Traumatic spinal cord injury (tSCI) presents a complex pathophysiological model similar to traumatic brain injury (TBI), where primary mechanical damage is followed by secondary damage that spreads to adjacent tissues. While primary damage is irreversible, secondary damage offers a potential target for therapeutic interventions. The management of tSCI has evolved over the past decade, with guidelines primarily focusing on optimizing spinal cord perfusion to prevent secondary ischemic damage. Pre-hospital management remains challenging, with limited evidence guiding interventions such as vasopressor use, fluid resuscitation, and coagulation support. Current guidelines emphasize the importance of avoiding hypotension in the pre-hospital phase and suggest cautious MAP augmentation within safe limits to optimize spinal cord perfusion and recovery. MAP augmentation should be pursued by inotropes instead of fluid resuscitation with large volumes of crystalloids, even though the literature is quite limited. Emerging data suggest a possible role for tranexamic acid (TXA) in reducing intraspinal bleeding and improving outcomes, though its efficacy in humans remains to be fully established. Early, aggressive coagulation support is supported by animal model evidence, but it has never been challenged in clinical trials. Pre-hospital management of tSCI patients remains an area with very little robust evidence and undeniable difficulty in designing and conducting good-quality clinical trials. However, some evidence can be derived from retrospective and animal data and should guide our clinical practice.