Appendix to spinal cord injury destination policy
New Zealand has three spinal cord impairment (SCI) centres. They are:
For the upper two thirds of the North Island:
Middlemore Hospital for adults (15 years or older).
Starship Hospital for children (younger than 15 years).
For the lower third of the North Island and all of the South Island:
Christchurch Hospital for all patients (adults and children).
See the catchment area map on page x (to be inserted).
One of the main principles within the National Spinal Cord Impairment Initiative is that patients with SCI should be treated in a SCI centre as soon as is feasible. From a pre-hospital perspective this means that patients with spinal cord injury will be transported direct from the scene to a SCI centre, whenever this is both feasible and safe for the patient.
Spinal cord injury
For the purposes of this policy, signs of spinal cord injury require the patient to have signs of paralysis with paraplegia or quadriplegia.
Altered sensation and/or weakness (without paralysis) are not sufficient because it is relatively common for a patient to have these symptoms pre-hospital in the absence of spinal cord injury.
Other signs of major trauma
The patient must be transported to the nearest hospital designated to receive major trauma if there are any signs of major trauma in addition to that of spinal cord injury.
All of the SCI centres are within hospitals that are also designated to receive major trauma.
See the major trauma destination policy for further details (note: still in development).
Assessing the adequacy of breathing
Clinical judgement is required when determining that breathing is clinically inadequate, but the presence of clinically inadequate breathing requires the patient to be transported to the nearest hospital designated to receive major trauma.
Clinically inadequate breathing is uncommon pre-hospital following spinal cord injury and usually only occurs with a high cervical cord injury. In this setting the patient will usually have diaphragmatic breathing and quadriplegia, but may be able to shrug their shoulders and weakly bend their elbows.
Most patients with diaphragmatic breathing have clinically adequate breathing but an inadequate cough. In this setting it is appropriate to transport the patient direct to a SCI centre, provided this is feasible and the patient has adequate oxygenation and their breathing is not deteriorating.
Severe or worsening shock is uncommon in the setting of spinal cord injury. If severe or worsening shock is present it must be presumed to be hypovolaemic shock until proven otherwise, requiring the patient to be transported to the nearest hospital designated to receive major trauma.
Spinal cord injury results in loss of sympathetic outflow from the spinal cord. This results in vasodilatation which may cause shock. This is often referred to as ‘spinal shock’. For spinal shock to occur a significant amount of vasodilatation must be present and this usually requires spinal cord injury to occur at or above the mid-thoracic area. If the patient has shock with an injury below the mid-thoracic area then it should be presumed that the cause is hypovolaemic shock until proven otherwise.
Many patients with spinal cord injury will have subtle signs of shock, but will not have severe or worsening shock. In this setting, clinical judgement is required but it is appropriate to consider transport direct to a SCI centre provided the signs of shock are not severe or worsening. If there is any doubt, the patient should be transported to the nearest hospital designated to receive major trauma.
If the patient has spinal shock, the following features are usually present:
Clinical signs of vasodilatation below the site of injury (which may include erection in males).
Hypotension with a widened pulse pressure.
Tachycardia with a ‘relatively fixed’ heart rate.
Fluid loading results in very little change in the blood pressure or heart rate.
Clinical signs of vasoconstriction.
A narrowed pulse pressure.
Fluid loading results in a change in the blood pressure and heart rate.
Transportation direct to a SCI centre by road
If the patient is already in the normal DHB catchment area for a hospital that is also a SCI centre, no specific decision is required because the patient will be transported to that hospital.
For patients in another DHB catchment area, the decision to transport direct to one of the SCI centres by road requires clinical judgement. The practical reality is that this is usually only feasible in and around the fringes of Auckland and Canterbury.
In the Auckland area:
Adults should be transported to Middlemore Hospital unless there is a compelling reason (for example severe traumatic brain injury) to transport to Auckland City Hospital instead.
Children should be transported to Starship Hospital.
On the fringes of the Auckland area (for example the southern area of Northland and the northern area of Waikato and Hauraki), it is appropriate to consider transport direct to a SCI centre by road (if helicopter transport is not indicated or available), rather than transporting by road to Whangarei Hospital or Waikato Hospital.
In the Canterbury area the only hospital suitable for patients with major trauma is Christchurch Hospital and all patients should be transported there direct.
Transportation direct to a SCI centre by helicopter
If a patient meets criteria to be transported by helicopter it is appropriate to transport the patient direct to a SCI centre provided they do not have signs of major trauma in addition to that of spinal cord injury. If there are signs of major trauma in addition to that of spinal cord injury the patient must be transported to the most appropriate hospital, noting that this must be a hospital designated to receive major trauma.
The ‘most appropriate’ hospital is not always the nearest hospital. Determining the ‘most appropriate’ hospital requires clinical judgement that takes into consideration all of the following:
The nature of the patient’s injuries.
The anticipated treatment requirements once in-hospital.
The facilities of the potential receiving hospitals.
The total transport time (including any road transfer required from the landing site to the hospital) to the potential receiving hospitals.
A combination of appropriate weather (including visibility) and adequate fuel is required for it to be both feasible and safe to fly direct to one of the SCI centres. It is appropriate for refueling to occur en route to a SCI centre provided doing do does not result in a clinically significant delay.
If for any reason it is not feasible to transport the patient direct to a SCI centre by helicopter, the patient will be transported to the most appropriate hospital, noting that this must be a hospital designated to receive major trauma.
It will usually be feasible to transport a patient from within the upper two thirds of the North Island direct to Middlemore Hospital or Starship Hospital.
It is not feasible to transport a patient by helicopter from within the lower third of the North Island direct to Christchurch Hospital. If a patient is being transported by helicopter within the lower third of the North Island, the patient will be transported to the most appropriate hospital, noting that this must be a hospital designated to receive major trauma and then subsequently referred to a SCI centre.
It will often (but not always) be feasible to transport a patient by helicopter from within the South Island direct to Christchurch Hospital.
Seeking clinical advice
Pre-hospital personnel requiring advice will contact the doctor on call for the ambulance service via the Clinical Desk within the Ambulance Clinical Control Centre.
In the event that further advice is required, the doctor on call for the ambulance service will contact the on call spinal surgeon within the appropriate SCI centre.