Spinal Cord Injuries Treatment & Management - Approach Considerations, Prehospital Management, Emergency Department Management

12/2/2015
SpinalCordInjuriesTreatment&Management:ApproachConsiderations,PrehospitalManagement,EmergencyDepartmentManagement
SpinalCordInjuriesTreatment&
Management
Author:LawrenceSChin,MD,FACSChiefEditor:BrianHKopell,MDmore...
Updated:Jul07,2015
ApproachConsiderations
Admitallpatientswithanacutespinalcordinjury(SCI).Dependingonthelevelofneurologic
deficitandassociatedinjuries,thepatientmayrequireadmissiontotheintensivecareunit
(ICU),neurosurgicalobservationunit,orgeneralward.
ThemostcommonlevelsofinjuryonadmissionareC4,C5(themostcommon),andC6,
whereasthelevelforparaplegiaisthethoracolumbarjunction(T12).Themostcommontypeof
injuryonadmissionisAmericanSpinalInjuryAssociation(ASIA)levelA(seeNeurologiclevel
andextentofinjuryunderClinical).
Transfer
Dependingonlocalpolicy,patientswithacutespinalcordinjuryarebesttreatedataregional
spinalcordinjurycenter.Therefore,oncestabilized,earlyreferraltoaregionalspinalcordinjury
centerisbest.Thecentershouldbeorganizedtoprovideongoingdefinitivecare.
Otherreasonstotransferthepatientincludethelackofappropriatediagnosticimaging
(computedtomography[CT]scanningormagneticresonanceimaging[MRI])and/orinadequate
spineconsultantsupport(orthopedistorneurosurgeon).
Consultations
Consultationwithaneurosurgeonand/oranorthopedistisrequired,dependingonlocal
preferences.Becausemostpatientswithspinalcordinjuryhavemultipleassociatedinjuries,
consultationwithageneralsurgeonoratraumaspecialistaswellasotherspecialistsmayalso
berequired.
PrehospitalManagement
Mostprehospitalcareprovidersrecognizetheneedtostabilizeandimmobilizethespineonthe
basisofmechanismofinjury,paininthevertebralcolumn,orneurologicsymptoms.Patientsare
usuallytransportedtotheemergencydepartment(ED)withacervicalhardcollaronahard
backboard.Commercialdevicesareavailabletosecurethepatienttotheboard.
Thepatientshouldbesecuredsothatintheeventofemesis,thebackboardmayberapidly
rotated90whilethepatientremainsfullyimmobilizedinaneutralposition.Spinal
immobilizationprotocolsshouldbestandardinallprehospitalcaresystems.
EmergencyDepartmentManagement
Mostpatientswithspinalcordinjuries(SCIs)haveassociatedinjuries.Inthissetting,
assessmentandtreatmentofairway,respiration,andcirculation(ABCs)takesprecedence.
Thepatientisbesttreatedinitiallyinthesupineposition.Occasionally,thepatientmayhave
beentransportedpronebytheprehospitalcareproviders.Logrollingthepatienttothesupine
positionissafetofacilitatediagnosticevaluationandtreatment.Useanalgesicsappropriately
andaggressivelytomaintainthepatient'scomfortifheorshehasbeenlyingonahard
backboardforanextendedperiod.
Airwaymanagement
Airwaymanagementinthesettingofspinalcordinjury,withorwithoutacervicalspineinjury,is
http://emedicine.medscape.com/article/793582treatment
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complexanddifficult.Thecervicalspinemustbemaintainedinneutralalignmentatalltimes.
Clearingoforalsecretionsand/ordebrisisessentialtomaintainairwaypatencyandtoprevent
aspiration.Themodifiedjawthrustandinsertionofanoralairwaymaybeallthatisrequiredto
maintainanairwayinsomecases.However,intubationmayberequiredinothers.Failureto
intubateemergentlywhenindicatedbecauseofconcernsregardingtheinstabilityofthepatient's
cervicalspineisapotentialpitfall.
Hypotension,hemorrhage,andshock
Hypotensionmaybehemorrhagicand/orneurogenicinacutespinalcordinjury.Becauseofthe
vitalsignconfusioninacutespinalcordinjuryandthehighincidenceofassociatedinjuries,a
diligentsearchforoccultsourcesofhemorrhagemustbemade.
