Care of a patient with a spinal injury within the acute phase (G065)

When a patient is admitted with a suspected spinal injury the following care should be initiated:

1. Patients with a spinal injury should be nursed on specific spinal beds. These beds are located in University Hospital Crosshouse, Trauma Orthopeadic Unit 2B.
2. If all spinal beds are in use, and a hire bed is not available for immediate use, the patient can be nursed flat on a normal bed with very close nursing observation due to the increased risk of aspiration.
3. Two PAT slides, or one prolateral transfer board should be used to transfer a patient from an Accident and Emergency trolley. If it is an unstable cervical fracture, nursing staff should seek advice from medical staff to support the patient’s head and neck on transfer onto the spinal bed. If cervical injury, ensure that there are five to seven members of staff to transfer. If thoracic or lumbar, four members of staff are adequate.
4. Limb assessment will be used initially. If required, the patient’s conscious level will be assessed using the Glasgow Coma Scale. Frequency will be dependent on patient’s condition.
5. High thoracic and cervical injuries will have cardiac monitoring in place. Close observation of oxygen saturation levels, respiratory rate and pattern should be carried out and recorded in the NEWS chart.
6. Administer humidified oxygen therapy as prescribed by medical staff. This will be dependent on oxygen saturation levels, past medical history and level of spinal injury.
7. Refer to physiotherapy for respiratory assessment. If the patient requires an assisted cough, nursing staff may be required to participate in supporting the fracture site.
8. If the patient has a neurological deficit, a urinary catheter should be inserted to prevent loss of bladder tone in the rehabilitation phase. If the patient has no neurological deficit and has not passed urine for six hours post admission, then catheterisation should be considered. A bladder scanner should be used to determine the amount of residual urine in the bladder.
9. After the acute phase of injury, and once a treatment plan is in place, a decision should be made regarding the removal of the urinary catheter. Regular bladder scanning should be carried out to ensure non retention of urine post catheter removal.
10. Urinals should be used if the patient is not catheterised - bedpans should never be used (see section on bowel management).
11. Apply anti-embolic (TED) stockings, unless contra-indicated – confirm with medical staff.

Key medical issues to be considered include:

1. Patients with cervical spine injury should be nil by mouth until otherwise stated. A peripheral venous cannula should be inserted, and appropriate intravenous fluids prescribed.
2. Dalteparin 2,500 – 5,000 units subcutaneously, should be prescribed daily if no contra-indications.
3. All cervical spine injuries should have intravenous drugs prescribed until nil by mouth status is revoked.
4. Ranitidine to be prescribed either intravenously or orally as appropriate.
5. The patient will be examined for bowel sounds prior to the commencement of diet and fluids, and daily to avoid paralytic ileus. If there is evidence of paralytic ileus, or if vomiting is severe, a nasogastric tube should be inserted.
6. Prescribe laxatives on admission.
7. Analgesia will be determined on individual patient needs. Caution should be used with opiates due to the risk of respiratory depression.
8. All paediatric unstable spinal injuries will have their medical prescription kardex completed in A&E by the Paediatric Medical Team.
9. Patients with cervical spine injuries should be prescribed salbutamol and ipratropium nebulisers routinely.
10. Patients with cervical/thoracic/lumbar injuries should be prescribed salbutamol and ipratropium nebulisers as and when required. If any of these patients show signs of respiratory wheeze or chest infection, nebulisers should be prescribed routinely.
11. Patients admitted with a spinal injury should have an American Spinal Injuries Association (ASIA) chart completed. The ASIA chart is an objective assessment that allows clear communication regarding the extent and level of injury. It facilitates remote decision making at tertiary referral centres and allows detection of neurological deterioration. Any completed ASIA chart should have a date and time documented and be filed in the notes. An example ASIA chart is available Appendix I.

Acute spinal injuries moving and handling

1. On admission, the patient should be log rolled and their skin condition assessed and documented using the SSKIN Bundle. This should be reassessed as appropriate.
2. Clothing or nightwear should be removed to prevent pressure that could compromise skin integrity. A theatre gown may be more practical.
3. Pressure area inspection should occur at least once in a 24 hour period.
4. All visible areas must be inspected (i.e. elbows, ears, underneath hard collar or Miami J collar).
5. If patient’s skin is not compromised, then bed tilting should be carried out two hourly using the spinal bed.
6. If patient’s skin is compromised by pressure ulcer or traumatic injury, the tilting regime will vary.
7. Time between tilts should be increased by one hour, and tilts should not exceed 4 hours, while the patient is on the spinal bed. The decision to increase the time between tilts should be taken following the daily log roll.
8. No alternating mattresses should be used for any spinal injury.

1. A rectal examination should be undertaken by medical staff as part of the neurological examination on admission, to ascertain anal sphincter reflex.
2. Auscultation of the abdomen for presence of bowel sounds should be carried out to assess if the patient has a paralytic ileus.
3. If bowel sounds are present, medication for bowel routine should be prescribed.

