A nurse is caring for a client with a complete C5 spinal cord injury who was admitted 2 hours ago following a fall. Which nursing action should be the priority?

This client has sustained a complete C5 spinal cord injury (SCI) and is in the immediate post-injury phase (2 hours post-admission). In this acute period, the primary threats to life are physiological instability and secondary injury to the spinal cord. The nursing priority must align with the ABC (Airway, Breathing, Circulation) framework and the prevention of further neurological deterioration. A C5 injury directly compromises the diaphragm and intercostal muscles, placing the client at immediate risk for respiratory failure.

Spinal immobilization is critical to prevent secondary injury from unstable vertebral fractures. The consensus guideline on trauma management emphasizes that prehospital and early hospital care must focus on strict spinal motion restriction to avoid exacerbating the injury ^[1]. Simultaneously, assessing respiratory status is non-negotiable because a C5 lesion disrupts innervation to the phrenic nerve (C3-C5) and intercostal nerves, leading to diaphragmatic weakness and ineffective cough. This directly threatens airway clearance and ventilation. The case report on cervical dislocation highlights that early decompression and stabilization are essential for neurological preservation, but only after the patient is systemically stabilized ^[2].

While monitoring for spinal shock (option 2) and assessing for sensation or movement below the injury (option 4) are important components of the neurological assessment, they are secondary to ensuring a patent airway and adequate breathing in the immediate post-injury phase. Spinal shock involves a temporary loss of reflexes and muscle tone below the injury level, but it is not immediately life-threatening unless accompanied by respiratory compromise. The rare complication of subacute post-traumatic ascending myelopathy (SPAM) described in the literature involves neurological deterioration days to weeks after trauma, not within the first hours ^[3], so it does not dictate the priority action at this time.

Autonomic dysreflexia (option 1) is a critical concern in clients with SCI at or above T6, but it typically develops after the resolution of spinal shock, not in the acute phase. It is triggered by noxious stimuli below the injury level and manifests with severe hypertension, bradycardia, and headache. This complication does not occur within the first few hours post-injury, making it an inappropriate priority for this client.

The Canadian C-Spine Rule study underscores the importance of systematic assessment and immobilization protocols in the prehospital and early hospital setting to identify and protect potentially unstable cervical injuries . The nurse must ensure that the cervical collar and spinal precautions are maintained while simultaneously evaluating the client's respiratory rate, depth, oxygen saturation, and ability to clear secretions. Any decline in respiratory function requires immediate intervention, including potential airway support.