerbate hypoxia during intercurrent illness.

Box 1. Typical features of autonomic dysreflexia.

Sudden uncontrolled rise in blood pressure, w ith other signs of sympa thetic overactivity:
systolic pressures re ach i ng up to 250300 mmHg d iastolic pressures re ach i ng up to 200220 mmHg.

Cardiovascular system
In individuals with tetraplegia, symptomatic bradycardia and, of more concern, asystolic cardiac arrest, are well recognised during the acute phase. This is due to the loss of sympathetic activity with preservation of parasympathetic (vagal) activity. Significant bradycardia usually resolves several weeks after injury, but this mechanism can complicate anaesthetic and chest care in chronic tetraplegia, particularly in hypoxia or during suctioning. In individuals with high spinal cord lesions (above mid-thoracic level (T7)), hypotension (eg 80/50) and low or relatively low pulse rate (eg 4050 bpm) can be physiologically 'normal' for that level of spinal

Other fea tures of a utonomic imba l a nce vary, but may include:
pound i ng h e ad ach e swe at i ng or sh iveri ng f ee li ngs of a nxi ety ch est t igh t n ess b l urre d vision n asal congest ion b lotchy ski n rash or f l ush e d above t h e l e ve l of t h e ir sp i n al i n j ur y (du e to p arasymp at h et ic act ivi ty cold wi t h goose bumps ('cu t is a nseri n a') be low t h e l e ve l of i n j ur y (du e to t h e symp at h et ic act ivi ty).

2 Chron ic sp i n al cord i n j ur y: m a n age me n t of p at i e n ts i n acu te hosp i t al sett i ngs

cord lesion and are still compatible with effective tissue perfusion. Hypotension from other causes needs to be distinguished carefully from this picture. Overzealous fluid resuscitation or transfusion can cause pulmonary oedema and increased morbidity/mortality. It is helpful to ascertain individuals' normal resting vital signs before planning intervention.

Individuals with SCI at or above T6 level are at risk of autonomic dysreflexia (AD) an excessive autonomic response to stimuli below the level of the SCI, such as a blocked catheter or faecal impaction. This is an acute and life-threatening condition which all physicians should be aware of. Typical features are shown in Box 1 (p 2), and a suggested pathway for management is given in Fig 1.

Fig 1. Management of patients with autonomic dysreflexia (AD).

Symptoms or signs of AD (eg pound i ng h e ad ach e, f l ush i ng, swe at i ng or b lotch i ng ski n above i n j ur y l e ve l ; p al e, cold, goose bumps be low)

Check blood pressure Con f irm d iagnosis (b lood pressure gre ater t h a n 200/100 or 2040 mmHg h igh er t h a n norm al)

Sit the patient up avoid lying down

For patients with catheter: e mpty l eg b ag a nd note vol ume ch eck t ub i ng not b locke d/ ki n ke d i f cat h eter b locke d re move a nd re-cat h eterise usi ng l ubrica n t con t ai n i ng lidocai n e

For patients without catheter: i f b ladder d iste nde d a nd p at i e n t un ab l e to p ass uri n e i nsert cat h eter usi ng l ubrica n t con t ai n i ng lidocai n e

If bladder distension excluded gently examine per rectum For f a ecal m ass i n rect um: ge n t ly i nsert glove d f i nger covere d i n lidocai n e j e lly i n to rect um a nd re move f a ecal m ass

If symptoms persist or cause is unknown Give n i f e d ip i n e or glycer yl tri n trate (GTN). In adu l ts, p lace sub li ngu ally: t h e con te n ts of a 10 mg sub li ngu al n i f e d ip i n e capsu l e or 12 GTN t ab l ets. Re pe at dose ca n be give n a f ter 20 m i nu tes, i f symptoms persist .

If blood pressure remains high, then an IV hypotensive may be required: hydralazi n e 20 mg iv slowly or d iazoxide 20 mg bol us. Con t i nu e to se arch for ca use a nd mon i tor b lood pressure . May require management on high dependency unit if problem persists. Contact a spinal cord injur y centre for further advice (see Appe nd ix 4).

