Spinal Cord Injury

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Spinal Cord Injury

• SCI

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Spinal Cord Injury

• Etiology
• Males, 15-30 years old, risk takers
• cord compression by bone displacement
• interruption of blood supply to the cord
• traction of the cord
• A patient with a head injury must be presumed to
  have SCI
• MVA, Falls, Sports
• Violence related injuries on the rise
• 8,000-10,000 NEW SCIs per year in US

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Classification

• Mechanism flexion, hyperextension, rotation, and
  compression
• Level
• cervical C1-C8--50
• thoracic T 1- T12--33
• lumbar L1-L5--the remainder
• Degree complete or incomplete

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Common Mechanisms of Injury
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Complete SCI

• Results in flaccid paralysis and total loss of
  sensory and motor function below the level of the
  lesion
• If cervical cord involved, paralysis of all four
  extremities, resulting in quadriplegia
• Thoracic or lumbar cord results in paraplegia

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Incomplete SCI

• Anterior Cord Syndrome
• disrupted blood flow through the anterior spinal
  artery mixed loss of sensory and motor function
  
• only the dorsal column which controls
  proprioception is fully preserved

• Brown-Sequard
• penetrating trauma,
• ipsilateral motor function and proprioception is
  lost
• contralateral pain and temperature are lost
• The extremities that can move cant feel, and
  those that can feel cant move

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Incomplete SCI(Good diagram in your text, page
1724)

• Central Cord Syndrome
• hyperextension with hemorrhaging in center of
  cord
• U/E gt impaired than the L/E

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Complete SCI

• Level of Complete Injury Determines Sensory and
  Motor Functioning
• Below Level of Injury, Patient Will have No
  Senses, No Function
• May have some degree of Rehabability depending
  on level, patient, age, attitude, training, use
  of adaptive devices

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Dermatones What Innervates What
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Quadriplegia

• C 6 Still ? respiratory reserve
• Have full biceps, weak thumb grasp, shoulder
  rotation, back shoulder abduction
• Some transfer, some self care with devices
• C 7- C-8 Still ? respiratory reserve
• Triceps, finger mvt. Better grasp
• Self transfer, rollover sit up in bed,most self
  care, drive wheelchair and car w/ adaptive
  devices

• C 1-3 Often Fatal
• If lives, No Respiratory ability
• Ventilator dependent
• Only functioning from chin, face, tongue
• C 4 Still no respiratory ability-Vent dependent
• Sensory and Motor functioning from neck up
• C5 Some respiratory ability but ? reserve
• Havel neck, partial shoulder back, biceps
• Some use of hands w/ supports ( feeding)

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Paraplegia

• T 1-T6 Full innervation of upper extremity
• Still with ? Resp. reserve
• ? trunk stability
• No ambulation
• No Bowel/Bladder
• T7-12 Full Respiratory Reserve
• Stable trunk
• Ambulate/ stand w/ devices
• No bowel/Bladder

• L1-L2
• Varying leg control
• Low back instability
• L3-L4
• No Hamstring function
• Full bowel and Bladder Continence

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Emergency Care of SCI(A-B-C-D-E)

• Airway
• jaw thrust maneuver
• neutral position
• intubation
• additional O2

• Breathing
• diaphragm-C3 C4 C5
• intercostals C2-C7
• abdominal T1-T12
• therefore cervical lesions paralyze accessory
  muscles and threaten diaphragm function
• manual ventilation

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Emergency Care of SCI

• Circulation
• hemorrhage difficult to assess because abdominal
  pain and muscular rigidity may be absent
• neurogenic shock masks hypovolemia
• fluids (LR)
• meds dobutamine and dopamine

• Disability
• baseline neuro evaluation
• Exposure
• remove clothing
• log roll
• poikilothermia
• hypothermia worsens bradycardia
• sweating lost below level of lesion

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Spinal Shock(Neurogenic Shock)

• Occurs quickly after SCI
• Loss of motor, sensory, reflxic, and autonomic
  functioning below level of injury
• Loss of sympathetic innervations causes unopposed
  parasympathetic responses
• Vasodilatation, venous pooling, hypotension,
  bradycardia, loss of temperature control

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Vital Signs????In Neurogenic or Spinal Shock??

