Immediate Management of Acute Quadriplegia in Adults

Hemodynamic Stabilization

Spinal immobilization – Apply a cervical collar and backboard and maintain complete immobilization until the injury is definitively ruled out or surgically stabilized, avoiding any unnecessary movement that could aggravate neurological damage. 1
Systolic blood‑pressure target – Keep systolic arterial pressure > 110 mm Hg immediately after injury; hypotension below this threshold is an independent predictor of mortality in patients with spinal cord injury. 1, 2
Mean arterial pressure (MAP) goal – Maintain MAP ≥ 70 mm Hg for the first week post‑injury to limit progression of neurological deficit; the strongest correlation between MAP and neurological improvement is observed for MAP values > 70–75 mm Hg, especially during the first 2–3 days. 1, 2
Arterial line monitoring – Insert an arterial catheter for continuous blood‑pressure monitoring, as achieving the MAP target without invasive monitoring fails in roughly one‑quarter of measurements. 1

Rapid‑sequence induction with videolaryngoscopy – Use videolaryngoscopy (e.g., Airtraq) as the first‑line device for emergency intubation; it reduces intubation‑failure rates from ≈ 28 % to ≈ 3 % compared with a conventional Macintosh blade. 3, 4
Succinylcholine use – Succinylcholine may be administered safely for rapid‑sequence induction within the first 48 hours after spinal cord injury; after 48 hours it should be avoided because denervated muscle is prone to hyperkalaemia. 3, 4, 5
Fiberoptic intubation for anticipated difficulty – In cooperative patients where difficult mask ventilation or limited mouth opening (< 2.5 cm) is expected, perform awake fiberoptic intubation with spontaneous ventilation. 3, 4

Direct admission to a Level 1 trauma centre – Immediate transfer to a Level 1 trauma centre is associated with lower morbidity and mortality, earlier definitive surgical intervention, shorter intensive‑care stays, and improved neurological outcomes. 1, 2

Early tracheostomy – For injuries involving the upper cervical spine (C2–C5), consider performing a tracheostomy within 7 days to facilitate faster weaning from mechanical ventilation. 3, 4, 5
Respiratory care bundle – Apply an abdominal containment belt, provide active physiotherapy with mechanically‑assisted insufflation/exsufflation, and deliver aerosol therapy using β₂‑agonists and anticholinergics to optimise pulmonary function. 3, 4, 5
Pressure‑ulcer prevention – Conduct visual and tactile skin assessments at least once daily, reposition the patient every 2–4 hours, and use high‑tech support surfaces (air‑loss or dynamic mattresses). Pressure‑ulcer prevalence can reach ≈ 26 % in this population, most commonly affecting the sacrum, heels, ischium, and occiput. 6
Urinary‑catheter management – Remove indwelling urinary catheters as soon as the patient is medically stable and initiate intermittent catheterization to lower the risk of urinary‑tract infection, stone formation, and to improve continence outcomes. 6