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Pharmacy & Acute Care University
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Emergency Medicine Trauma 212

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  1. Increased Intracerebral Pressure Reduction
    9 Topics
    |
    2 Quizzes
  2. Open Fracture Antibiotics
    8 Topics
    |
    2 Quizzes
  3. Spinal cord injury
    6 Topics
    |
    2 Quizzes
  4. Trauma resuscitation
    9 Topics
    |
    2 Quizzes
  5. Traumatic brain injury
    9 Topics
    |
    2 Quizzes

Participants 396

  • Allison Clemens
  • April
  • ababaabhay
  • achoi2392
  • adhoward1
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GuidelinesRecommendations
NICE Guidelines on Corticosteroid Use in Acute Spinal Cord Injury– Do not use methylprednisolone, nimodipine, or naloxone in the acute stage of traumatic spinal cord injury to provide neuroprotection and prevent secondary deterioration.  – Reference: NICE guideline on spinal injury assessment and initial management (NICE 2016 Feb:NG41)
AANS/CNS Guidelines on Corticosteroid Use in Acute Spinal Cord Injury– Do not give methylprednisolone for acute spinal cord injury; high-dose corticosteroids are associated with adverse effects and death (AANS/CNS Level I)  – Reference: AANS/CNS recommendations for pharmacological therapy for acute SCI (Neurosurgery 2013 Mar;72 Suppl 2:93)
CSCM Guidelines on Corticosteroid Use in Acute Spinal Cord Injury– No clinical evidence to definitively recommend the use of any neuroprotective medication, including steroids, to improve functional recovery (CSCM Expert consensus, Strong agreement).  – Stop the use of methylprednisolone as soon as possible in neurologically normal patients, and in patients whose previous neurologic symptoms have resolved, to reduce side effects (CSCM Expert consensus, Strong agreement). – Reference: CSCM guideline on early acute management in adults with SCI (J Spinal Cord Med 2008;31(4):403)
SCI-GDG Guidelines on Corticosteroid Use in Acute Spinal Cord Injury– Consider a 24-hour infusion of high-dose methylprednisolone sodium succinate for adults who present within 8 hours of injury (SCI-GDG Grade Weak, Level Moderate). – Do not offer a 48-hour infusion of high-dose methylprednisolone sodium succinate (SCI-GDG Grade Weak, No direct evidence).
– Reference: Global Spine Journal 2017 Sep;7(3 Suppl):203
  • Corticosteroids have been used to treat spinal cord injury since the 1960s.
  • The National Acute Spinal Cord Injury Study (NASCIS) trials demonstrated some benefits of using corticosteroids, but the trials have faced criticisms about the use of subgroup analysis, potential confounders, clinical significance of results, reproducibility, and risk of complications.
  • The use of corticosteroids for acute spinal cord injury remains controversial, with uneven adoption of the NASCIS recommendations among healthcare providers.
  • Studies of practice patterns in North America and the United Kingdom suggest decreasing use of corticosteroids for acute spinal cord injury, but medicolegal concerns are often cited as the justification for use.
  • Recent guidelines from the American Association of Neurological Surgeons/Congress of Neurological Surgeons and the European Association of Neurosurgical Societies recommend against using corticosteroids for acute spinal cord injury beyond 8 hours post-injury.

Pharmacist Takeaways

1.The use of corticosteroids for acute spinal cord injury is controversial and the guidelines recommend against their routine use beyond 8 hours after injury.

2.Clinical pharmacists can play a crucial role in monitoring patients who are receiving steroids for acute spinal cord injury to manage potential side effects such as increased risk of infections, gastrointestinal bleeding, and hyperglycemia.

3.Pharmacists should also educate healthcare providers and patients about the potential risks and benefits of steroid use, and the importance of following evidence-based guidelines to improve patient outcomes.

References

•  Breslin K, Agrawal D. The use of methylprednisolone in acute spinal cord injury: a review of the evidence, controversies, and recommendations. Pediatr Emerg Care. 2012 Nov;28(11):1238-45; quiz 1246-8. doi: 10.1097/PEC.0b013e3182724434. PMID: 23128657.

•  Bracken MB, Shepard MJ, Hellenbrand KG, et al. Methylprednisolone and neurological function 1 year after spinal cord injury. Results of the National Acute Spinal Cord Injury Study. J Neurosurg. 1985;63:704Y713.

•  Bracken MB, Shepard MJ, Collins WF, et al. A randomized, controlled trial of methylprednisolone or naloxone in the treatment of acute spinal-cord injury. Results of the Second National Acute Spinal Cord Injury Study. N Engl J Med. 1990;322:1405Y1411.

•  Bracken MB, Shepard MJ, Holford TR, et al. Administration of methylprednisolone for 24 or 48 hours or tirilazad mesylate for 48 hours in the treatment of acute spinal cord injury. Results of the Third National Acute Spinal Cord Injury Randomized Controlled Trial. National Acute Spinal Cord Injury Study. JAMA. 1997;277:1597Y1604.

•  Bracken MB, Shepard MJ, Holford TR, et al. Methylprednisolone or tirilazad mesylate administration after acute spinal cord injury: 1-year follow up. Results of the third National Acute Spinal Cord Injury randomized controlled trial. J Neurosurg. 1998;89:699Y706.

•  Nesathurai S. Steroids and spinal cord injury: revisiting the NASCIS 2 and NASCIS 3 trials. J Trauma. 1998;45:1088Y1093.

•  Canadian Association of Emergency Physicians. 2011. Steroids in Acute Spinal Cord Injury. Available at: http://www.caep.ca/ template.asp?id=6AC5624E27AA4CBA8BBCC037EE2D4355. Accessed March 5, 2023.

•  American Academy of Emergency Medicine. 1997-2003. Position Statements Steroids in Acute Spinal Care Injury. Available at: http://www.aaem.org/positionstatements/steroidsinacuteinjury.php.Accessed March 5, 2023.

•  British Association of Spinal Cord Injury Specialists. 2005. Good Practice. Available at: http://www.bascis.pwp.blueyonder.co.uk/philosophy.htm. Accessed March 5, 2023.

•  American College of Surgeons Committee on Trauma. Advanced Trauma Life Support for Doctors ATLS Student Course Manual. 7th ed. 2004.

•  Consortium for Spinal Cord Medicine. Early Acute Management in Adults with Spinal Cord Injury: A Clinical Practice Guideline for Health-Care 2008; Paralyzed Veterans of America. Available at:http://www.pva.org/site/c.ajIRK9NJLcJ2E/b.6305831/k.986B/Guidelines_and_Publications.htm.

•  Eck JC, Nachtigall D, Humphreys SC, et al. Questionnaire survey of spine surgeons on the use of methylprednisolone for acute spinal cord injury. Spine (Phila Pa 1976). 2006;31:E250YE253.

•  Hurlbert RJ, Hamilton MG. Methylprednisolone for acute spinal cord injury: 5-year practice reversal. Can J Neurol Sci. 2008;35:41Y45.