In the emergency room

When arriving at the hospital the person with a cervical spinal cord injury presents with the following symptoms: flaccid paresis, exclusively diaphragmatic respiration, low blood pressure and mostly bradycardia. It is well recognized that spinal cord injury implies inability to empty the bladder voluntary and, accordingly, an indwelling catheter is always placed in the urinary bladder in the emergency room when a spinal cord injury is suspected. At this stage, new risks appear. Because the spinal cord injury is often part of a multitrauma the low blood pressure after cervical spinal cord injury may be misinterpreted as consequent to extensive blood loss. A treatment with rapid infusion of intravenous fluids might lead to pulmonary edema. On the other hand, the cord-injured person may be bleeding in the abdomen and this may be difficult to diagnose because of the pre-existing low blood pressure, absence of tonic contraction of the abdominal muscles (guarding reaction) and absence of pain. For this and other reasons, the cord-injured person needs to be carefully investigated by computerized tomography scanning and magnetic resonance imaging. An unstable fracture in the spinal column with the risk of deterioration of the neurological outcome sometimes results in placing the patient on a hard table, a so-called "spine board.'' Then the patient can be moved from the emergency room to X-ray or to the intensive care unit without having to be moved from bed to examination tables and back. However, if the injured person lies more than 2 h in the same position on a hard spine board, he/she is at risk of developing pressure sores. This risk is attributed to the loss of sensory inputs to the brain from below the level of the lesion, but this may not be the whole explanation since unconscious patients without spinal cord injury do not seem to be at as high risk of developing pressure sore as are the cord injury patients, conscious or unconscious. Regulation of blood flow in the skin exposed to pressure seems to be deranged in the decentralized areas of the body, even though subcutaneous adipose tissue blood flow during resting conditions shows no difference when compared to that in able-bodied people (Karlsson et al., 1997a).

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