Chron ic sp i n al cord i n j ur y: m a n age me n t of p at i e n ts i n acu te hosp i t al sett i ngs 3

Neurological system

Sensa t ion
Sensory loss will complicate the presentation of acute illness in individuals with SCI as the history will not necessarily include localising symptoms or pain, and localising signs may not be present.

Bladder
The great majority of individuals with SCI also have impairments in bladder function but this will depend on the grade and level of injury. Urinary tract infections are one of the most common complications following spinal cord injury and may require hospitalisation. The goals of bladder management are to preserve the upper tracts, minimise lower tract complications and be compatible with the individual's lifestyle. In the main, patients are followed up at their spinal cord injury centre and have ongoing assessment of urological needs. Many patients are maintained on intermittent self-catheterisation (ISC) regimens, which may be impossible to maintain during acute illness. In this case, it may be appropriate to pass an indwelling catheter if the admission is short. However, long-term indwelling urethral catheters can lead to complications such as infection or urethral stricture. In the longer term, it is preferable to reestablish them, if possible, on their normal bladder routine, in liaison with their regular team. A common scenario is the patient with incomplete SCI who has some spontaneous voiding but retains a residual volume which gradually increases: this can eventually lead to complications if not appropriately managed. Figure 2 shows a decision pathway for basic investigation and referral in this situation.

pain or other symptoms in intercurrent illness. Sensory and motor control of the anorectum is impaired and therefore individuals will be unable to feel the need to evacuate the bowel, or control the process of defaecation. Without intervention, individuals will be incontinent of faeces and chronically constipated, with all the secondary complications these imply, including the potential risk of autonomic dysreflexia, in patients with lesions above the level of T56. Fig 3 (p 6) provides a flow chart for bowel management.

References
1 2 Grundy D, Swain A. ABC of spinal cord injury, 4th edn. London: BMJ Books, 2002. Kennedy P. Spinal cord injuries. In: Bellack AS, Hersen M (eds), Comprehensive clinical psychology. London: Elsevier Science, 1998. Department of Health. National Service Framework for Long term Conditions. London: DH, 2005.

Further reading
1 Consortium for Spinal Cord Medicine. Acute management of autonomic dysreflexia: individuals with spinal cord injury presenting to health-care facilities, 2nd edn. Washington: Paralyzed Veterans of America, 2001.* Consortium for Spinal Cord Medicine. Prevention of thromboembolism in spinal cord injury, 2nd edn. Washington: Paralyzed Veterans of America, 1999.* Royal College of Nursing. Pressure ulcer risk assessment and prevention. Clinical practice guidelines. London: RCN, 2001. National Institute for Health and Clinical Excellence. The prevention and treatment of pressure ulcers. NICE clinical guideline. London: NICE, 2005 Consortium for Spinal Cord Medicine. Pressure ulcer prevention and treatment following spinal cord injury. A clinical practice guideline for healthcare professionals. Washington: Paralyzed Veterans of America, 2000.* National Patient Safety Agency. Bowel care for people with established spinal cord lesions. Patient Safety Information. London: NPSA, 2004. Multidisciplinary Association of Spinal Cord Injury Professionals. National guidelines for bowel management after SCI. MASCIP, 2004. Consortium for Spinal Cord Medicine. Neurogenic bowel management in adults with spinal cord injury. Washington: Paralyzed Veterans of America, 1998.* Royal College of Nursing. Digital rectal examination and manual evacuation of faeces. Guidance for nurses. London: RCN, 2004. Consortium for Spinal Cord Medicine. Respiratory management following spinal cord injury. A clinical practice guideline for healthcare professionals. Washington: Paralyzed Veterans of America, 2005.*

3 4

Bowel
Spinal cord injury has a profound impact on the function of the large bowel and on maintenance of faecal continence. Stool transit through the bowel is slowed, placing individuals at high risk of constipation, especially where morphine or codeinerelated drugs or anticholinergics are used to control

10

4 Chron ic sp i n al cord i n j ur y: m a n age me n t of p at i e n ts i n acu te hosp i t al sett i ngs

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Consortium for Spinal Cord Medicine. Preservation of upper limb function following spinal cord injury. A clinical practice guideline for healthcare professionals. Washington: Paralyzed Veterans of America, 2005.* Consortium for Spinal Cord Medicine. Depression following SCI. A clinical practice guideline for primary care physicians. Washington: Paralyzed Veterans of America, 1998.*

13

Department of Health. Discharge from hospital: pathway, process and practice. London: DH, 2003. The guidelines can be downloaded from the website of the Paralyzed Veterans of America www.pva.org/site/PageServer?pagename=pubs_main

Fig 2. Bladder management in spinal cord injur y patients who void spontaneousy but fail to empty their bladder completely. UTI=uri n ar y tract i n f ect ion .

