2. Why do spinal injured patients die? Diagnostic dilemmas Management errors Misunderstanding spinal cord injuries Why do things go wrong ? Long term problems arise from shortsightedness

4. Incidence 20/million population per year RTA Motorbike car pedestrian cyclist Falls jumped pushed Sports Diving horseriding rugby Infections Tumours Discs Iatrogenic

5. SCIWORA

6. Spinal Cord Injury Without Radiographic Abnormality

10. Neuronal dysfunction/ death Direct trauma Haematoma Ischaemia Hypotension Hypoxia Oedema Pathophysiology of spinal cord injury

11. Cardiorespiratory physiology

13. Respiratory Afferents Intrapulmonary receptorsVagus Stretch/proprioreceptors ribs/intercostalsT1-T12 ClaviclesLow Cervical ChemoreceptorsCarotid body ChemoreceptorsBrainstem

14. Respiratory dysfunction LumbarUnable to cough Low thoracic  chest wall compliance  Vital capacity High thoracic  chest wall compliance  Vital capacity poor expansion. Basal collapse C5/C6Diaphragms and accessory only C3/C4/C5Accessory only Above C3Very little

17. Respiratory autonomic dysfunction Bronchial hypersecretion Bronchial hyper-responsiveness

18. Respiratory monitoring Lung functionFVC, PEFR, Speech, RR FVC> 1L FVC < 1L FVC= Tidal volume Pulse oximeter Blood gasses Watch closely in an appropriate environment for several days

19. Respiratory treatment Oxygen A good physiotherapist NIPPB (Birding) Non-invasive ventilation Invasive ventilation Tracheostomy

20. Respiratory treatment What if they do get ventilated ? Weaning is likely to be slow and difficult Wait until pulmonary compliance is normal and chest is clear Extubate onto noninvasive bipap

23. How to intubate? Emergency or elective? Awake or sedated or asleep? Suxamethonium?

25. Acute cardiovascular changes Vasodilation  Vasoconstriction T4-T6 Hypotension Loss of cardiac sympathetics Bradycardia

26. Acute cardiovascular changes Be carefull….. Postural hypotension Vagal stimulation (tracheal suction) Pressure sores

27. Cardiovascular management Judicious fluid management CVP monitoring PA catheter Oesophageal doppler Inotropes Chronotropes Temporary pacing Why Bother ?

30. NASCIS III Methylprednisolone 30mg/Kg over 15 minutes wait 45 minutes 5.4 mg/Kg/Hr for 23 hours if >4 hours post injury 5.4 mg/Kg/Hr for 47 hours if >4 but <8 hours