1. Spinal Cord Injury & Disorders (SCI/D) Service
M. Kristi Henzel, MD, PhD
Staff Physiatrist, SCI/D
Debbie Rovito, APRN, CNS
Clinical Nurse Specialist, SCI/D
June 21, 2013

2. VA SCI/D CENTERS
SCI/D includes traumatic and non-traumatic spinal cord injuries, multiple sclerosis (MS) , and amyotrophic lateral sclerosis (ALS)
Comprehensive system of care formalized in 1996 by the VA, that established a “Hub & Spokes System of Care” to provide acute, sub-acute, and life-long care to Veterans with SCI/Disorders

3. 23 VA SCI/D Centers serve ~42,000 veterans with SCI/D
Spinal Cord Injury and Disorders Center
Puerto Rico
23 VA SCI/D Centers serve ~42,000 veterans with SCI/D

4. SCI/D CENTERS Referral base: Local trauma centers/hospitals - Veterans
Department of Defense – Active duty
Spoke sites - Veterans
Local primary care providers including CBOCs
Standards of care:
VHA Handbook 1176
CARF (Rehab Accreditation) standards
Consortium for Spinal Cord Medicine Clinical Practice Guidelines
Acuity:
Acute medical conditions
Complications of chronic SCI
Respite care
Annual evaluations

5. SCI/D Hubs & Spokes Each CENTER has inpatient and outpatient services.
SCI/D Centers provide :
Primary care for veterans with SCI/D in the local area
Acute rehabilitation and tertiary care for veterans referred from the Spoke sites
Each SPOKE site provides primary care and outpatient services for veterans with SCI/D.

6. CLEVELAND SPOKE SITES
Also West Virginia, eastern Indiana, northern Kentucky

7. CLEVELAND SCI/D CENTER
32 bed inpatient unit
SCI outpatient clinic, home care & telemedicine program
MDs: Physiatry (PM&R, Internal Medicine, Neurology
Interdisciplinary:
Physical Tx -Rehab nursing
Occupational Tx -Recreational Tx
SCI Psychology -Social work
Research: close affiliation with FES & APT Centers

8. KEY POINTS Call us early (transfers OR consults)
When admitting an SCI pt through Urgent Care/ED after hours, page the SCI Attending on call if questions.
Pts are admitted to Medicine Service overnights and transferred to SCI Service the next day, IF appropriate from medical acuity standpoint.
Difference between admission to WSCI (6B floor for SCI nursing care) vs. SCI Service (physician management on WSCI).
Nursing acuity must be less frequent than q4hrs on WSCI/6B.
WSCI has no telemetry.

9. KEY POINTS
Even if the patient needs to stay on medical floor SCI Service will help with:
Prognostication and classification of SCI
Rehabilitation evaluation
Bowel program
Bladder management
Spasticity management
Skin/Wound issues
Respiratory issues
Treatment of Autonomic Dysreflexia

10. KEY POINTS
Prognostication – determination of functional recovery and rehabilitation potential.
Neurogenic Bowel – bowel care program best started early to avoid constipation, incontinence and skin breakdown.
Neurogenic Bladder – prevention of renal failure, hydronephrosis and skin breakdown due to incontinence.
Pressure Ulcer Prevention/Treatment – mattress type, turning q2h, avoidance of too much moisture. Wound treatments for new or chronic pressure ulcers.
Spasticity- if acutely changed from pt’s baseline, usually something else is wrong! (i.e. UTI, pressure ulcer, etc.)

11. EMERGENCIES IN SPINAL CORD INJURY
There are two common SCI emergencies
AUTONOMIC DYSREFLEXIA (AD)
IS AN ACUTE HYPERTENSIVE EVENT
MUCUS PLUGS
CAN CAUSE ACUTE RESPIRATORY DISTRESS OR RESPIRATORY FAILURE

12. Areas of Autonomic Dysfunction after Spinal Cord Injury
Cardiovascular Function
Respiratory Function
GI function
Lower Urinary Tract Function
Sexual Function
Sudomotor Function
Thermoregulation

13. Why should you care about AD?

14. AUTONOMIC DYSREFLEXIA
People with SCI who are at risk have injuries at T6 and above.
Noxious stimuli cause unopposed sympathetic reflex activity below the level of injury.
If untreated, acute elevation of BP may lead to stroke, seizures or myocardial infarction

15. Nervous System Organ Control

16. Nervous System Organ Control

17. Nervous System Organ Control

18. SNS
(tonic
stimulation)
SNS
T1-T5
PSNS
SNS
(~T5-L2)

19. X SNS (tonic stimulation) SCI SNS T1-T5 PSNS + + + SNS (~T5-L2) +
Noxious
stimuli
from
below
SCI level + +
Increased Afterload
vasoconstriction + + +
R=8mL/pr4 +

