11.3 Spinal Cord Injury
Key Takeaways
- Complete injury means no motor or sensory function, including sacral sparing, below the level; incomplete preserves something—write that distinction down after every roll.
- Spinal shock is temporary areflexia; neurogenic shock is hypotension, bradycardia, and warm dry skin from lost sympathetic tone, usually T6 and above.
- C3–5 keeps the diaphragm alive; abdominal breathing plus an unpressurized climb is a Dalton hypoxia emergency, not a wait-and-see saturation.
- AANS/CNS-style teaching commonly targets MAP 85–90 mm Hg for early cord perfusion; phenylephrine or norepinephrine supports that pressure, and methylprednisolone is not routinely given.
- Priapism is a cord sign, log-roll as a unit, recognize late autonomic dysreflexia on delayed hops, and fly to a spine-capable trauma center.
A broken cord is not only a motor score. Domain 3.B of the August 2026 Board of Certification for Emergency Nursing (BCEN) Certified Flight Registered Nurse (CFRN) outline tests spinal cord injury (SCI) because the airway, the blood pressure, and the destination decide whether remaining cord lives. High cervical injuries add a respiratory problem that altitude makes worse.
Complete versus incomplete
A complete injury means no motor and no sensory function, including sacral sparing, below the neurologic level. An incomplete injury preserves something below—sacral pinprick, a flicker of toe flexion, or a sensory band. High-level patterns include central cord (upper worse than lower), anterior cord, Brown-Séquard, and posterior cord. On the ramp you need the last normal level, whether sacral sparing exists, and whether the exam is changing after each move.
Priapism after trauma is a cord sign and often marks a complete injury. It is not a urology consult on scene. Package the spine and treat the shock picture that travels with it.
Spinal shock is not neurogenic shock
The exam versus the pipes
Spinal shock is a temporary loss of reflexes and flaccid paralysis below the injury. Bulbocavernosus and deep-tendon reflexes are gone. It is a neurologic-exam problem, not a blood-pressure diagnosis. It can last hours to weeks. When reflexes return, the same patient may later develop autonomic dysreflexia.
Neurogenic shock is loss of sympathetic vasomotor tone, typically at T6 and above. The picture is hypotension (a falling mean arterial pressure (MAP)), bradycardia, and warm dry skin below the lesion. The pipes are open and the heart will not compensate with tachycardia. This is distributive shock, the same family you already treated in Chapter 9. You still have to exclude hemorrhage—a warm bradycardic patient can also be bleeding into a pelvis or a chest.
| Feature | Spinal shock | Neurogenic shock |
|---|---|---|
| What fails | Reflexes and motor below the lesion | Sympathetic tone to vessels and heart |
| Blood pressure | Not defined by this term | Hypotension with bradycardia |
| Skin | Not the defining clue | Warm and dry below the injury |
| Timeline | Hours to weeks of areflexia | Immediate hemodynamic problem |
| Flight action | Document the exam; protect the spine | Pressors and a higher MAP target |
Airway, C3–5, and altitude
C3 through C5 keep the diaphragm alive. A complete injury at or above C5 is a predicted ventilator patient. Even C6–C7 patients can fatigue because they have lost intercostals and abdominal wall. Watch for abdominal breathing—the belly rises and the chest does not. That pattern plus an unpressurized climb is a planned desaturation. Dalton's law drops the partial pressure of inspired oxygen (PIO2); a patient who was barely compensating at the roadside will fail at cabin altitude. Raise fraction of inspired oxygen (FiO2) early, support ventilation before the patient is exhausted, and do not wait for a pretty pulse oximetry (SpO2) number to fall.
Intubate with manual in-line stabilization. A rigid collar stays on except for the look. High-cord patients desaturate fast because they have little reserve, a full stomach, and no cough. Have a suction in each hand. If the only spontaneous effort is a tired belly, the time to support the airway is on the ground.
Blood pressure, steroids, and packaging
American Association of Neurological Surgeons / Congress of Neurological Surgeons (AANS/CNS)-style teaching commonly targets a MAP of 85–90 mm Hg for injured cord perfusion in the early period. Label that range as AANS/CNS-style teaching, not as a number BCEN published. Many programs still use it; later CNS writing has discussed slightly lower floors. The exam idea is higher than a generic 65 mm Hg sepsis MAP, and you still look for bleeding before you chase the number with a pure vasoconstrictor.
First-line pressors for neurogenic shock are phenylephrine (pure alpha, useful when the heart rate is already adequate) or norepinephrine (alpha plus some beta, useful if the rate is very slow or contractility is poor). Atropine or glycopyrrolate can treat symptomatic bradycardia. Do not drown the patient in crystalloid; a high-cord bladder and a leaky capillary bed will repay you with pulmonary edema at altitude.
Methylprednisolone is not routinely given. The National Acute Spinal Cord Injury Study (NASCIS) infusion is not standard flight care. Do not start a 24-hour steroid because a sending nurse "always does."
Log-roll as a unit. One person holds the head. The vacuum mattress or scoop is not an excuse to twist the pelvis off the shoulders. Recheck motor and sacral sparing after every roll. Packaging hides a changing exam the same way it hides a hematoma.
Autonomic dysreflexia is usually later—after spinal shock recedes—in T6-and-above injuries. A noxious stimulus below the lesion (distended bladder, tight binder) produces severe hypertension, reflex bradycardia, and flushing above the injury. Sit the patient up if the package allows, loosen the stimulus, and treat the pressure. You may still see it on a delayed hop; it is not "pain only."
Destination is a spine-capable trauma center—surgeons who decompress and stabilize, and an intensive-care unit that can hold a MAP and a ventilator. A closer hospital without spine coverage is the wrong pad for a complete cervical injury.
- Incomplete means something is still working below the level; write sacral sparing down.
- Spinal shock is areflexia; neurogenic shock is warm, dry, and bradycardic hypotension.
- C3–5 plus abdominal breathing plus altitude is a ventilation emergency.
- MAP 85–90 is AANS/CNS-style teaching; methylprednisolone is not routine.
- Fly to a spine-capable trauma center.
After a T4 fracture, a patient is hypotensive with a heart rate of 48 beats per minute, warm dry skin below the nipple line, and no ongoing external bleeding. Which label and first vasoactive plan are correct?
Which statement about early flight care of acute spinal cord injury is correct?
A complete C4 injury shows abdominal breathing on the ramp. The aircraft will climb unpressurized. What is the greatest threat and the right destination?