Author: Sammy Reed Source: Neuroprotection & Spinal Precautions 2024.pptx (55 slides) Learning Level: Intermediate to Advanced
Learning Objectives
- Understand what neuroprotection is and why it is important to be aware of as a physiotherapist
- Understand what spinal precautions are and why they are important to follow
- Practically be able to apply neuroprotection and spinal precautions
Part 1: Neuroprotection
1.1 What Is Neuroprotection?
Medical management strategies that:
- Limit secondary injury: oedema, ischaemia, inflammation, hypoxia, tissue loss
- Prevent brain damage and herniation (coning)
- Decrease the brain’s metabolic demand and thus oxygen consumption
- Maintain homeostasis
1.2 When Might a Patient Be on Neuroprotection?
Post:
- Severe traumatic brain injury (TBI)
- Post cardiac arrest
- Any hypoxic event or cause of neurological insult
Key facts:
- TBI is one of the top causes of morbidity and mortality in paediatrics in the UK
- Head injury is the most common cause of death or disability in 1-40 year olds in the UK
- 1.4 million ED visits for head injury each year; one-third to one-half are under 15 years old
Part 2: Neuroprotection Principles
2.1 Cerebral Perfusion Pressure (CPP)
CPP is the pressure gradient that drives cerebral blood flow.
CPP = MAP - ICP
- MAP = Mean Arterial Pressure (pressure pushing blood into the brain)
- ICP = Intracranial Pressure (pressure pushing blood out of the brain)
Clinical reasoning:
- The cardiovascular system (CVS) needs to overcome the ICP to maintain adequate blood flow
- In a brain injury, pressure increases in the brain due to oedema/bleeding, which increases ICP
- If ICP rises and CPP target is not met, the brain suffers from lack of blood flow leading to ischaemia and tissue death
- Therefore there are two options: increase MAP or reduce ICP
2.2 Mean Arterial Pressure (MAP)
Goal: Drive the MAP high to help CPP.
| Condition | Effect on CPP | Consequence |
|---|---|---|
| Hypotensive | Reduced CPP | Brain ischaemia |
| Hypertensive | Increased CPP | Cerebral oedema |
Management:
- Require a stable BP, age-appropriate
- Medical use of fluids +/- inotropes to achieve this
2.3 Intracranial Pressure (ICP)
The cranium is a closed system comprised of:
| Component | Proportion |
|---|---|
| Brain mass | 80% |
| Blood | 10% |
| CSF | 10% |
These components are tightly packed so will have an element of pressure. If any one component increases in size then ICP will increase. If any component decreases in size then ICP will reduce. CSF protects the brain.
Pathophysiology of raised ICP:
Cerebral oedema (usually 24-72 hours post-injury) causes:
- Increased brain mass
- CSF displaced into the spinal canal
- If displacement is not adequate, blood volume in the cranium decreases secondary to increased ICP
- If this is not sufficient, brain mass will be forced out — herniation/coning
ICP Monitoring:
- ICP bolt will be in situ
- Value is displayed on the monitor (alongside HR, SpO2)
2.4 Signs of Raised ICP in an Intubated and Ventilated Patient
- Pupil dilation
- Cardiovascular instability
- Abnormal posturing
- Vomiting
2.5 Target Values
Always check the medical notes for patient-specific targets!
| Parameter | Target |
|---|---|
| ICP | < 20 mmHg (via ICP bolt) |
| CPP — Infants (< 6 years) | 40 mmHg |
| CPP — Children (> 6 years) | 50 mmHg |
| MAP | As per age |
2.6 ICP Reduction Strategies
MDT Strategies
- 30-degree bed tilt (straight bed only until spine is cleared)
- Head in midline to aid venous drainage from head
Midline positioning prevents obstruction of arteries and veins in the neck.
Medical Strategies
| Strategy | Mechanism / Notes |
|---|---|
| 3% NaCl fluid | Raises sodium, draws water out of neurons via osmosis, reduces oedema and brain mass, reduces ICP |
| Decompressive craniectomy | Skull is removed surgically but not immediately replaced; patient needs a helmet for rehabilitation |
| Craniotomy | Skull removed to convert cranium into an open system to reduce pressure; bone flap replaced at end of surgery |
2.7 Adequate Oxygenation
- Need to maintain adequate oxygen delivery to the brain by maintaining CPP, avoiding ischaemia, and decreasing the brain’s metabolic demand
- Hypoxia leads to ischaemia and tissue death
- Hypoxia can also cause cerebral vasodilation leading to increased blood volume, increased oedema, and increased ICP
NOTE: Hyperventilation can cause hypoxia.