Themostcommonsourcesofocculthemorrhageareinjuriestothechest,abdomen,and
retroperitoneumandfracturesofthepelvisorlongbones.Appropriateinvestigations,including
radiographyorcomputedtomography(CT)scanning,arerequired.Intheunstablepatient,
diagnosticperitoneallavageorbedsideFAST(focusedabdominalsonographyfortrauma)
ultrasonographicstudymayberequiredtodetectintraabdominalhemorrhage.
Neurogenicshockmanagementandtreatmentgoals
Onceoccultsourcesofhemorrhagehavebeenexcluded,initialtreatmentofneurogenicshock
focusesonfluidresuscitation.Judiciousfluidreplacementwithisotoniccrystalloidsolutiontoa
maximumof2Listheinitialtreatmentofchoice.Overzealouscrystalloidadministrationmay
causepulmonaryedema,becausethesepatientsareatriskfortheacuterespiratorydistress
syndrome(ARDS).
Thetherapeuticgoalforneurogenicshockisadequateperfusionwiththefollowingparameters:
Asystolicbloodpressure(BP)of90100mmHgshouldbeachievedsystolicBPsinthis
rangearetypicalforpatientswithcompletecordlesions.Compellinganimalandhuman
studiesrecommendmaintenanceofsystolicBPabove90mmHgandtoavoidany
hypotensiveepisodes[6,7]
Themostimportanttreatmentconsiderationistomaintainadequateoxygenationand
perfusionoftheinjuredspinalcordsupplementaloxygenationand/ormechanical
ventilationmayberequired[6,7]
Heartrateshouldbe60100beatsperminute(bpm)innormalsinusrhythm
Hemodynamicallysignificantbradycardiamaybetreatedwithatropine
Urineoutputshouldbemorethan30mL/hplacementofaFoleycathetertomonitorurine
outputandtodecompresstheneurogenicbladderisessential
Rarely,inotropicsupportwithdopamineornorepinephrineisrequiredthisshouldbe
reservedforpatientswhohavedecreasedurinaryoutputdespiteadequatefluid
resuscitationusually,lowdosesofdopamineinthe2to5mcg/kg/minrangeare
sufficient
Preventhypothermia
Headinjuriesandneurologicevaluation
Associatedheadinjuryoccursinabout25%ofpatientswithspinalcordinjury.Acareful
neurologicassessmentforassociatedheadinjuryiscompulsory.Thepresenceofamnesia,
externalsignsofheadinjuryorbasilarskullfracture,focalneurologicdeficits,associatedalcohol
intoxicationordrugabuse,andahistoryoflossofconsciousnessmandatesathorough
evaluationforintracranialinjury,startingwithnoncontrastheadCTscanning.
Ileus
Ileusiscommon.Placementofanasogastric(NG)tubeisessential.Aspirationpneumonitisisa
seriouscomplicationinthepatientwithaspinalcordinjurywithcompromisedrespiratory
function(seeTreatmentofPulmonaryComplicationsandInjury).Antiemeticsshouldbeused
aggressively.
Pressuresores
Preventpressuresores.Denervatedskinisparticularlypronetopressurenecrosis.Turnthe
patientevery12hours.Padallextensorsurfaces.Undressthepatienttoremovebeltsandback
pocketkeysorwallets.Removethespineboardassoonaspossible.
SteroidTherapyinSCIandControversies
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TheNationalAcuteSpinalCordInjuryStudies(NASCIS)IIandIII,[42,43]aCochraneDatabase
ofSystematicReviewsarticleofallrandomizedclinicaltrials,[44]andotherpublishedreports,
haveverifiedsignificantimprovementinmotorfunctionandsensationinpatientswithcomplete
orincompletespinalcordinjuries(SCIs)whoweretreatedwithhighdosesof
methylprednisolonewithin8hoursofinjury.
NASCISIIandIIItrials
HighdosesofsteroidsortirilazadarethoughttominimizethesecondaryeffectsofacuteSCI.
TheNASCISIIstudyevaluateda30mg/kgbolusofmethylprednisoloneadministeredwithin8
hoursofinjury,whereastheNASCISIIIstudyevaluatedmethylprednisolone5.4mg/kg/hfor24or
48hoursversustirilazad2.5mg/kgq6hfor48hours.(Tirilazadisapotentlipidpreoxidation
inhibitor.)