Total voided volume Increased: > 2,000 ml Diabetes, d iabetes i nsip idus, chron ic re n al f ail ure, drugs, obsessive dri n ki ng Decreased: < 2,000 ml Incomp l ete ch art, i nsu ff ici e n t f l u id i n t ake

Spontaneous voiding but suspicion of incomplete emptying, symptoms of: i ncon t i n e nce fre qu e n t void i ng of uri n e UTIs d iste nde d abdome n/d iscomfort /n a use a a u tonom ic dysre f l exia

Voided volume charts x3

Post-micturition ultrasound

Large volumes ( > 500 m l)

Small, frequent volumes ( > 300 m l)

Residual volume ( > 50100 m l)

Exclude obstruction Const ip at ion, drugs etc

Exclude UTI

Ensure more frequent bladder emptying To avoid b ladder f illi ng more t h a n 500 m l

Consider: Detrusor sphincter dyssynergia Other outflow obstruction eg: prost a t ic hypertrophy uret hral strict ure b ladder ston es

Ultrasound upper tracts to excl ude d ilat at ion, ide n t i fy ston es etc

If necessar y with catherisation In term i tte n t steril e cat h erisat ion is pre f erab l e . See k advice from con t i n e nce nurse i f n ecessar y.

Clear upper tracts Refer to specialist urology/spinal cord injur y centre

Dilated upper tracts Urgent referral to urology Place i ndwe lli ng cat h eter wh il e wai t i ng

Specialist investigations : urodyn am ics to assess pressures Ot h er i nvest igat ions m ay i ncl ude : tra nsrect al u l trasound uret hrogram

Chron ic sp i n al cord i n j ur y: m a n age me n t of p at i e n ts i n acu te hosp i t al sett i ngs 5

Fig 3. Bowel management for patients with spinal cord injur y.

Maintain regular stool chart Avoid const ip at i ng me d icat ions (eg morph i n e derivat ives, a n t icholi n ergics) as f ar as possib l e .

Continue patients own bowel management routine unless problematic In terve n t ions recogn ise d as be n e f icial i ncl ude : d i et ar y m a n age me n t b ala nce d d i et, rol e of f l u id, f ibre a nd st imu la n t foods regu lar rou t i n e (regu lar food, regu lar bowe l rou t i n e same t ime e ach d ay, same locat ion i e toil et /be d) physical u t ilisi ng gastrocolic re f l ex i e a f ter hot d i et ar y trigger, abdom i n al m assage, physical act ivi ty posi t ion i ng si t on toil et /commode i f possib l e con t i nu e i nd ividu als usu al rou t i n e as f ar as possib l e ph arm acological stool sof te n ers, st imu la n t or osmot ic laxat ives local triggers for de f a ecat ion (eg supposi tori es, d igi t al st imu lat ion, m a nu al e vacu at ion).

If any change is required or planned, assess : p at i e n t s perce pt ion of bowe l care prob l e ms onset of prob l e ms a nd re l e va n t f actors p ast me d ical h istor y a nd me d icat ion cli n ical exam i n at ion i ncl ud i ng rect al exam i n at ion f l u id a nd d i et ar y i n t ake i ncl ud i ng d aily f ibre i n t ake (m i n im al f ibre 10 g/d ay, me d i um 18 g/d ay, h igh 25 g/d ay).

Avoid frequent changes of regimen Give e ach i n terve n t ion t ime to work be fore ch a ngi ng. Followi ng assessme n t, agree durat ion of trial .

If stools are too soft: i f f ibre is h igh or me d i um: re duce i nsol ub l e f ibre* i f t h ere is no be n e f i t, re duce sol ub l e f ibre i f f ibre is m i n im al : gradu ally i ncre ase i nsol ub l e f ibre .
*Insol ub l e f ibre i ncl udes whol egrai ns, eg wh e at, m aize, rice .