2.8 Maintain Normal CO2
CO2 causes vasodilation. The body’s response: if CO2 increases, the body recognises it is working harder, causing vasodilation of blood vessels to meet the body’s demand.
| CO2 Level | Effect | Consequence |
|---|---|---|
| High CO2 | Vasodilation | Higher ICP (more blood brought to the area) |
| Low CO2 | Vasoconstriction | Lower ICP BUT reduced blood flow leading to increased risk of hypoxia and ischaemia |
A low CO2 will cause vasoconstriction, reducing blood flow and decreasing ICP. However, less blood means less oxygen, which means ischaemia. Also consider potential barotrauma if having to increase ventilation to keep CO2 down. A balance is therefore needed.
Target Values:
| Parameter | Target |
|---|---|
| PaO2 | > 8 kPa |
| PaCO2 | 4.5 - 5.2 kPa |
| SpO2 | Continuous monitoring |
| EtCO2 | Continuous monitoring, should match ABG |
Always check the medical notes for patient-specific targets!
2.9 Adequate Sedation and Paralysis
Goal: Reduce the body’s metabolic demand to reduce oxygen consumption.
Consider:
- Shivering
- Seizures
- Dystonia
- Asynchronisation with ventilator
- Analgesia requirements
Clinical reasoning:
- Not too high: will cause side effects e.g. withdrawal, delirium
- Not too low: will increase body’s metabolic demand and patient will fight the ventilator
- Appropriate sedation reduces oxygen requirement, reduces CO2, and therefore reduces ICP
2.10 Temperature Regulation
| Target | Action if Abnormal |
|---|---|
| 36-37 degrees Celsius (optimal) | Too high: cool with wet towels and cooling mat |
| Too low: warm with a bair hugger |
2.11 Seizure Activity
- Consider phenytoin as prophylaxis to prevent secondary hypoxic event
- Patient may have a CFAM (cerebral function analysing monitor) on
- Patient may have an EEG
2.12 Nursing Care
- TEDS for DVT/PE prevention
- Consider flowtrons +/- blood thinner if > 12 years old
- Pressure ulcer management
- Prophylactic laxatives if sedated for > 48 hours
Part 3: Neuroprotection and Physiotherapy
3.1 Why Is Chest Physio Needed?
- Head injury patients tend to aspirate at the scene, which can cause lung contusions
- The chest will become more productive likely after 48 hours
- Therefore chest assessment and physiotherapy is important
3.2 Before Starting Physiotherapy
Checklist before treating a neuroprotection patient:
- Liaise with the medical team (Consultant if possible)
- Weigh up the risk vs benefit of physiotherapy
- Know your parameters and target values
- Obtain a good nursing/medical/physio handover
- Ask about sedation bolus
3.3 Physiotherapy and ICP
- ICP may spike with interventions e.g. suction
- These spikes should be short-lived (i.e. increase with suction and then immediately decrease)
- Avoid high or sustained spikes — if this happens:
- Know your rescue plan
- Stop treatment
- Liaise with the medical team
3.4 Physiotherapy and Manual Hyperinflation (MHI)
| Effect | Mechanism |
|---|---|
| MHI increases intrathoracic volumes | Reduces venous return from head |
| Reduced venous return | Increases ICP |
| Hyperventilation blows off CO2 | Causes cerebral vasoconstriction, reducing ICP |
You MUST keep the EtCO2 monitor in the circuit whilst bagging!
3.5 Physiotherapy and Positioning
- Bed at 30-degree tilt
- Ensure patient’s head in midline (will need rolls to support)
- Patient can be rolled if the above conditions are maintained
- If the patient is on spinal precautions they MUST be log-rolled
3.6 Additional Physiotherapy Considerations
CRITICAL: Check the CT head report for base of skull fractures — NO nasopharyngeal (NP) suction, NP airway, or NGT if present.