Bowel care when paralytic ileus present

Perform daily rectal examination to assess for presence of faeces. If faeces is present, this should be manually evacuated by a suitably trained registered practitioner. This is in accordance with the Guideline for digital rectal examination and/or removal of faeces.

Check for presence of bowel sounds to assess if paralytic ileus has resolved. When bowel sounds return, bowel routine should be commenced to achieve regular emptying of the bowel.

Bowel medication in acute phase

To prevent constipation, senna and lactulose should be prescribed. Suppositories and enemas may also be used if necessary. Bedpans should not be used. The use of incontinence pads are advised to ensure that there is limited movement of the spine.

Transferring patient to computed tomography (CT) room

The patient should attend CT room on spinal bed and be transferred onto trolley once in the department. If there is an unstable cervical fracture, it is advisable for medical staff to accompany patient to CT room to ensure adequate support of the head and neck when transferring patient onto scanner trolley.

Two members of staff should also accompany patient to CT room for transfer onto the scanner, one of which must be a registered nurse. When moving the patient onto the scanner trolley, the moving and handling techniques should be applied (as above).

Generally, a time is given for a CT scan, but staff should telephone to confirm that there will be no delay to prevent patient waiting in the x-ray area.

Transfer of Patient to Queen Elizabeth National Spinal Injuries Unit

If, following assessment it has been agreed that the patient should be transferred to Eden Hall (Queen Elizabeth National Spinal Injuries Unit), this will be co-ordinated by medical staff.

If the patient has cervical or high thoracic injury, then anaesthetic assessment may be required prior to transfer, due to the potential problems with airway and respiratory management. Depending on the assessment, medical staff may be required during transfer.

Contact Eden Hall prior to transfer to establish bed availability. To obtain ambulance for transfer, contact ambulance control for an emergency ambulance – not patient transport ambulance.

Ensure documentation accompanies patient including photocopied relevant medical and nursing notes/ medical transfer letter and nursing SBAR transfer. Include Methicillin resistant staph aureus (MRSA) status on transfer letter and level of spinal injury. Ensure the patient has a patent peripheral catheter prior to transfer.

A vacuum mattress must be used to protect skin and stabilise the spine (A&E ambulance will supply, inform on booking). Following assessment, the patient may also require nasogastric tube insertion for transfer due to risk of aspiration on transfer.

Queen Elizabeth National Spinal Injuries Unit transfer checklist

Children/adolescents presenting with spinal/unstable spinal injuries to the Accident and Emergency Department, University Crosshouse Hospital, will be assessed on a paediatric to orthopaedic consultant basis. Based on this assessment the patient will be transferred to the appropriate area which meets the individual needs of the child/adolescent.

If, following this patient assessment, Ward 2B is the most appropriate area to meet their individual needs, paediatric expertise and support should be accessed from the Paediatric Unit, University Hospital Crosshouse. If the child /adolescent is placed in the Paediatric Unit, orthopaedic expertise and support should be accessed from Ward 2B, University Hospital Crosshouse.

The most appropriate clinical team will carry out any invasive procedures that may be required, such as catheterisation, venepuncture or cannulation etc.

Child/adolescents being cared for in Ward 2B will require two staff members to be present when carrying out any nurse intervention to meet their individual needs.

Employees are reminded that they may have patients/carers who require communication in an alternative format e.g. other languages or signing. Additionally, some patients/carers may have difficulties with written material. At all times, communication and material should be in the patient’s/carer’s preferred format. This may also apply to patients with learning difficulties.

In some circumstances there may be religious and/or cultural issues which may impact on clinical guidelines e.g. choice of gender of health care professional. Consideration should be given to these issues when treating/examining patients.

Some patients may have a physical disability or impairment that makes it difficult for them to be treated/examined as set out for a particular procedure requiring adaptations to be made.

Patients’ sexual orientation may or may not be relevant to the implementation of this guideline. However, non-sexuality specific language should be used when asking patients about their sexual history. Where sexual orientation may be relevant, tailored advice and information may be given.

This guideline has been impact assessed using the NHS Ayrshire and Arran Equality Impact Assessment Tool Kit. No additional equality & diversity issues were identified.

The ASIA chart is available here.

Reproduced with kind permission of the American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2019; Richmond, VA.

Related documents

Health and Safety Executive. Manual handling at work: a brief guide. 01/20 INDG143(rev4). 2020. Available from: https://www.hse.gov.uk/pubns/indg143.PDF

NHS National Services Scotland. National Infection Prevention and Control Manual. Available from: https://www.nipcm.scot.nhs.uk/ [Accessed 14.04.2023]

Consent Policy for Health Professionals (2021)

NHS Ayrshire and Arran. Skincare management in adults with continence problems - reference guide (G076).

Healthcare Improvement Scotland. Scottish palliative care guidelines. Malignant spinal cord compression. 2014. Last updated 21 Jun 2021. Available from: https://www.palliativecareguidelines.scot.nhs.uk/guidelines/palliative-emergencies/malignant-spinal-cord-compression.aspx

Guideline for the transfer of critically ill adult patients within NHS Ayrshire & Arran (2020)

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