Betweenthe2studies,itwasdeterminedthat:(1)inpatientstreatedearlierthan3hoursafter
injury,theadministrationofmethylprednisolonefor24hourswasbest(2)inpatientstreated38
hoursafterinjury,theuseofmethylprednisolonefor48hourswasbest(3)Tirilazadwas
equivalenttomethylprednisolonefor24hours.[43]
BothNASCISstudiesevaluatedthepatients'neurologicstatusatbaselineonenrollmentintothe
study,at6weeks,andat6monthsandfoundabsolutelynoevidencesuggeststhatgivingthe
medicationearlier(eg,inthefirsthour)providesmorebenefitthangivingitlater(eg,between
hours7and8).Theauthorsconcludedthattherewasonlyabenefitifmethylprednisoloneor
tirilazadweregivenwithin8hoursofinjury.[43]
ControversyreresultsofNASCISstudies
FollowingtheNASCIStrials,theuseofhighdosemethylprednisoloneinnonpenetratingacute
SCIhadbecomethestandardofcareinNorthAmerica.NesathuraiandShankerrevisitedthese
studiesandquestionedthevalidityoftheresults.[45]Theseauthorscitedconcernsaboutthe
statisticalanalysis,randomization,andclinicalendpointsusedinthestudy.Inaddition,the
investigatorsnotedthatevenifthebenefitsofsteroidtherapywerevalid,theclinicalgainswere
questionable.Otherreportshavealsocitedflawsinthestudydesigns,trialconduct,andfinal
presentationofthedata.
Therisksofsteroidtherapyarenotinconsequential.Anincreasedincidenceofinfectionand
avascularnecrosishasbeendocumented.
Revisedrecommendations
AsaresultofthecontroversyovertheNACSISIIandIIIstudies,anumberofprofessional
organizationshaverevisedtheirrecommendationspertainingtosteroidtherapyinSCI.[46,47]
TheCongressofNeurologicalSurgeons(CNS)hasstatedthatsteroidtherapy"shouldonlybe
undertakenwiththeknowledgethattheevidencesuggestingharmfulsideeffectsismore
consistentthananysuggestionofclinicalbenefit."[48]TheAmericanCollegeofSurgeons(ACS)
hasmodifiedtheiradvancedtraumalifesupport(ACLS)guidelinestostatethat
methylprednisoloneis"arecommendedtreatment"ratherthan"therecommendedtreatment."
TheCanadianAssociationofEmergencyPhysicians(CAEP)isnolongerrecommendinghigh
dosemethylprednisoloneasthestandardofcare.
InasurveyconductedbyEckandcolleagues,90.5%ofspinesurgeonssurveyedusedsteroids
inSCI,butonly24%believedthattheywereofanyclinicalbenefit.[49]Notethattheinvestigators
notonlydiscoveredthatapproximately7%ofspinesurgeonsdonotrecommendorusesteroids
atallinacuteSCI,butthatmostcenterswerefollowingtheNASCISIItrialprotocol.
Updatedguidelinesissuedin2013bytheCNSandtheAmericanAssociationofNeurological
Surgeons(AANS)recommendagainsttheuseofsteroidsearlyafteranacuteSCI.The
guidelinesrecommendthatmethylprednisolonenotbeusedforthetreatmentofacuteSCIwithin
thefirst2448hoursfollowinginjury.Thepreviousstandardwasrevisedbecauseofalackof
medicalevidencesupportingthebenefitsofsteroidsinclinicalsettingsandevidencethathigh
dosesteroidsareassociatedwithharmfuladverseeffects.[50,51]
GM1
TwoNorthAmericanstudieshaveaddressedtheadministrationofmonosialotetrahexosyl
ganglioside(GM1)followingacutespinalcordinjury.Theavailablemedicalevidencedoesnot
supportasignificantclinicalbenefit.Itwasevaluatedasatreatmentadjunctafterthe
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administrationofmethylprednisolone.[7,52]
Insummary
Overall,thebenefitfromsteroidsisconsideredmodestatbest,butforpatientswithcompleteor
incompletequadriplegia,asmallimprovementinmotorstrengthinoneormoremusclescan
provideimportantfunctionalgains.
Theadministrationofsteroidsremainsaninstitutionalandphysicianpreferenceinspinalcord
injury.Nevertheless,theadministrationofhighdosesteroidswithin8hoursofinjuryforall
patientswithacutespinalcordinjuryispracticedbymostphysicians.
Thecurrentrecommendationistotreatallpatientswithspinalcordinjuryaccordingtothe
local/regionalprotocol.Ifsteroidsarerecommended,theyshouldbeinitiatedwithin8hoursof
injurywiththefollowingsteroidprotocol:methylprednisolone30mg/kgbolusover15minutes
andaninfusionofmethylprednisoloneat5.4mg/kg/hfor23hoursbeginning45minutesafterthe
bolus.