- Trauma patients can have significant facial fractures — exercise care with suctioning and handling
Part 4: Spinal Cord Injuries and Precautions
4.1 Paediatric Spinal Cord Injuries (SCI) — Overview
- Paediatric SCIs are uncommon, making up only 2-5% of all SCIs
- Cervical spine injuries are most common (> 80%)
- 14-year-olds resemble adult mechanisms of injury (MOI)
- Management principles are still largely controversial
- Children have large heads and flexible spines
- Therefore ligamentous, traction, or dislocation injuries are more common than bony injuries
4.2 Symptoms of Paediatric SCI
- Pain / tenderness
- Restricted neck movements
- Neurological symptoms
- Chin trauma
- Tooth / jaw fractures
- May be asymptomatic
4.3 Diagnosis
Imaging Modalities
| Modality | Notes |
|---|---|
| 3-view cervical spine X-rays | Should not be routinely completed due to radiation effects; cannot always obtain if polytrauma patient |
| CT scan | More effective in older children where bony fracture injury is more common; usually performed alongside CT head. Role in < 10 years may be less important due to ligamentous disruption without fracture |
| MRI scan | Should be completed if concerns (see below) |
Indications for MRI:
- Unresponsive child with clear X-ray and suspicious MOI
- Neurological symptoms
- Unable to clear cervical spine
Cervical Spine Clearance by Age
| Age | Clearance Method |
|---|---|
| > 8 years old | Can clear the C-spine with X-ray or CT scan (radiologically) |
| < 8 years old | Must clear the C-spine radiologically AND clinically |
4.4 Clinical Clearance
Gold Standard:
- Lift sedation and paralysis
- Advise the patient to remain still until the medical team completes assessment (e.g. ROM, pain, GCS, movement patterns)
In reality this rarely happens, so the practical approach is:
Practical approach: Is the patient moving all four limbs appropriately?
ONCE THE C-SPINE IS CLEARED THIS MUST BE DOCUMENTED IN THE CRS NOTES BY THE MEDICAL TEAM (usually PCCU team)
If inappropriate neurology is found (e.g. lesion on CT, no movement, one-sided movements, pain):
- The patient is placed back to sleep
- Will proceed to MRI scan
4.5 Management of Suspected or Confirmed SCI
Immediate management:
- Immediate immobilisation keeping head and spine in neutral
- If the patient is paralysed: use blocks/towels for stabilisation
- If only sedated or awake: MUST be in a hard collar
Note: Hard collars can restrict blood flow to the brain and therefore increase ICP, so blocks are preferable when the patient is paralysed.
Ongoing management — MUST be:
- Log-rolled
- On a flat mattress (not air)
- Have a physiotherapy assessment in the first 24 hours
- If manual chest techniques are chosen, these must be completed with counterpressures
4.6 Counterpressures for Stabilisation
Counterpressures counteract the force of manual techniques to ensure the spine remains in alignment.
Counterpressures MUST be applied for:
- Percussions
- Vibrations
Vibrations must be BILATERAL and only in SUPINE so equal force is administered through the spine.
Counterpressure Levels by Lesion
| Lesion Level | Counterpressure Required |
|---|---|
| Lesion > T4 | Shoulder AND cervical spine stabilisation |
| Lesion T4-T12 | Shoulder stabilisation |
These apply to all manual techniques, coughing, and suctioning. Nursing staff need to be aware to apply these as the patient wakes.
Practical Application
| Role | Action |
|---|---|
| Cervical spine stabilisation | Ensure head remains in neutral position |
| Shoulder stabilisation | Ensure shoulders are pushed downwards, backwards, and into the bed |
You will need multiple people to ensure an effective treatment! E.g. 1 person for C-spine stabilisation, 1 for shoulder stabilisation, 1 for manual techniques, 1 for bagging/suction.
4.7 Respiratory Innervation and SCI
Key dermatome levels for respiratory function:
| Level | Innervation |
|---|---|
| C3, C4, C5 | Diaphragm |
| C1 - T1 | Accessory muscles |
| T1 - T11 | Intercostals |
| T6 - L1 | Abdominals |
Goal: Detect early deterioration in respiratory function so that management can be guided appropriately.
