Early treatment of spinal injury includes on-site rescue, emergency treatment and early specialist treatment. Whether the early treatment measures are correct or not directly affects the life safety of patients and the recovery of spinal cord function.
Early evaluation of patients with various injuries should start from the injury site. Patients who are unconscious or unconscious usually cannot complain about pain. Patients with craniocerebral injury, severe laceration of face or scalp and multiple injuries should be suspected of spinal cord injury, and further damage to nerve tissue should be reduced through orderly rescue and transportation.
Follow the principle of ABC rescue, that is, keep airway unobstructed, restore ventilation and maintain stable blood circulation. It is necessary to distinguish between nervous shock and hypotension caused by hypovolemic shock caused by blood loss. Neurogenic shock refers to the interruption of sympathetic output signal (T 1-L2) and the disorder of vagus nerve activity after cervical or upper thoracic spinal cord injury, which leads to hypotension and bradycardia. Hypotension complicated with tachycardia is mostly due to insufficient blood volume. Whatever the reason, hypotension must be corrected as soon as possible to avoid further spinal cord ischemia. Actively transfuse blood to replenish blood volume, and perform emergency surgery on life-threatening bleeding when necessary. When there is still hypotension with bradycardia after volume expansion, pressor and sympathomimetic drugs should be used.
2. Drug therapy
When patients with spinal cord injury are satisfied, the main treatment task is to prevent further injury of the injured spinal cord and protect normal spinal cord tissue. To do this, restoring the spinal sequence and stabilizing the spine are the key links. In terms of treatment, drug therapy may be the fastest way to reduce the degree of spinal cord injury.
(1) The corticosteroid methylprednisolone (MP) is the only drug approved by FDA to treat spinal cord injury (SCI). It is recommended to give the medicine within 8 hours. Methylprednisolone is recommended as a treatment option rather than a standard or recommended treatment. In addition, the research results of a few scholars show that MP is ineffective in the treatment of acute spinal cord injury and can cause serious complications.
MP is not effective for patients with spinal cord rupture, and mild spinal cord injury can recover without MP. Complete spinal cord injury and severe incomplete spinal cord injury are the goals of MP treatment. However, it should be noted that high-dose MP may cause pulmonary and gastrointestinal complications, and the elderly are prone to respiratory complications and infections. In a word, we should pay attention to the prevention of complications during MP treatment. Dexamethasone can also be used and stopped for 5 days to avoid complications caused by long-term high-dose use of hormones.
(2) Ganglioside is a kind of sialic acid with sugar ester, which widely exists in mammalian cell membrane and has a high concentration in the outer cell membrane of the central nervous system, especially in the synaptic region. Patients with spinal cord injury were treated with GM- 1 and followed up after 1 year, and the curative effect was better than that of the control group. Although their real function is not clear, experimental evidence shows that they can promote axon regeneration and germination mediated by nerve exogenesis and synaptic transmission, reduce nerve degeneration after injury, and promote nerve development and shaping. It is considered that GM- 1 is usually administered 48 hours after injury, lasting for 26 days on average, and methylprednisolone has the best effect within 8 hours after injury. Some scholars believe that GM- 1 can not stop the process of secondary injury. At present, ganglioside has been used in the treatment of spinal cord injury, but its mechanism of action is still unclear, and the research is still going on, so its wide clinical application is also limited.
(3) Scopolamine can regulate microcirculation, improve microcirculation disturbance caused by capillary rupture, bleeding and blockage after spinal cord injury, reduce spinal cord ischemia and necrosis, and is beneficial to the recovery of spinal cord function. The sooner you use it, the better. It should be used the day after the injury.
(4) Mecobalamin, a neurotrophic drug, is coenzyme B 12, and its central cobalt atom is bound with active methyl, which is easy to be absorbed, so that the concentration of vitamin B 12 in serum is increased and further transported to the organelles of nerve tissue. Its main pharmacological effects are: enhancing the synthesis of nucleic acid and protein in nerve cells; Promoting the synthesis of lecithin, the main component of myelin sheath, is beneficial to the repair of damaged nerve fibers.
(5) Mannitol is commonly used to relieve spinal edema. Patients with cardiac insufficiency, coronary heart disease and renal insufficiency may suffer from fatal diseases if they drip too fast. For the elderly or potential renal insufficiency, we should closely observe the changes of urine volume, urine color and urine routine. If the daily urine output is less than 1500ml, it should be used with caution. Water and electrolyte should be properly supplemented to prevent dehydration and insufficient blood volume, and water, electrolyte and renal function should be monitored.