• Heart Rate????
• SLOW--40-70 RANGE
• Blood Pressure???
• LOW---SBP 60-90
• Respirations?
• Depending on level of injury
• Temp?
• Depending on Environment

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Medical Intervention in SCI

• High dose steroids within 8 hours to limit
  swelling
• Reduction, spine realigned through traction
  device
• Surgery to remove bony fragments, drain hematoma
• Fixation, stabilizing vertebral fractures with
  hardware ( Gardner Wells Tongues or halo vest)
• Fusion attaching injured vertebrae to uninjured
  with bone grafts and steel rods
• Immobilization devices halo vest, body cast,
  brace

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Head to Toe Physical Exam

• Three Clinical Manifestations
• neck or back pain
• sensory or motor deficits
• spinal deformity
• Diagnostics
• X-ray detects most lateral Cx SCI
• CT reveals bony fragments and spinal cord
  compression
• MRI reveals cord impingement, hematoma and infarct

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Nursing Interventions Respiratory

• ASSESS
• Breath sounds
• ABGs
• tidal volume
• vital capacity
• skin color
• breathing patterns
• subjective comments
• amount and color of sputum

• DO
• chest physiotherapy
• postural drainage
• incentive spirometer
• suctioning
• antibiotic therapy
• DVT protocol for PE
• ROM

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Nursing InterventionCardiovascular

• Unopposed vagal response- bradycardia
• Loss of sympathetic tone-chronic low BP
• Diminished venous return-DVT
• Vital Signs HR, Orthostatic Hypertension
• Vasopressor agents dopamine and fluids
• Compression stockings
• DVT Protocol
• ROM
• Hgb, Hct-monitor for internal bleeding

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Nursing Intervention Fluid and Nutrition

• Paralytic Ileus NG tube to suction
• Catabolism high protein, high calorie for energy
  and tissue repair
• TPN prn
• increased roughage
• anorexia
• pt. need for control

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Nursing InterventionBowel and Bladder

• Bowel (constipation)
• suppositories, stool softeners
• BS Q 4 hours
• note N V
• establish bowel routine
• bulk, fiber, fluids

• Urinary (retention)
• catheter indwelling progress to intermittent
• palpate bladder
• fluid restrictions0
• acidify urine
• low calcium diet
• BUN/Creatinine
• Crede

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Nursing InterventionSensory Deprivation
Reflexes

• Sensory Deprivation
• stimulate pt. above level of injury
• conversation, music aromas, interesting flavors
• prism glasses
• altered sensorium, vivid dreams
• disrupted sleep patterns

• Reflexes
• can be inappropriate and excessive
• erections
• spasms
• spasticity

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Nursing Intervention Skin Integrity, Injury, Pain

• Skin integrity
• inspect Q 2 hrs
• turn Q 2 hours
• rotational bed
• clean and dry skin

• Injury
• use padded side rails
• anticipate needs
• Pain
• positioning
• antispasmodic agents
• analgesics
• use slow, gentle versus sudden movements

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Nursing Intervention Temperature Stress Ulcers

• Thermoregulation
• no vasoconstriction, piloerection, perspiration
• temperature is largely controlled by environment

• Stress ulcers
• physiological response to stress
• psychological stress
• high dose corticosteroids
• peak incidence 6-14 days s/p injury
• H2 blockers prophylactically

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Autonomic Dysreflexia

• Hypertensive crisis in SCI above T6 (sympathetic
  outflow)
• Noxious stimulus below the level of SCI triggers
  the SNS, causing a massive release of
  catecholamines.
• Increased BP stimulates the baroreceptors to send
  an inhibitory signal to the medulla.
• Cont.

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• The inhibitory impulses cant transverse the cord
  lesion. Vasodilatation occurs above the injury
  red, flushed, warm skin, headache and nasal
  congestion.
• Below the lesion, the skin turns cold, producing
  goosebumps.
• Vagal stimulation induces bradycardia as a
  compensatory mechanism to lower CO and BP. Cant
  lower BP to WNL.
• The HTN if left untreated can lead to MI, Stroke,
  intracranial hemorrhage

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Nursing Interventions Autonomic Dysreflexia

• Remove noxious stimuli
• urinary catheterization
• fecal impaction
• tight clothing
• pain stimulation
• HOB 45
• Alpha blocker, vasodilator
• Vital signs monitoring
• Patient and family education

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Will I Ever Walk Again?

• Multidisciplinary/Team approach
• Grieving Process shock and denial, anger,
  depression, adjustment , focus on rehab.
• Nursing Diagnoses
• Self-care deficit
• Altered family processes
• Risk for ineffective coping
• Alteration in body images
• Sexual dysfunction

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Then What.

• Keeping these individuals alive longer and
  longer huge social implications
• Issues of an immobile lifestyle high
• risk of Disease, Diabetes
• GI problems Colon CA , bowel deterioration, Gall
  Bladder DX-7X freq.
• GU Infections, Bladder CA- 9 Xfreq.