4.8 Spirometry
FVC (Forced Vital Capacity):
- The greatest total amount of air that can be forcefully breathed out after maximal inhalation
- No reference values for paediatrics; concern if < 1L
- Liaise with lung function team or adults to borrow the machine
- If old enough, compare with adult values
4.9 Peak Cough Flow (PCF)
| PCF Value | Action |
|---|---|
| < 270 L/min | Airway clearance techniques (ACT) should be started |
| < 160 L/min | Cough augmentation should be started |
4.10 Spirometry and PCF — Practical Considerations
- Cannot always measure these (e.g. age of patient)
- Ensure as optimal a technique as possible
- Measure x3 to obtain an average
- Record all measurements on CRS
- Comment on technique (e.g. poor seal, poor compliance)
- Liaise with nursing and medical teams
4.11 ROM Limitations for Unstable/Uncleared Spine
| Lesion Level | ROM Limitation |
|---|---|
| > T4 | Shoulder flexion to 90 degrees only |
| T5 - T7 | Limit hip flexion to 90 degrees |
| < T8 | Limit hip flexion to 30 degrees |
Note: Frog legs (full external rotation of hips with knee flexion) can be completed for injuries below T8 to maintain range.
- Refer to separate presentation on ASIA Charting
- If fixation occurs, follow post-operative instructions
- By this point the patient will have likely been transferred to Stanmore
4.12 Complications of SCI
| Complication | Description |
|---|---|
| Neurogenic shock | Associated with disruption of autonomic pathways within the spinal cord e.g. bradycardias, hypotension. Duration variable but approximately 4 weeks |
| Spinal shock | Early stages of neurogenic shock; typically characterised by complete loss of muscle tone and absent reflexes |
| Autonomic dysreflexia | Medical emergency. Sudden onset of excessively high BP caused by an irritant below level of injury (e.g. bowels) |
| Pressure sores | Largest cause of death in SCI patients |
References
Cited Guidelines and Resources
- NICE Guidelines (2019, updated 2023). Head injury: assessment and early management. https://www.nice.org.uk/guidance/cg176/chapter/Introduction
- Updated (2026): NICE CG176 has been superseded by NICE NG232 (“Head injury: assessment and early management”), published 18 May 2023. The current guideline should be cited as: NICE (2023). Head injury: assessment and early management. NICE guideline [NG232]. https://www.nice.org.uk/guidance/ng232. NG232 introduces new guidance on anticoagulant-related head injury, post-head-injury hypopituitarism (including paediatric presentations), updated CT scanning criteria, age-appropriate trauma centre resources, and tranexamic acid administration within 2 hours of injury.
- NICE Guidelines (2016, updated 2021). Spinal injury: assessment and initial management.
- Severe traumatic brain injury and neuroprotection guideline for children (Barts Health)
- Cervical spine assessment, clearance and management within the paediatric critical care unit (Barts Health)
- Neuroprotective measures in children with traumatic brain injury - PMC (nih.gov)
- Approaches to neuroprotection in pediatric neurocritical care - PMC (nih.gov)
- Protecting #1 — Neuroprotective strategies for Severe Traumatic Brain Injury — PaediatricFOAM
Academic References
- Agrawal, S. and Branco, R.G. (2016). Neuroprotective measures in children with traumatic brain injury. World Journal of Critical Care Medicine, 5(1), pp. 36-46.
- Bell, M. and Kochanek, P. (2013). Pediatric Traumatic Brain Injury in 2012. Journal of Critical Care Clinics, 29(2), pp. 223-238.
- Chatwin, M. et al. (2018). Airway clearance techniques in neuromuscular disorders: a state of the art review. Journal of Respiratory Medicine, 136, pp. 98-110.
- Gopinathan, N. et al. (2018). Cervical spine evaluation in pediatric trauma: a review and update of current concepts. Indian Journal of Orthopaedics, 52(5), pp. 489-500.
- Hardcastle, N. et al. (2014). Update on the 2012 guidelines for the management of paediatric traumatic brain injury — information for the anesthesiologist. Paediatric Anaesthesia, 24(7), pp. 703-710.
- Herman, M. et al. (2019). Pediatric Cervical Spine Clearance. The Orthopaedic Forum, 101, pp. 1-9.
- Kochanek, P. et al. (2019). Management of paediatric severe traumatic brain injury: 2019 consensus and guidelines based on algorithm for first and second tier therapies. Pediatric Critical Care Medicine.
- Ness-Cochinwala, M. and Dwarakanathan, B. (2019). Protecting #1 — neuroprotective strategies for traumatic brain injury. Paediatric FOAMed.
- A review on the etiology and management of pediatric traumatic spinal cord injuries (2019).