Case-Based Modules > Case 18 > Conclusion

Great job! This patient had a significant thoracic traumatic spinal cord injury. We had some special considerations for his acute SCI management.

Pearl 1: Hypotension after trauma is hemorrhagic shock until proven otherwise.

This can be assessed with imaging, specifically point-of-care ultrasound (with eFAST) and cross-sectional imaging. It's important for us not to jump straight to assuming that neurogenic shock is the etiology for these tSCI patients.


Pearl 2: Surgical decompression for tSCI should occur early, i.e. within 24 hours of injury.

This is recommended by the most recent 2024 Clinical Practice Guideline for the Management of Patients with Acute SCI, and reflects a systematic review of a large population of patients across multiple prospective multicenter studies. Early intervention should generally be offered in order to improve neurologic function. Subsequent ICU care is also influenced by whether or not early stabilization/decompression are performed.


Pearl 3: MAP augmentation for tSCI has a poor quality of evidence, and its systemic implications (e.g. impact on cardiac function) must be considered.

There haven't been any notable prospective studies on the subject. The studies that inspired the original guidelines were observational single-arm studies that also didn't actually target a specific MAP goal as an intervention; time spent in each MAP tier was retrospectively calculated. The most recent 2020 systematic review on MAP augmentation for tSCI concluded that there's insufficient evidence for making recommendations supporting this intervention. So, if this is something that is going to be pursued, it's paramount to consider the systemic ramifications, such as the impact on the patient's perfusion as a result of any impact on cardiac function.

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