3. Treatment of complications
The death of patients with spinal cord injury can be divided into early and late stages. Early death occurred within 1 ~ 2 weeks after injury, mostly in cervical spinal cord injury. The cause of death is persistent high fever, low temperature, respiratory failure or heart failure. Late death occurs several months or years later, which is mostly caused by pressure sore, urinary tract infection, respiratory tract infection and malnutrition. Late death may occur in cervical spinal cord and thoracolumbar spinal cord injuries. There is no certain boundary between early death and late death, and most patients with spinal cord injury die of complications. However, if prevention and good rehabilitation can be given, patients can not only survive for a long time, but also sit, stand, walk and even take part in work, which shows the importance of prevention and treatment of complications.
(1) Dysuria after spinal cord injury and its treatment. The main purpose of treating dysuria is to improve urination function, reduce the inconvenience in daily life, make patients urinate regularly, have no catheter, have little or no residual urine, have urinary incontinence, prevent urinary system infection and restore normal bladder function.
1) Continuous drainage and bladder exercise in the early stage of spinal cord injury, bladder detrusor weakness, urine can not be discharged due to internal sphincter, indwelling catheter drainage is the best treatment. Generally, rubber catheter or silicone rubber catheter with smaller diameter should be retained, and bladder emptying should be maintained at first to facilitate the recovery of detrusor function. 1 ~ 2 weeks later, the tube was opened every four hours and kept open after falling asleep at night. When the catheter is opened, train the patient to massage the bladder with both hands and squeeze out urine as much as possible.
2) Prevention of urinary tract infections and stones Due to bladder paralysis and urinary retention, it is necessary to use indwelling catheters for a long time, but bladder contracture, urinary tract infections and stones are prone to occur. Over time, infection will be difficult to control, which will seriously damage the kidney and lead to renal failure. ① Raising the bedside is beneficial to the urine drainage from the kidney to the bladder through the ureter, reducing the chance that pyelonephritis, hydronephrosis and pyelonephritis will eventually damage the renal function. ② The daily water consumption of patients who drink more water should be kept above 2500m 1, so that they can urinate more and have the function of mechanical flushing. In summer, patients can be encouraged to eat more watermelons for the same reason. (3) Flush the bladder under strict aseptic operation, and use the catheter for a short time or intermittently to make urination smooth. Rinse the bladder with normal saline, 3% boric acid solution or 0. 1-0.05% nitrofuracilin solution twice a day. (4) after cleaning urethral orifice and indwelling catheter, secretions often accumulate at urethral orifice due to the stimulation of catheter, which is easy to breed bacteria and should be removed every day. ⑤ Replacing the catheter for too long can easily lead to infection and stone formation, so it should be replaced regularly. Ordinary rubber catheters are generally replaced every 1 ~ 2 weeks. If the plastic pipe with less irritation and smaller outer diameter and inner diameter of 1.5 ~ 2mm is used, it can be replaced every 2 ~ 3 weeks. Urine should be emptied as much as possible before changing the tube so that the urethra can rest for several hours after extubation. During this time, the patient can try to urinate. If urination is successful, intubation is not needed. Urine can overflow around the catheter on weekdays, indicating that the bladder has resumed urination function, which is an indication of extubation.
3) Drug treatment ① Urinary retention stimulates parasympathetic nerve to enhance detrusor strength, and opens internal sphincter to restore urination function. Inhibition of sympathetic nerve makes the internal sphincter not tense to facilitate urination, and adrenergic receptor inhibitors can be used. Use drugs to inhibit urethral and sphincter spasm. ② Urinary incontinence and bladder detrusor spasm: Atropine drugs can be used. Internal sphincter weakness: Ephedrine can be used in combination with ethinylestradiol. Relaxation of internal sphincter of bladder: the effect of western medicine is not good, so you can try Chinese medicine Suoquan Pill or Suoquan Decoction.
4) Surgical treatment According to the different conditions of patients, the following surgical methods can be selected: ① patients with dysuria due to exercise bladder after internal urethral sphincter incision, who still cannot urinate on their own for half a year after injury; Transurethral sphincterotomy for patients with upper motor dysuria, increased tension of internal sphincter of bladder and increased urination resistance, which can not be relieved for a long time. ② External urethral sphincterotomy can't be controlled because of long-term dysuria or urinary tract infection, and it is feasible to perform external urethral sphincterotomy when it is confirmed that the main resistance of dysuria comes from external urethral sphincter. (3) Ileal bladder replacement is feasible for patients with bladder contracture caused by long-term indwelling catheter or long-term chronic urinary tract infection, which can expand bladder muscle capacity, eradicate bladder infection and reduce urination times. ④ Suprapubic cystostomy is feasible due to long-term dysuria and indwelling catheter. The general condition of patients is poor, and nephrostomy is feasible for those with urinary tract obstruction complicated with hydronephrosis, pyelonephritis and renal failure. Ureterostomy is feasible if ileum cannot be used instead of bladder for bladder contracture for some reason.