If stools are too hard: e nsure f l u id i n t ake > 2 L/d ay i f i nsol ub l e f ibre is m i n im al or me d i um, gradu ally i ncre ase i f i nsol ub l e f ibre is h igh, tr y re duci ng.

If no bowel actions are occurring despite careful regimen as above, a proactive approach is needed: opt im ise f l u id a nd d i et con t i nu e local e vacu at ion m a n age me n t (supposi tori es/m a nu al e vacu at ion).

Exclude obstruction: ch eck rect um for f a ecal load i ng p lai n abdom i n al x-ray or u l trasound i f n ecessar y to excl ude bowe l obstruct ion a nd proxim al f a ecal load i ng.

Obstruction excluded Consider add i ng laxat ive, eg se nn a 12 nocte, or Movicol, i ncre asi ng t h is as re qu ire d.

Severe proximal faecal loading May re qu ire a h igh dose of laxat ives to cl e ar, bu t tre at me n t ca n be comp licate d. Contact local spinal cord injur y centre for advice (see Appe nd ix 4).

6 Chron ic sp i n al cord i n j ur y: m a n age me n t of p at i e n ts i n acu te hosp i t al sett i ngs

THE GUIDELINES
Recommenda tion Grade

A Staff awareness and training

1 The possibility of the following complications should be considered in any patient with established spinal cord injur y (SCI) admitted to hospital : C

resp irator y prob l e ms i ncl ud i ng resp irator y f ail ure a nd i n f ect ion a u tonom ic dysre f l exia i n l esions at or above T6 dee p ve i n t hrombosis (DVT) pressure sores i n ade qu ate nu tri t ion n e urological deteriorat ion bowe l prob l e ms i ncl ud i ng const ip at ion a nd i ncon t i n e nce b ladder prob l e ms i ncl ud i ng uri n ar y rete n t ion, i n f ect ion a nd calcu li muscu loske l et al prob l e ms i ncl ud i ng p ai n, i n j ur y a nd con tract ures de pression, a nxi ety a nd ot h er mood d ist urb a nce .

Specific staff training In particular, all nursing and medical staff should have specific training in the recognition of symptoms and management of: C

second ar y muscu loske l et al p ai n, i n j ur y a nd con tract ure i ncl ud i ng pre ve n t ion a nd m a n age me n t of sp ast ici ty a u tonom ic dysre f l exia (AD) b ladder m a n age me n t techn iqu es i ncl ud i ng
cl e a n i n term i tte n t ca t h eterisa t ion

bowe l m a n age me n t techn iqu es

appropria te use of supposi tori es, e n e m as a nd laxa t ives d igi t al st i mu la t ion a nd m a nu al e vacu a t ion

St a ff should be aware tha t some pa t ients are dependent on m anual evacua t ion for their bowel care. Failure to provide this m ay resul t in const ipa t ion and risk of serious complica t ions, including bowel obstruct ion and autonomic dysref lexia .

e mot ion al d ist urb a nce .

Continued overlea f

Chron ic sp i n al cord i n j ur y: m a n age me n t of p at i e n ts i n acu te hosp i t al sett i ngs 7

THE GUIDELINES
Recommenda tion Grade

B Assessment of patients with SCI

1 Initial assessment of all patients on admission should include the following: C

resp irator y assessme n t : f u ll h istor y a nd exam i n at ion i ncl ud i ng b ase li n e : pu lse, resp irator y rate, a nd te mperat ure oximetr y vi t al cap aci ty (VC) a nd force d exp ira tor y vol um e (FEV)1 (i f possi b l e) for perioperat ive p at i e n ts, or ot h er i ncre ase d risk of ch est p at hology:
arterial b lood gases a nd ch est x-rays

ski n a nd pressure u lcer risk assessme n t : wi t h grad i ng of a ny exist i ng u lcers b ase li n e cal f a nd t h igh me asure me n ts to allow e arly detect ion of DVT uri n ar y assessme n t i ncl ud i ng: re vi e w of voi d i ng m et hod a nd p a ttern 24-hour voi d e d vol um e ch art post-voi d resi du al vol um e (by ca t h eter or b ladd er sca n), i f voi d i ng on urge or by re f l ex uri n ar y m icroscopy a nd cu l t ure, i f symp toms or signs of local or syste m ic i n f ect ion assessme n t of bowe l care n ee ds: p la n of m a n age m e n t d e ve lop e d wi t h i n 24 hours of adm ission nu tri t ion al assessme n t i ncl ud i ng:
d i et ar y i n t ake we igh t a nd b ioch e m istr y (al bum i n, h a e moglob i n, h a e m a t i n ics).

