A middle-aged construction worker had a significant fall on the job and presents with obvious high cervical spine injury. Which of the following statement(s) is/are true concerning his diagnosis and management?

a. A paradoxical breathing pattern in which the abdomen protrudes on inhalation may be observed

d. The patient’s extremities are likely to appear warm and well perfused despite the presence of hypotension

 Fractures to the axial spine, especially in the high cervical spine, can cause varying degrees of respiratory compromise. Patients with ventilatory failure from acute cord injury typically present with a paradoxical breathing pattern in which the abdomen protrudes on inhalation, creating a see-saw appearance. This is caused by paralysis of abdominal musculature and is seen with injuries as low as T-10 to T-11. Early endotracheal intubation and mechanical ventilation must be considered, even in patients who appear compensated on initial evaluation. There is a strong tendency for such patients to tire and develop respiratory failure a few hours after the injury

In addition to ventilatory compromise, high axial spinal lesions can cause significant hypotension, confusing the initial evaluation of the patient. Most CNS control of arterial tone is mediated through the sympathetic nervous system. In high thoracic and cervical spinal cord injuries, these controlling pathways may be interrupted, with subsequent loss of vasomotor tone. This results in hypotension even without significant blood loss. Unlike hypovolemic shock, the patient’s extremities are warm and well perfused. A prospective, randomized trial has suggested that high doses of methylprednisolone given within 8 hours of injury have improved neurologic recovery. Starting treatment with steroids more than 8 hours after injury results in worse recovery than the placebo and is not recommended.