Feb 15, 1986 - JoHN RUSSELL. Duke of Cornwall Spinal Treatment Centre,. Odstock Hospital,. Salisbury SP2 8PJ. AREw SWAIN. Accident and Emergency ...
BRITISH MEDICAL JOURNAL
VOLUME 292
sibility of future spinal deformity, which can be the consequence of conservative management. Finally, it is our experience that after the early postoperative period the pain associated with the fracture is less with internally fixed spines than in those conservatively managed. No matter what hospital management is finally embarked on, the important aspect of the care of a potentially unstable spinal injury is, firstly, to recognise that this possibility exists and, secondly, to transport the patient without risking displacement of the spine by using the techniques described in the article. J A FAIRCLOUGH D H R JENKINS Cardiff Royal Infirmary, Cardiff CF2 I SZ
***The authors reply below.-ED, BMJ.
SIR,-The series of articles relates to the management of spinal cord injuries. We did not feel it was in our terms of reference to discuss in detail the problems of patients with spinal column injury and no neurological deficit. However, if the first six articles are taken as a whole the points raised by Mr Fairclough and Mr Jenkins are largely covered. A baseline neurological examination, however brief, should always be performed when the patient is first seen after injury. Without this we fail to see how the object of management-to "stop any further damage to the spinal cord by the displacement of the spine"-can be properly assessed. Indeed, one of the criteria for operative treatment may be neurological deterioration. We cannot accept that transporting patients in the position they have been found is necessarily without risk (see our letter of 11 January, p 139). In discussing the treatment of thoracolumbar injuries we assumed that the patient had neurological damage, and in these circumstances our suggested management is similar to that practised in many spinal injuries units. We certainly do not advocate postural reduction ofthoracic and lumbar spine dislocations in patients with incomplete or no neurological deficit and agree that internal fixation by Harrington distraction rods or other devices is indicated to minimise or prevent damage to the spinal cord and cauda equina. We feel that a distinction should be drawn between the pain arising from the spinal cord injury and that due to skeletal damage. In the former group we are not convinced that there is any difference in the degree, quality, or duration of pain in those patients who have internal fixation when compared with those treated conservatively.
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depolarising effect of suxamethonium. This does not occur with normally innervated myoneural junctions but appears to coincide with the development of membrane instability, as shown by electromyography, which begins about 21 days after denervation of the muscle.2 The case reports quoted cite five patients who developed hyperkalaemia after the use of suxamethonium from 23 to 60 days after cord transection. I 2 Avoiding hypoxia is as essential in the patient with a spinal cord injury as in any other, and a potentially hypoxic patient should be intubated as rapidly as possible to maintain tissue oxygenation. This can best be managed with the use of suxamethonium, which gives a profound block ofrapid onset yet of short duration. Within the past four years we have seen three patients with cervical cord injury who required intubation for the treatment of severe hypoxia refractory to inspired oxygen therapy. One of these was vomiting and, as we saw all within 72 hours of injury, we used suxamethonium to facilitate intubation. There were no untoward effects. The use of suxamethonium for intubating the patient with spinal cord injury is quite safe if used within the first 72 hours after injury by those experienced in its use. We do not urge its use in patients with a severely compromised airway due to coexisting facial injury, who must be treated differently. PATRICK K PLUNKETT R G WILKINS J DENNIS EDwARDS Intensive Care Unit, Withington Hospital, Manchester M20 8LR 1 Stone WA, Beach TTP, Hamelberg W. Succinylcholinedanger in the spinal cord injured patient. Anaesthesiolorj 1970;32: 168-9. 2 Brooke MM, Donovan WH, Stolov WC. Paraplegia: succinylcholine-induced hyperkalaemia and cardiac arrest. Arch Pkys Med Rehabil 1978;59:306-9. 3 Doolan LA, O'Brien JF. Safe intubation in cervical spine injury. Anaesth Inensive Care 1985;13:319-24.
SIR,-In their otherwise excellent series on the management of spinal cord injuries Mr David Grundy and colleagues make one serious error about endotracheal intubation. They state that suxamethonium (succinylcholine) should be avoided in all patients with spinal cord injuries because of the associated hyperkalaemia resulting from massive potassium efflux from denervated muscle. This situation does not apply during the acute phase of spinal cord trauma. It is perfectly safe for this agent to be used to facilitate intubation for at least one week after trauma. '-5 To deny the acutely injured patient the benefits this drug increases the risk from aspiration of DAVID GRUNDY of contents and of prolonging the hypoxic gastric JoHN RUSSELL period before intubation. Duke of Cornwall Spinal Treatment Centre, During laryngoscopy, however, the anaesthetist Odstock Hospital, Salisbury SP2 8PJ AREw SWAIN must be aware of the possibility of an unstable cervical fracture and may have to resort to alternAccident and Emergency Department, ative techniques of securing the airway.