f u ll n e urological assessme n t as soon as possib l e to ide n t i fy p at i e n t's b ase li n e, t h ere by e nsuri ng e arly detect ion of a ny deteriorat ion muscu loske l et al assessme n t i ncl ud i ng sp ast ici ty assessme n t, assessme n t of joi n t ra nge of move me n t a nd p ai n . psych iatric h istor y i ncl ud i ng scree n i ng for de pression . Use of at l e ast two qu est ions:
'Duri ng t h e last mon t h, h ave you of te n b ee n bot h ere d by f ee li ng down, d e presse d or hop e l ess?' 'Duri ng t h e last mon t h, h ave you of te n b ee n bot h ere d by h avi ng li tt l e i n terest or p l e asure i n doi ng t h i ngs?'

Regular assessments thereafter should include the following:

d aily assessme n t of : calf and thigh measurements to allow early detection of DVT skin and pressure areas fre qu e n t assessme n t, as appropriate, of :

resp irator y f unct ion i ncl ud i ng:

symp tom ch eck a nd exam i n a t ion pu lse, resp ira tor y ra te, te mp era t ure oxi m etr y, VC a nd FEV1 (i f unst ab l e or a t risk)

bowe l f unct ion, i ncl ud i ng: stool consiste ncy fre qu e ncy of bowe l act ion a nd i n terve n t ions n e urological imp airme n ts, i f t h ere is concern t h at t h is is ch a ngi ng.

Continued overlea f
8 Chron ic sp i n al cord i n j ur y: m a n age me n t of p at i e n ts i n acu te hosp i t al sett i ngs

THE GUIDELINES
Recommenda tion Grade

C Management of patients with SCI

1 All patients with SCI admitted to hospital should:
be d iscusse d ( followi ng t h e ir conse n t) wi t h t h e ir sp i n al cord i n j ur y ce n tre for i n form at ion a nd advice as i nd icate d (see Appe nd ix 4 for det ails of ce n tres) h ave a wri tte n care p la n wh ich i ncl udes: management of autonomic dysreflexia for patients at risk (T56 or above) see Fig 1 (p 3). respiratory management to prevent or treat chest complications, developed in conjunction with a ch est or n e urophysiot h erap ist . Th is m ay i ncl ude : cl e ari ng of airway secret ions: assiste d cough i ng, suct ion i ng (b e aware of t h e risk of bradycard ia i nduce d by suct ion) re-exp a nsion of a ff ecte d l ung i ncl ud i ng d ee p bre a t h i ng, posi t ion i ng, IPPV, BiPAP, bronchoscopy wi t h lavage a nd me d icat ions

comme nci ng t hromboe mbolic prophylaxis i f immob ilise d wi t h be d rest or adm i tte d for me d ical ill n ess or surger y (as per hosp i t al policy) i ncl ud i ng:
t hromboe mbolism d eterre n t (TED) stocki ngs un l ess con trai nd ica te d low mol ecu lar we igh t h e p ari n*

pre ve n t at ive me asures to avoid pressure sores, or f u ll pressure re li e f i n t h e prese nce of exist i ng u lcers ade qu ate nu tri t ion provide d to meet i nd ividu al n ee ds i ncl ud i ng calori es, prote i n, m icronu tri e n ts a nd f l u ids. aggressive nu tri t ion al support i f :
d i et ar y i n t ake is i n ad e qu a te, or t h e i nd ivi du al is nu tri t ion ally comprom ise d

con t i nu at ion of norm al bowe l m a n age me n t programme, un l ess t h ere is re ason to ch a nge, i ncl ud i ng d i et, use of laxa t ives a nd bowe l st i mu la n ts d igi t al st i mu la t ion a nd m a nu al e vacu a t ion as re qu ire d con t i nu at ion of norm al b ladder m a n age me n t programme, un l ess t h ere is re ason to ch a nge . If a n i ndwe lli ng uret hral cat h eter h as bee n n ecessar y duri ng t h e adm ission i t shou ld be re move d as soon as is possib l e a nd t h e p at i e n t's usu al b ladder care regime n re-est ab lish e d m a n age me n t of sp ast ici ty a nd avoid a nce of second ar y muscu loske l et al comp licat ions i ncl ud i ng:
sp li n t i ng, stretch i ng a nd p assive move m e n t, i f appropria te regu lar st a nd i ng programm e, i f appropria te .

