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Review article.To review the pathophysiology and management of the pulmonary and hemodynamic derangements that occur after acute spinal cord injury.Acute spinal cord injury is often associated with alterations in pulmonary and cardiovascular function that require treatment in the intensive care unit.Review of published reports.Careful attention to the support of the pulmonary and cardiovascular systems can reduce the morbidity associated with acute spinal cord injury. Pulmonary function decreases markedly in the immediate postinjury period but improves in the subsequent weeks, allowing most patients with injury levels at C4 and below to be weaned from ventilatory support. Bradycardia and hypotension often accompany acute spinal cord injury, and management strategies are reviewed. The prophylaxis and diagnosis of thromboembolic disease are reviewed.