Early Acute Management in Adults with Spinal Cord Injury - 51

CLINICAL PRACTICE GUIDELINE

Social workers, psychologists, psychiatrists, or other mental health professionals on the team should evaluate the patient for depression and feelings of hopelessness and make recommendations for intervention (Kishi et al., 2001). When evaluating a request for withdrawal of life support, major depression needs to be ruled out as this condition may impact the capacity for making decisions. It may be necessary to treat major depression first to see if the wish to die resolves (Leeman, 1999). If, after pain, depression, and other acute or chronic conditions have been adequately treated the patient persists in seeking withdrawal of life support, the patient’s ability to make an informed choice must be reassessed. The decision-making capacity involves the ability to (1) understand information about treatment options and their consequences, (2) determine how the information applies in the current situation and weigh the risks and consequences of each treatment or nontreatment, and (3) make a choice and communicate that choice (Bramstedt and Arroliga, 2004; Gross and Kazmer, 2006; Scanlon, 2003). In patients who have suspected concomitant brain injury or are receiving mechanical ventilation, it may be difficult if not impossible to determine the patient’s decisionmaking capacity (Scanlon, 2003). Any request for discontinuation of life-sustaining treatment in a patient with decision-making capacity must be given serious consideration (Beauchamp and Childress, 2001). However, these discussions may pose ethical dilemmas for the staff. Healthcare providers may be reluctant to honor such a request early in the recovery period following SCI because multiple studies suggest good quality of life after even high tetraplegia. Also, the severity and irreversibility of the outcome being considered requires exceptional attention to informed consent considerations. If possible, action on the decision should be delayed to give the patient and family time to reconsider the request. In order to assure adequate informed consent for withdrawal of life support, efforts should be made to have patients undergo inpatient rehabilitation, have interactions with persons living in the community with similar injury level and go through a trial of living out of the hospital in order to determine for themselves what quality of life is possible for them. If the patient insists on withdrawal of life support without going through these steps, staff should seek the assistance of an ethics consultant or committee to help them decide whether to act on the request for treatment withdrawal (Bramstedt and Arroliga, 2004). If the patient’s choice is clear and unwavering, withdrawal of life-sustaining therapies may be justified ethically. If a patient’s request is honored, a mutually agreed-upon plan must be

established to provide not only for the physical comfort of the patient, but also for the emotional and spiritual needs of the patient, family members, and staff. Satisfactory resolution of this dilemma may require involvement of the family or friends, if desired by the patient.

Special Mechanisms of Injury
A small number of nonmechanical injury mechanisms may lead to spinal cord–related patterns of paralysis. Although SCI is most commonly seen following mechanical trauma, it can also be associated with other, less often seen, insults to the cord. 78. Screen for SCI in the patient with high-voltage electrical injury.
(Scientific evidence–II/IV; Grade of recommendation–B; Strength of panel opinion–5)

Rationale: Arevalo et al. (1999) reported 2 cases of injury to the spinal cord among 52 patients admitted with high-voltage electrical injury. The investigators noted that such injuries may occur with or without radiographic or MRI abnormality, leading to a delay in diagnosis. Cherington (1995) described the various types of lightning strikes—direct, side flash, stride (ground) current, and indoor exposure—and the various patterns of manifestation of the injury, including the possibility of SCI from a fall caused by the lightning strike. Ko et al. (2004) noted that features of electrical burn-related spinal cord injury may be transient or may present early or late, and may be progressive, beginning with paraplegia and progressing to tetraplegia. MRI may not be helpful. There is no evidence concerning specific optimal treatment methods. Deficits may improve or may be permanent. Cherington (1995) noted that most patients with SCI from electrical causes are left with a permanent disability. 79. Suspect spinal cord injury in any scuba or commercial diver presenting with neurologic symptoms. Consult with and consider urgent transfer to a hyperbaric unit.
(Scientific evidence–III/IV; Grade of recommendation–C; Strength of panel opinion–5)

Rationale: Decompression sickness should be strongly considered when divers experience pain or other neurologic symptoms after diving. Barratt and Van Meter (2004) reported that decompression sickness in scuba and commercial divers can present as spinal cord damage, requiring urgent transfer to a recompression chamber if

Early Acute Management in Adults with Spinal Cord Injury

Table of Contents for the Digital Edition of Early Acute Management in Adults with Spinal Cord Injury