All patients with SCI admitted to hospital should have appropriate discharge planning involving:
t h e p at i e n t a nd t h e ir f am ily re l e va n t me mbers of t h e mu l t id iscip li n ar y te am d irect con t act wi t h t h e commun i ty care te am (eg GP, d istrict nurse, commun i ty re h ab ili t at ion prof ession als) be fore d isch arge . Th e followi ng shou ld be i n p lace be fore d isch arge : all required arrangements for transport, care and equipment needs etc full reports from all professionals involved with their care appropriate transport arrangements made for any future outpatient or review appointments.

IPPV = intermittent positive pressure ventilation; BiPAP = bi-phasic positive airway pressure. * Patients with established SCI do not require long-term thromboprophylaxis unless there is a history of thromboembolic disease. Therefore normal prophylaxis should be given for the illness/procedure, according to local policy and can be stopped as usual when the patient is medically well.

Chron ic sp i n al cord i n j ur y: m a n age me n t of p at i e n ts i n acu te hosp i t al sett i ngs 9

Appendix 1. Guideline development process

Scope and purpose Overall ob j ect ive of t h e gu ide li n es Th e p at i e n t group covere d Target a ud i e nce C li n ical are as covere d To h igh ligh t t h e import a n t aspects i n t h e assessme n t a nd m a n age me n t of i nd ividu als wi t h chron ic . sp i n al cord i n j ur y (SCI). Adu l ts wi t h est ab lish e d SCI who prese n t i n a n acu te hosp i t al sett i ng wi t h a re late d or unre late d cond i t ion . Th ese gu ide li n es do not address t h e m a n age me n t of acu te SCI. Ge n eral physicia ns a nd ot h er cli n icia ns i nvolve d i n t h e m a n age me n t of adu l ts wi t h SCI wh e n t h e y are adm i tte d to a n acu te hosp i t al sett i ng. Ge n eral assessme n t of adu l ts wi t h SCI wh e n adm i tte d to hosp i t al wi t h re late d or unre late d cond i t ion . Ge n eral m a n age me n t pri ncip l es for adu l ts wi t h SCI wh e n adm i tte d to hosp i t al wi t h re late d or unre late d cond i t ion .

Stakeholder involvement Th e Gu ide li n e De ve lopme n t Group Fund i ng Con f licts of i n terest Rigour of development Evide nce gat h eri ng Re vi e w process Li n k betwee n e vide nce a nd recomme nd at ions Pilot i ng a nd peer re vi e w Implementation Tools for app licat ion Th is gu ide li n e will be m ade availab l e to hosp i t al cli n icia ns t hrough t h e Pub licat ions De p art me n t of t h e Royal Coll ege of Physicia ns a nd will appe ar on t h e we bsi tes of t h e Bri t ish Soci ety of Re h ab ili t at ion Me d ici n e (www.bsrm.co. u k), t h e Mu l t id iscip li n ar y Associat ion of Sp i n al Cord In j ur y Prof ession als (www.m ascip.co. u k), t h e Bri t ish Associat ion of Sp i n al Cord In j ur y Specialists (www.b ascis.pwp.b l u e yonder.co. u k) a nd t h e Sp i n al In j uri es Associat ion (www.sp i n al .co. u k). Th e gu ide li n es will be re vi e we d i n 2012. Evide nce for t h is gu ide li n e was provide d by re vi e w of Cochra n e Librar y, Me d li n e, Emb ase a nd ot h er gu ide li n es up to Se pte mber 2006. Th e e vide nce was e val u ate d by me mbers of t h e GDG. Th e syste m use d to grade e vide nce a nd gu id a nce recomme nd at ions is ad apte d from t h at pub lish e d by t h e Royal Coll ege of Physicia ns (see Appe nd ix 2). Not yet p ilote d al t hough i t h as bee n re vi e we d by st ake holder groups. A mu l t id iscip li n ar y group represe n t i ng: physicia ns a nd surgeons pract isi ng i n sp i n al cord i n j ur y m a n age me n t, physiot h erapy, occup at ion al t h erapy, nursi ng, psychology a nd users. Fund i ng was ki nd ly provide d by t h e Bri t ish Soci ety of Re h ab ili t at ion Me d ici n e . Non e declare d