Charing Cross Hospital, London W6 8RF
Early management of spinal cord injury SIR,-We write to express our concern about the advice given recently by Mr David Grundy and colleagues on the intubation of those suffering from spinal injuries (4 January, p 44). We accept that the use of suxamethonium (succinylcholine) for intubating those with longstanding spinal transection may well precipitate fatal hyperkalaemia.'l2 We would, however, suggest that in the first 48-72 hours after injury there is no risk of this occurring.3 The hyperkalaemia appears to be due to sensitivity of the entire muscle membrane to the
JOHN PENNANT Department of Anaesthesia, King's College Hospital, London SES 8RX 1 Thompson MA. Muscle relaxant drugs. BrJ Hosp Med 1980;23: 153-78. 2 Vaughan RS, Lunn JN. Potassium and the anaesthetist. Anaes-
thesia 1973;28:118-131.
3 Ellis FR. Neuromuscular disease and anaesthesia. Brj Anaesth
1974;46:603-12.
4 Stone WS, Beach TP, Hamelberg W. Succinyicholine-danger in the spinal cord injured patient. Anaesthesiolog 1970;32:
168-9. 5 Stone WA, Beach TP, Hamelberg W. Succinylcholine-induced hyperkalaemia in dogs with transected sciatic nerves or spinal cords. Anaesthesi010gy 1970;32:515-20.
**$The authors' reply follows.-ED, BMJ.
SIR,-In a general article we felt that it was particularly important to give information that was above all safe for the clinician who may only occasionally have to deal with an acute spinal cord injury. A district general hospital will see perhaps three or four such injuries a year. Although we agree with Mr Plunkett and his colleagues that suxamethonium can be used in the first 48-72 hours after injury, the safe period for its use is by no means as accurately defined as Dr Pennant implies. The advice of Fraser and Edmonds-Seal is "to avoid suxamethonium from 3 days to 9 months post injury,"' a view confirmed by others.2 In the state of current knowledge, if muscle relaxation is required to facilitate intubation after the first 48-72 hours a non-depolarising muscle relaxant such as pancuronium is indicated to avoid the risk of hyperkalaemic cardiac arrest.2 DAVID GRUNDY JOHN RUSSELL Duke of Cornwall Spinal Treatment Centre, Odstock Hospital, Salisbury SP2 8PJ ANDREW SWAIN Accident and Emergency Department, Charing Cross Hospital, London W6 8RF I Fraser A, Edmonds-Seal J. Spinal cord injuries-a review of the problemsfacing theanaesthetist. Anaesthesia 1982;37:1084-98. 2 Doolan LA, O'Brien JF. Safe intubation in cervical spine injury. Anaesth Intensive Care 1985;13:319-24.
Fatal airway obstruction in infectious mononucleosis SIR,-We have recently managed a case similar to that described in the Lesson of the Week by Dr P Carrington and Dr J I Hall (18 January, p 195), although happily ours was a non-fatal obstruction. A 20 year old man was admitted to this hospital with a three day history of difficulty in swallowing and breathing associated with general malaise and a sore throat. He had massive tonsillar enlargement and cervical adenopathy. Full blood count showed lymphocytic leucocytosis and the Monospot test was positive, confirming the clinical diagnosis of infectious mononucleosis. He was managed initially with intravenous fluids and humidified air in an isolation ward. His condition deteriorated on the third day after admission with worsening respiratory obstruction, and the opinion of an ear, nose, and throat surgeon was sought. It was thought that he would benefit from acute tonsillectomy and an x ray picture of the airways was taken to determine the degree of obstruction at glottic level. His respiratory obstruction rapidly worsened and he became cyanosed in extreme respiratory distress, sitting up in bed with a pronounced tracheal tug and intercostal indrawing, drooling like a child with acute epiglottitis. Transfer to theatre was a frightening and dangerous experience in the freezing November air, and his respiratory obstruction worsened. He suffered complete respiratory arrest in the anaesthetic room, became deepty cyanosed, and began convulsing. He was laid down and after two attempts at puncturing the cricothyroid membrane with a 12G Medicut needle, through which he could not be ventilated, an emergency midline tracheostomy was performed by the ENT surgeon. This undoubtedly saved his life. After the airway was established he roused rapidly and was then anaesthetised for formalisation of the tracheostomy. He made a full recovery, complicated only by an area of aspiration pneumonia that responded well to antibiotics. In view of this experience we would add three recommendations to those of Dr Garrington and DrHall.
