Management of Spinal Shock

Immediate Prehospital Stabilization

The American College of Surgeons recommends early spinal immobilization to prevent onset or worsening of neurological deficit in any patient with suspected spinal cord injury 1, 2, 4, 5
The American Heart Association suggests applying manual in-line stabilization (MILS) immediately combined with a rigid cervical collar 1, 4, 5
Transport on a rigid backboard with vacuum mattress is recommended 3
Maintaining head-neck-chest stabilization throughout transport is crucial 1

The American Society of Anesthesiologists recommends removing only the anterior portion of the cervical collar during intubation to improve mouth opening and glottic exposure while maintaining posterior stabilization 1, 3, 4, 5
Performing rapid sequence induction with direct laryngoscopy is suggested 1, 4, 5
Using a gum elastic bougie to increase first-attempt success rate is recommended 1, 3, 4, 5
Maintaining cervical spine in neutral axis without Sellick maneuver is advised 1, 4
Succinylcholine can be safely used only within the first 48 hours after spinal cord injury; after 48 hours it risks life-threatening hyperkalemia due to denervation hypersensitivity 4

The European Society of Anaesthesiology recommends maintaining systolic blood pressure >110 mmHg before injury assessment to reduce mortality 1, 3
Targeting mean arterial pressure ≥70 mmHg during the first 7 days to limit worsening of neurological deficit is suggested 3
The French guidelines recommend targeting MAP ≥70 mmHg based on evidence showing reverse correlation between time spent with MAP <65-70 mmHg and neurological improvement 3

The American Thoracic Society recommends performing early tracheostomy within the first 7 days to accelerate ventilatory weaning and reduce ICU hospitalization times in high cervical injuries (C2-C5) 4, 5
Immediate intubation is mandatory for high cervical cord injuries 4

No evidence-based recommendations for pathomechanistically targeted therapies are available 4, 5

The National Pressure Injury Advisory Panel recommends implementing aggressive prevention from the acute phase with early mobilization once spine is stabilized 4, 5
Visual and tactile checks of all at-risk areas at least once daily are advised 4, 5
Repositioning every 2-4 hours is recommended 4, 5
The American Urological Association suggests intermittent urinary catheterization as soon as daily diuresis volume is adequate 4, 5
Self-intermittent urethral catheterization is the gold standard 4, 5

The American Pain Society recommends a multimodal analgesia approach combining non-opioid analgesics, antihyperalgesic drugs (ketamine), and opioids during acute management 4, 5
For neuropathic pain: oral gabapentinoids for more than 6 months are suggested 4, 5

The American Physical Therapy Association recommends beginning rehabilitation immediately after stabilization to maximize neurological recovery 4, 5
Physical exercise to enhance central nervous system regeneration through neurotrophic factors is advised 4, 5
Stretching techniques for at least 20 minutes per zone are recommended 4, 5

Delaying immobilization in suspected spinal cord injury leads to worsening neurological outcomes 4, 5
Using succinylcholine after 48 hours post-injury risks life-threatening hyperkalemia 4
Inadequate blood pressure support below target thresholds increases secondary injury 3
Neglecting early rehabilitation results in preventable complications and poorer functional outcomes 4, 5