Pla ns for upd ate

10 Chron ic sp i n al cord i n j ur y: m a n age me n t of p at i e n ts i n acu te hosp i t al sett i ngs

Appendix 2. Levels of evidence

Level Type of evidence IA IB IIA IIB III IV Met a-a n alysis of ra ndom ise d cli n ical trials or i nce pt ion cohort st ud i es At l e ast 1 ra ndom ise d cli n ical trial or we ll design e d cohort st udy wi t h good follow-up At l e ast 1 we ll design e d con troll e d st udy wi t hou t ra ndom isat ion or a met a-a n alysis of case con trol st ud i es At l e ast on e st udy wi t h qu asi experime n t al design or case-con trol st udy At l e ast 1 non-experime n t al st udy (eg descript ive st udy) Expert comm i ttee reports or reports by recogn ise d a u t hori t i es Grade of recommendation A A B B C C

Chron ic sp i n al cord i n j ur y: m a n age me n t of p at i e n ts i n acu te hosp i t al sett i ngs 11

Appendix 3. Checklist for assessment and management of individuals with established spinal cord injury
No
C are p la n for a u tonom ic dysre f l exia Resp irator y assessme n t a nd m a n age me n t p la n Thromboe mbolic prophylaxis:

Yes

Date

Signature

t hromboe mbolic deterre n t stocki ngs low mol ecu lar we igh t h e p ari n

Ski n assessme n t a nd pressure sore pre ve n t ion strategy i n p lace Nu tri t ion al assessme n t a nd m a n age me n t p la n Bowe l assessme n t a nd m a n age me n t p la n Bladder assessme n t a nd m a n age me n t p la n Ne urological assessme n t Muscu loske l et al assessme n t a nd m a n age me n t p la n De pression scree n i ng qu est ions a nd follow-up as re qu ire d Disch arge p la nn i ng:

care arra nge me n ts for d isch arge GP a nd commun i ty nursi ng i n forme d d isch arge reports

Te l e phon e advice is availab l e from sp i n al cord i n j ur y ce n tres. Local specialist n e urore h ab ili t at ion te ams ca n also of te n off er use f u l pract ical support 'on t h e ground'.

12 Chron ic sp i n al cord i n j ur y: m a n age me n t of p at i e n ts i n acu te hosp i t al sett i ngs

Appendix 4. Spinal cord injury centres (SCICs)

Area
England Midd l esbrough Os w e s t r y Pi nderf i e lds Salisbur y Sh e ff i e ld Sou t hport St a nmore Stoke Ma nde vill e Northern Ireland B e l f ast Scotland Glasgow Wales C ard i ff

Unit
Golde n Jub il ee Region al SCIC Mid la nd SCIC Yorksh ire Region al SCIC Du ke of York Sp i n al Tre at me n t C e n tre Pri ncess Royal Sp i n al In j uri es Un i t Sou t hport Region al Sp i n al In j uri es Un i t London SCIC (Royal Nat ion al Ort hop a e d ic Hosp i t al) Th e Nat ion al Sp i n al In j uri es C e n tre SCIC Musgrave Park Hosp i t al Th e Qu ee n Elizabet h Sp i n al In j uri es C e n tre Rookwood Sp i n al In j uri es Re h ab ili t at ion C e n tre

Telephone
01642 282641 01691 404000 01924 212358 01722 336262 0114 2715609 01704 704345 0208 909 5583/8 01296 315000 02890 902000 0141 2012530 02920 415415

Chron ic sp i n al cord i n j ur y: m a n age me n t of p at i e n ts i n acu te hosp i t al sett i ngs 13