20. AUTONOMIC DYSREFLEXIA: CAUSES
Distended bowel or bladder
UTI, Kidney stones
Menstruation, pregnancy, labor, delivery
Gastric ulcer
Sunburn or insect bites
Sexual intercourse, ejaculation
Scrotal compression
DVT and PE
Constrictive clothing
Ingrown toenail
Heterotrophic Ossification, Fractures
Infection, Pressure ulcers, Pain

21. SIGNS AND SYMPTOMS OF AD
Sudden systolic/diastolic BP elevation mmHg above baseline.
Individuals with SCI Level of Injury (LOI) above T6 often have baseline SBP’s
AD Symptoms:
Bradycardia
Pounding headache
Nasal stuffiness
Profuse sweating usually above the LOI
Goose bumps usually above the LOI
Flushing or blotches usually above the LOI
Blurred vision or spots
Feelings of anxiety
Cardiac arrythmias
AND THEN THERE IS SILENT AD

22. TREATMENT OF AD To stop AD you have to identify and remove the cause!
We have a protocol for that!
To order the AD protocol for an at risk patient with SCI go to the SCI Admission Order Set.
With a few clicks you will allow the SCI nurses to start the protocol and safely search for the cause of AD using meds such as lidocaine gel and nitroglycerine ointment.
SCI Nursing will call when they initiate the protocol, and when they need further guidance (usually when they cannot find a cause, or they are really concerned about the patient and his blood pressure).

23. AD Protocol

24. AD Protocol

26. THE SCI CENTER AD PROTOCOL
Developed from Spinal Cord Consortium CPG & SCI Model Center guidelines and local policy.
Protocol basics
CHECK BLOOD PRESSURE + PULSE Q2-5MINUTES
SIT THE PATIENT UP / LOOSEN CLOTHING
REMOVE SPLINTS + SHOES / CHECK SKIN +
TUBES + BODY POSITION
CHECK BLADDER / CATHETERS
CHECK BOWEL LAST
USE MEDS: LIDOCAINE GEL
for changing caths or bowel checks
NITROPASTE 1 INCH:
when BP is above 150

29. WRAP UP ON AD AD ends when patient BPs return to baseline.
If the nurse calls you to report all the usual interventions have been tried and BP remains high what should you do?
Even when AD appears resolved, it can reoccur quickly. Nurses will continue to monitor BPs every half hour for two hours after AD ends.
Nurses will put official AD documentation related to their utilization of the protocol in a CPRS Nursing Treatment Note using an Autonomic Dysreflexia template.
At the bedside, the nurses use a worksheet that can guide you, also!

30. Case Study
54 yo man with C6 tetraplegia is admitted with pneumonia. He is a night float admission to a medical floor but will be transferred to SCI in the morning. At 3AM, the nurse calls to report the patient’s BP is 200/90. His BP was 90/60 when you admitted him.
What do you ask the nurse to do?
Once you open CPRS what do you do?
Who do you call next?

31. Case Study
54 yo man with C6 tetraplegia is admitted with pneumonia. He is a night float admission to a medical floor but will be transferred to SCI in the morning. At 3AM, the nurse calls to report the patient’s BP is 200/90. His BP was 90/60 when you admitted him.
What do you ask the nurse to do?
Once you open CPRS what do you do?
Who do you call next?
By the time you arrive to see how things are going, the early interventions have been done and it was found that the patient was turned on top of his Foley tubing. Once repositioned the bag filled with 600ml of urine and his blood pressure lowered to 90/60

32. Somatic Innervations of the Respiratory System
The main respiratory muscles are the diaphragm, intercostals and abdominals.
C1-2 SCI: diaphragm is paralyzed and ventilator is required to sustain life.
C3–5 SCI: diaphragm is partially denervated affecting inspiration. C4–C5 SCI do not require ventilation
C6-8 SCI: Primary inspiratory muscles are preserved, but inspiration and expiration impaired,
T1-12: Denervated intercostal Muscles affecting expiration >> inspiration.
T7-L2 SCI: Denervated abdominal muscles causing ineffective cough.

33. Respiratory Dysfunction following SCI
Pneumonia
Atelectasis
Bronchitis
Restrictive Airway Syndrome
Sleep Apnea
Respiratory Insufficiency
Dyspnea on Exertion
Leading Cause of Death

34. MUCUS PLUGS Mucus plugging may present with acute dyspnea.
Patient may be misdiagnosed with pulmonary embolism or pneumonia
Aggressive pulmonary toilet by RT is essential to assist with
removing mucus plugs
Chest vest
Metanebs (Continuous High Frequency Oscillation with positive pressure pulses OR Continuous Positive Expiratory Pressure +/- nebulized medications)
Mechanical In/Ex-sufflation (“Coughalator”)
Keep in mind that some high tetraplegics can quickly experience respiratory failure due to aging, use of opioids, and URIs.
Many individuals with SCI also have OSA.

35. Thank you for your attention!
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