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1152 PART 10: The Surgical Patient

GASTROINTESTINAL TRACT ISSUES • Bracken MB, Shepard MJ, Holford TR, et al. Administration of

GI prophylaxis should be initiated H -receptor antagonists. Early enteral methylprednisolone for 24 or 48 hours or tirilazad mesylate for
2
feeding may also be protective of the gut mucosa. Acute SCI is an 48 hours in the treatment of acute spinal cord injury. Results of the
independent risk factor for upper GI bleeding, due to stress ulceration, Third National Acute Spinal Cord Injury Randomized Controlled
among trauma patients and complete cervical SCI is associated with Trial. National Acute Spinal Cord Injury Study. JAMA. May 28
higher risks of GI bleeding. Loss of colonic motility early after SCI 1997;277(20):1597-1604.
5
during the “spinal shock” phase is well recognized and critical illness, • Call MS, Kutcher ME, Izenberg RA, Singh T, Cohen MJ. Spinal
trauma, surgery, and medications can also decrease intestinal motility cord injury: outcomes of ventilatory weaning and extubation.
and cause ileus for an extended time. With upper motor injuries (ie, J Trauma. July 15, 2011;71(6):1673-1679.
above the sacral segments), intestinal motility will return, but with lower • Furlan JC, Fehlings MG. Cardiovascular complications after acute
motor neuron injuries at the sacral segments, chronic dysmotility can be spinal cord injury: pathophysiology, diagnosis, and management.
expected with greater risks of fecal impaction. After feeding is started, Neurosurg Focus. 2008;25(5):1-15.
92
bowel movements should be facilitated with stool softeners, laxatives, • Gould MK, Garcia DA, Wren SM, et al. Prevention of VTE in
and suppositories as indicated.
nonorthopedic surgical patients: Antithrombotic Therapy and
GENITOURINARY TRACT ISSUES Prevention of Thrombosis, 9th ed: American College of Chest
Physicians Evidence-Based Clinical Practice Guidelines. Chest.
The three main centers controlling bladder function are the cerebral February 2012;141(suppl 2):e227S-e277S.
cortex, the pontine micturition center, and the sacral micturition center • Hayes KC, Davies AL, Ashki N, Kramer JK, Close TE. Re: Ditunno JF,
(S2-S4). Sympathetic (inhibitory) efferent fibers originate from spinal Little JW, Tessler A, Burns AS. Spinal shock revisited: a four-
78
cord levels T10-L2 and the parasympathetic (excitatory) efferent fibers phase model. Spinal Cord. 2004;42:383-395. Spinal Cord. May
and the somatic motor neurons (external urethral sphincter control) 2007;45(5):395-396.
originate from spinal cord levels S2-S4. Initially after SCI, the bladder
and sphincter are usually hypotonic. With upper level SCI—cervical, • Nesathurai S. Steroids and spinal cord injury: revisiting the NASCIS
2 and NASCIS 3 trials. J Trauma. December 1998;45(6):1088-1093.
thoracic, and lumbar—as reflexes return, disruption of the descending
inhibitory spinal pathways leads to detrusor hyperactivity with loss of • Panczykowski DM, Tomycz ND, Okonkwo DO. Comparative
external urethral sphincter control with urinary incontinence due to effectiveness of using computed tomography alone to exclude
frequent involuntary voiding. With lower motor neuron damage (injury cervical spine injuries in obtunded or intubated patients: meta-
level above the cauda equina or terminal conus) to sacral S2-S4 level neu- analysis of 14,327 patients with blunt trauma. J Neurosurg.
rons, motor output is impaired leading to a flaccid, distended bladder. 78 September 2011;115(3):541-549.
Barring evidence of traumatic urethral injury, indwelling urinary • Parizel PM, van der Zijden T, Gaudino S, et al. Trauma of the
bladder catheters should be placed early on to monitor urinary output spine and spinal cord: imaging strategies. Eur Spine J. March
as part of acute SCI management and may be removed as soon as the 2010;19(suppl 1):S8-S17.
patient is hemodynamically stable and does not require strict intake and • Tomycz ND, Chew BG, Chang YF, et al. MRI is unnecessary to
output monitoring. Priapism may occur after acute SCI, is usually self- clear the cervical spine in obtunded/comatose trauma patients:
limited, and does not require treatment. Urinary bladder catheters may the four-year experience of a level I trauma center. J Trauma. May
be inserted in the presence of priapism secondary to acute SCI. 5 2008;64(5):1258-1263.

NEUROLOGICAL OUTCOME
The prognosis and expected outcome after acute SCI is determined by
the neurological examination (ASIA scoring system) and the results of REFERENCES
diagnostic imaging (CT and MRI) to define the level and completeness Complete references available online at www.mhprofessional.com/hall
of injury. Repeat neurological examinations give way to less frequent
exams; however, after 72 hours, barring any unexpected worsening, the
neurological findings are mainly permanent.

REHABILITATION CHAPTER Torso Trauma
within the first week or two after acute SCI. Patients with less severe 120 Jameel Ali
The available evidence suggests that most critical instability occurs
acute SCIs may require less time in a monitored setting. Following
14
spinal decompression and/or stabilization, and resolution of potentially
life-threatening cardiac and respiratory events, the goal is for rehabilita-
tion specialists to become involved early in the management of persons KEY POINTS
with SCI. Mobilization of the patient out of bed to chair or seated posi-
tion helps to reduce pressure ulcers, limit deconditioning, and should • Abdominal and thoracic injuries should be considered as one
commence as soon as the spine and medical condition permit. complex—torso trauma.
• Prioritization of intervention in torso trauma is based on the
relative threat to life from specific injuries.
KEY REFERENCES • In managing torso trauma, the surgeon must be prepared to
explore the chest and/or abdomen because the source of instability
• Bracken MB, Shepard MJ, Collins WF, et al. A randomized, con- frequently is not obvious.
trolled trial of methylprednisolone or naloxone in the treatment of
acute spinal-cord injury. Results of the Second National Acute Spinal • The major decision in assessing the traumatized abdomen is to
Cord Injury Study. N Engl J Med. May 17, 1990;322(20):1405-1411. recognize the need for surgical exploration.

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