LocalpolicywillalsodetermineiftheNASCISIIorNASCISIIIprotocolistobefollowed.
TreatmentofPulmonaryComplicationsandInjury
Treatmentofpulmonarycomplicationsand/orinjuryinpatientswithspinalcordinjury(SCI)
includessupplementaryoxygenforallpatientsandchesttubethoracostomyforthosewith
pneumothoraxand/orhemothorax.
Theidealtechniqueforemergentintubationinthesettingofspinalcordinjuryisfiberoptic
intubationwithcervicalspinecontrol.This,however,hasnotbeenprovenbetterthanorotracheal
withinlineimmobilization.Furthermore,nodefinitereportsofworseningneurologicinjurywith
properlyperformedorotrachealintubationandinlineimmobilizationexist.Ifthenecessary
experienceorequipmentislacking,blindnasotrachealororalintubationwithinline
immobilizationisacceptable.
Indicationsforintubationinspinalcordinjuryareacuterespiratoryfailure,decreasedlevelof
consciousness(Glasgowscore<9),increasedrespiratoryratewithhypoxia,partialpressureof
carbondioxide(PCO2)greaterthan50mmHg,andvitalcapacitylessthan10mL/kg.
Inthepresenceofautonomicdisruptionfromcervicalorhighthoracicspinalcordinjury,
intubationmaycauseseverebradyarrhythmiasfromunopposedvagalstimulation.Simpleoral
suctioningcanalsocausesignificantbradycardia.Preoxygenationwith100%oxygenmaybe
preventive.Atropinemayberequiredasanadjunct.Topicallidocainespraycanminimizeor
preventthisreaction.
SurgicalIntervention
Spineserviceconsultantsshoulddeterminetheneedforandtimingofanysurgicalintervention.
Currently,therearenodefinedstandardsexistingregardingthetimingofdecompressionand
stabilizationinspinalcordinjury.Theroleofimmediatesurgicalinterventionislimited.Emergent
decompressionofthespinalcordissuggestedinthesettingofacutespinalcordinjurywith
progressiveneurologicdeterioration,facetdislocation,orbilaterallockedfacets.Emergent
decompressionisalsosuggestedinthesettingofspinalnerveimpingementwithprogressive
radiculopathyandinthoseselectpatientswithextradurallesionssuchasepiduralhematomas
orabscessesorinthesettingofthecaudaequinasyndrome.
Aprospectivesurgicaltrial,theSurgicalTreatmentforAcuteSpinalCordInjuryStudy
(STASCIS)conductedbytheSpineTraumaStudyGroup,isongoing.Preliminarydatafromthis
studyareshowingthat24%ofpatientswhoreceivedecompressivesurgerywithin24hoursof
theirinjuryexperiencea2gradeorbetterimprovementontheASIAscale,comparedwith4%of
thoseinthedelayedtreatmentgroup.Furthermore,thestudyfoundthatcardiopulmonaryand
urinarytractcomplicationswerefoundtobe37%intheearlysurgerygroupcomparedwiththe
delayedgrouprateof48.6%.ThehopeisthatthefinaldatafromSTASCISwillbetterdefinethe
benefitsandtimingofearlysurgicaldecompressionandstabilization.
Areviewarticleofspinalfixationsurgeryforacutetraumaticspinalcordinjuryconcludedthat,in
theabsenceofanyrandomizedcontrolledstudies,norecommendationsregardingrisksor
benefitscouldbemade.[53]
Previousstudiesfromthe1960sand1970sshowedthatthepatientsexperiencedno
improvementwithemergentsurgicaldecompression,although2studiesinthelate1990s
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appearedtoshowimprovedneurologicoutcomeswithearlystabilization.Gaebleretalreported
thatearlydecompressionandstabilizationprocedureswithin8hoursofinjuryallowedfora
higherrateofneurologicrecovery.[54]Mirzaetalreportedthatstabilizationwithin72hoursof
injuryincervicalspinalcordinjuryimprovedneurologicoutcomes.[55]
Unfortunately,boththeabovestudiesandotherswerenotprospectivelycontrolledor
randomized.Intheonlyprospective,randomized,controlledstudytodeterminewhether
functionaloutcomeisimprovedinpatientswithcervicalspinalcordinjury,Vaccaroetalreported
nosignificantdifferencebetweenearly(<3d,mean1.8d)orlate(>5d,mean16.8d)surgery.
