Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Ok. Hi, good evening. Happy new year to everybody and welcome back to January's uh SI CS education uh update. Um uh I'm just gonna start by saying I know that many of the people on the call will be SI CS members. But if not, um the Scottish Intensive Care Society is an organization which aims to improve um the quality of care delivered to critically ill patients in Scotland and beyond. And really, we do that through three main ways through audit, through research and education. Um There are different categories of membership on our website. Um If you want to have a look and benefits of membership include um uh comprehensive uh travel insurance for transfer insurance. If you're transferring patients reduce rates um for attendance at our um our meetings and access to education and travel bursaries to allow you to uh to participate in personal development, professional development. Um So please have a look at our website if you're interested more in membership. Our annual scientific meeting is coming up this year on the 1st and 2nd of May, we're moving to a new location at Reef Hydro. So it'll be nice to see lots of you there. Um There's an, a really exciting program being put together um with a variety of breakout sessions for er, different types of streams and learning. So I'm gonna just introduce our speaker for this evening. Um We're really delighted to be joined by Doctor Sarah Lyford. She is a consultant in adult critical care and anesthesia at Nottingham University Hospital's NHS Trust and she has been there since 2016. She leads Nottingham's critical care rehabilitation and follow up service and a particular area of her focus is care of the long term critical care patient. She leads a multidisciplinary long term war for all patients that stay in their critical care unit for more than 12 days. And this includes many polytrauma spinal cord and pancreatic patients. And her other clinical interests include difficult ventilatory weaning neurointensive care and complex family communication outside of work. She's got three young kids who keep her and her husband busy along with a very enthusiastic dog. So thank you so much, Doctor Lynford for joining us this evening. I'm gonna hand over um to you. Um you are able to pop um any messages or chats in the chat box. If you have any questions for Doctor Lynford will put them to her at the end of this talk uh over to you. Thanks. Ok. Hi and good evening. So everyone and thank you so much for and Julie for the invitation to speak. Um as Julie already said I'm a consultant, critical care medicine, Anesthesia at Nottingham University Hospitals. N is a large tertiary referral center, a major trauma center. We split across two sites with 49 critical care beds at the Q MC, which is a major trauma center and 17 beds at the City Hospital. Both of mixed units. I generally describe myself as a jobbing intensivist. But as Julie already said, I've developed an interest over the years in the longer stage, critical care patient population and frequently therefore, I'm involved in the care of patients in IUD it with spinal cord injuries over the next 45 minutes or so, I'll talk through spinal cord injuries and then management from the front door to the point of transfer to the regional spinal cord er injury rehab center. Um I have no conflicts of interest to declare. So this is Ed and it's 2018. Ed is 23 years old and he was eight months into his f one year. In his words, I had friends, a career, a great girl and a diverse set of interests. If I wasn't at work, I would be either sleeping, eating or running around outside. I lived a really active lifestyle. I was always cycling in the gym or playing basketball. I was in the water as much as possible to swimming with my girlfriend at near training or preparing for our next scuba and free diving trip. I was confident and optimistic about my future. All of that was about to change. On the 15th of February 2018, I was hit by a car while cycling to work a night shift at my local hospital. It was the day before my girlfriend's birthday and also the day before we were due to go diving for two weeks in Indonesia. I sustained ac 34 dislocation, spinal cord injury. I was admitted to the hospital. I was going to work at my girlfriend was working at the hospital and met me in A&E I underwent emergency surgery that night. I was in a medically induced coma for 10 days. Again. In Ed's words, this is the first photo of me with a spinal cord injury. I can't remember anything from the ambulance right to waking up in intensive care. 10 days later, I couldn't move anything from the neck down. I couldn't talk, I couldn't eat, I couldn't even breathe independently. I spent 44 days on intensive care. And once my diaphragm was strong enough, I got off the ventilator and spent another 10 days on high dependency before moving to the spinal unit in Sheffield. After six months in the spinal unit, I was lucky enough to go to steps neurorehabilitation. Also in Sheffield several months later, I will start my transition home. So that sets the scene and gives us a taste of the human cost of these injuries. We'll hear a little more about from ed later on, but I'm gonna spend the next 40 minutes or so talking through the following epidemiology is spinal cord injury. It's pathophysiology and clinical presentation, the diagnosis and the pitfalls and that it's acute management and the literature surrounding some of that a bit about intensive care management. Obviously, it's compromises that we have to meet MDT management and weaning re rehab and longer term outcomes. And then as I said, a bit more from head at the end. So according to the Spinal Injuries Association, recent data suggest that there are around 2.5 1000 new cases per year of spinal cord injury with approximately 50,000 people living with a spinal cord injury. At any time, the etiology of injury is changing and while trauma still predominates, the incidence of nontraumatic causes is rising. A study published in the spinal cord in 2019. Environmental modeled the economic impact of spinal cord injuries in the UK. They estimated 1217 new spinal cord injured patients in 2016 13% would be nontraumatic, 35% percent tetraplegic abc graded injuries. And I'll explain the grading shortly and 70% over 46 years old. The lifetime cost at 2016 prices was estimated to be 1.43 billion for the whole group or 1.12 million lbs per case. With more than two thirds of that falling on the on the public purse. The model is, is always likely an underestimate as there are many assumptions and variances, for example, around lost earnings. The model also does not include the need for domiciliary ventilation, which is obviously very costly. So this is a table from the paper and it just looks at the lifetime costs and it's worth noting a massive difference between the tetraplegic high grade injuries and the paraplegic high grade injuries, Immediate inpatient care costs are 1.5 million for the paraplegic group and 9.1 million for the tetraplegic group. Similarly looking at their home care costs and productivity losses which were estimated at 100 and 35 million for the tetraplegic group and 59 million for a paraplegic group. So, moving on to think about pathophysiology and I'll keep this brief, but it's much like the theory around TBI I in terms of primary and secondary insult. Most spinal cord injuries are produced in association with um an injury to the vertebral column with the primary injury resulting from compression of the spinal cord from either bony fragments, blood soft tissue or foreign objects. Most vertebral injuries in adults involve both fracture and dislocation. The type of injury has implications for the stability of the spinal column and the risk of further spinal cord injury. What follows is then the secondary injury where vasogenic edema used to reduce blood supply, spinal cord ischemia, cell death and oxidative damage. Moving on to clinical presentation. And first thinking about the risk factors for a spinal cord injury. A high index of suspicion should be maintained at all times in the evaluation of trauma patients for the presence of the spinal cord injury mechanisms of injury associated with a higher possibility of spinal cord injury are falls from a height of over a meter or more than five steps and any injuries involving an axial load to the head in the states, 48% of traumatic spinal cord injury is secondary to road traffic collisions. 16% to falls, 12% of violence and 10% sports accidents. Fortunately, we see less of the violence associated injuries in the UK. Risk factors for traumatic spinal cord injury include male gender, age of 65. And then anyone with underlying spinal conditions such as ankylosing spondylitis or rheumatoid arthritis. So how does it present? Well, neck and back pain is commonplace but it's unreliable. A spinal cord injury often occurs as part of a multisystem trauma. And so the influence of distracting injuries is high if it is an isolated injury, meticulous neurological examination will allow clinical estimation of the level of injury and which parts of the spinal cord are involved. Approximately half a spinal cord injuries involve the cervical spine and so prevent with quadriparesis or quadriplegia. The American spinal injury association or Asia scale is used to classify the injury as we can see here. So a complete cord injury, also known as an Asia grade A is where there's no sensory or motor function below the level of the lesion. In the acute stage reflexes are absent, there's no response to plantar stimulation.