Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents following acute traumatic injury resulting in complete spinal cord injury at the C4 level. Patient reports total loss of motor and sensory function below the level of the clavicles. No preservation of sacral sparing noted. Respiratory status is compromised, requiring ventilatory support. Hemodynamic stability is currently being managed in the acute setting.
Clinical Examination Findings
General: Patient is intubated and sedated. Neurological: Complete tetraplegia. Motor: 0/5 strength in all muscle groups below C4 dermatome. Sensory: Complete anesthesia below C4 level. Reflexes: Areflexia below the level of injury (spinal shock phase). Autonomic: Bradycardia and hypotension noted, consistent with neurogenic shock.
Treatment Protocol
Immediate management includes cervical spine stabilization (halo vest or surgical fixation). Pharmacological intervention: High-dose methylprednisolone protocol (if within window), vasopressors for neurogenic shock, and DVT prophylaxis. Respiratory: Mechanical ventilation and aggressive pulmonary toilet. Bladder/Bowel: Indwelling urinary catheter and bowel regimen initiation.