[56]
Complications
Neurologicdeterioration,pressuresores,aspirationandpulmonarycomplications,andother
complicationsfollowingspinalcordinjury(SCI)arebrieflydiscussedinthissection.
Neurologicdeterioration
Theneurologicdeficitofspinalcordinjury(SCI)oftenincreasesduringthehourstodays
followingacuteinjury,despiteoptimaltreatment.
Oneofthefirstsignsofneurologicdeteriorationistheextensionofthesensorydeficitcephalad.
Carefulrepeatneurologicexaminationmayrevealthatthesensorylevelhasrisen1or2
segments.Repeatneurologicexaminationstocheckforprogressionareessential.
Pressuresores
Carefulandfrequentturningofthepatientisrequiredtopreventpressuresores.Denervated
skinisparticularlypronetothiscomplication.Removebeltsandobjectsfrombackpockets,
suchaskeysandwallets.
Trytoremovethepatientfromthebackboardassoonaspossible.Somepatientsmayrequire
spinalimmobilizationinahalovestoraStrykerframe.Manypatientswithacutespinalcord
injuryhavestablevertebralfracturesyetneedlesslyspendhoursonahardbackboard.
Aspirationandpulmonarycomplications
Patientswithspinalcordinjuryareathighriskforaspiration.Nasogastricdecompressionofthe
stomachismandatory.
Pulmonarycomplicationsinspinalcordinjuryarecommon.Suchcomplicationsaredirectly
correlatedwithmortality,andbotharerelatedtothelevelofneurologicinjury.Pulmonary
complicationsofspinalcordinjuryincludethefollowing:
Atelectasissecondarytodecreasedvitalcapacityanddecreasedfunctionalresidual
capacity
Ventilationperfusion(V/Q)mismatchduetosympathectomyand/oradrenergicblockade
Increasedworkofbreathingbecauseofdecreasedcompliance
Decreasedcoughing,whichincreasestheriskofretainedsecretions,atelectasis,and
pneumonia
Musclefatigue
Othercomplications
Severesepsisorpneumoniafrequentlyfollowstreatmentwithhighdosemethylprednisolonethat
isfrequentlyusedinspinalcordinjury.
Preventhypothermiabyusingexternalrewarmingtechniquesand/orwarmhumidifiedoxygen.
Medication
ContributorInformationandDisclosures
Author
LawrenceSChin,MD,FACSRobertBandMollyGKingEndowedProfessorandChair,
DepartmentofNeurosurgery,StateUniversityofNewYorkUpstateMedicalUniversity
LawrenceSChin,MD,FACSisamemberofthefollowingmedicalsocieties:AlphaOmega
Alpha,AmericanAssociationfortheAdvancementofScience,AmericanAssociationfor
5/10
12/2/2015
CancerResearch,Children&#039sOncologyGroup,SocietyforNeuroOncology,Congress
ofNeurologicalSurgeons,AmericanAssociationofNeurologicalSurgeons,American
CollegeofSurgeons,PhiBetaKappa
Disclosure:Nothingtodisclose.
Coauthor(s)
SegunToyinDawodu,MD,JD,MBA,LLM,FAAPMR,FAANEMAssociateProfessorof
RehabilitationMedicineandInterventionalPainMedicine,AlbanyMedicalCollege
SegunToyinDawodu,MD,JD,MBA,LLM,FAAPMR,FAANEMisamemberofthefollowing
medicalsocieties:AmericanCollegeofSportsMedicine,AmericanAcademyofPhysical
MedicineandRehabilitation,RoyalCollegeofSurgeonsofEngland,AmericanAssociationof
NeuromuscularandElectrodiagnosticMedicine,AmericanMedicalAssociation,American
MedicalInformaticsAssociation,AssociationofAcademicPhysiatrists,InternationalSociety
ofPhysicalandRehabilitationMedicine
FassilBMesfin,MD,PhDAssistantProfessorofNeurosurgery,DirectorofComplexSpine
andSpineOncologyProgram,UniversityofMissouriColumbiaSchoolofMedicine
FassilBMesfin,MD,PhDisamemberofthefollowingmedicalsocieties:AlphaOmega
Alpha,AmericanAssociationforCancerResearch,AmericanAssociationofNeurological
Surgeons,AmericanMedicalAssociation,NationalMedicalAssociation,Congressof
NeurologicalSurgeons,AmericanAcademyofNeurologicalSurgery
ChiefEditor
BrianHKopell,MDAssociateProfessor,DepartmentofNeurosurgery,IcahnSchoolof
MedicineatMountSinai
BrianHKopell,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,
AmericanAssociationofNeurologicalSurgeons,InternationalParkinsonandMovement
DisorderSociety,CongressofNeurologicalSurgeons,AmericanSocietyforStereotacticand
FunctionalNeurosurgery,NorthAmericanNeuromodulationSociety
Disclosure:ReceivedconsultingfeefromMedtronicforconsultingReceivedconsultingfee
fromStJudeNeuromodulationforconsultingReceivedconsultingfeefromMRIInterventions
forconsulting.
Acknowledgements
DeniseICampagnolo,MD,MSDirectorofMultipleSclerosisClinicalResearchandStaff
Physiatrist,BarrowNeurologyClinics,StJoseph'sHospitalandMedicalCenterInvestigator
forBarrowNeurologyClinicsDirector,NARCOMSProjectforConsortiumofMSCenters
DeniseICampagnolo,MD,MSisamemberofthefollowingmedicalsocieties:AlphaOmega
Alpha,AmericanAssociationofNeuromuscularandElectrodiagnosticMedicine,American
ParaplegiaSociety,AssociationofAcademicPhysiatrists,andConsortiumofMultiple
SclerosisCenters
Disclosure:TevaNeuroscienceHonorariaSpeakingandteachingSeronoPfizerHonoraria
SpeakingandteachingGenzymeCorporationGrant/researchfundsinvestigatorBiogenIdec
Grant/researchfundsinvestigatorGenentech,IncGrant/researchfundsinvestigatorEliLilly&
CompanyGrant/researchfundsinvestigatorNovartisinvestigatorMSDxLLCGrant/research
fundsinvestigatorBioMSTechnologyCorpGrant/researchfundsinvestigatorAvanir
PharmaceuticalsGrant/researchfundsinvestigator
DanielJDire,MD,FACEP,FAAP,FAAEMClinicalProfessor,DepartmentofEmergency
Medicine,UniversityofTexasMedicalSchoolatHoustonClinicalProfessor,Departmentof
Pediatrics,UniversityofTexasHealthSciencesCenterSanAntonio
DanielJDire,MD,FACEP,FAAP,FAAEMisamemberofthefollowingmedicalsocieties:
AmericanAcademyofClinicalToxicology,AmericanAcademyofEmergencyMedicine,
AmericanAcademyofPediatrics,AmericanCollegeofEmergencyPhysicians,and
AssociationofMilitarySurgeonsoftheUS
MiltonJKlein,DO,MBAConsultingPhysiatrist,HeritageValleyHealthSystemSewickley
6/10
12/2/2015
HospitalandOhioValleyGeneralHospital
MiltonJKlein,DO,MBAisamemberofthefollowingmedicalsocieties:AmericanAcademy
ofDisabilityEvaluatingPhysicians,AmericanAcademyofMedicalAcupuncture,American
AcademyofOsteopathy,AmericanAcademyofPhysicalMedicineandRehabilitation,
AmericanMedicalAssociation,AmericanOsteopathicAssociation,AmericanOsteopathic
CollegeofPhysicalMedicineandRehabilitation,AmericanPainSociety,andPennsylvania
MedicalSociety
RichardSalcido,MDChairman,ErdmanProfessorofRehabilitation,Departmentof
PhysicalMedicineandRehabilitation,UniversityofPennsylvaniaSchoolofMedicine
RichardSalcido,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyof
PainMedicine,AmericanAcademyofPhysicalMedicineandRehabilitation,American
CollegeofPhysicianExecutives,AmericanMedicalAssociation,andAmericanParaplegia
Society
TomScaletta,MDChair,DepartmentofEmergencyMedicine,EdwardHospitalPast
President,AmericanAcademyofEmergencyMedicine
TomScaletta,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyof
EmergencyMedicine
DonaldSchreiber,MD,CMAssociateProfessorofSurgery(EmergencyMedicine),
StanfordUniversitySchoolofMedicine
DonaldSchreiber,MD,CMisamemberofthefollowingmedicalsocieties:AmericanCollege
ofEmergencyPhysicians
Disclosure:AbbottPointofCareIncResearchGrantandSpeakersBureauSpeakingand
teachingNanosphereIncGrant/researchfundsResearchSingulexIncGrant/researchfunds
ResearchAbbottDiagnosticsIncGrant/researchfundsNone
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraska
MedicalCenterCollegeofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:MedscapeSalaryEmployment
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