2VA SCI/D CENTERSSCI/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
323 VA SCI/D Centers serve ~42,000 veterans with SCI/D Spinal Cord Injury and Disorders CenterPuerto Rico23 VA SCI/D Centers serve ~42,000 veterans with SCI/D
4SCI/D CENTERS Referral base: Local trauma centers/hospitals - Veterans Department of Defense – Active dutySpoke sites - VeteransLocal primary care providers including CBOCsStandards of care:VHA Handbook 1176CARF (Rehab Accreditation) standardsConsortium for Spinal Cord Medicine Clinical Practice GuidelinesAcuity:Acute medical conditionsComplications of chronic SCIRespite careAnnual evaluations
5SCI/D Hubs & Spokes Each CENTER has inpatient and outpatient services. SCI/D Centers provide :Primary care for veterans with SCI/D in the local areaAcute rehabilitation and tertiary care for veterans referred from the Spoke sitesEach SPOKE site provides primary care and outpatient services for veterans with SCI/D.
6CLEVELAND SPOKE SITESAlso West Virginia, eastern Indiana, northern Kentucky
7CLEVELAND SCI/D CENTER 32 bed inpatient unitSCI outpatient clinic, home care & telemedicine programMDs: Physiatry (PM&R, Internal Medicine, NeurologyInterdisciplinary:Physical Tx -Rehab nursingOccupational Tx -Recreational TxSCI Psychology -Social workResearch: close affiliation with FES & APT Centers
8KEY 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.
9KEY POINTSEven if the patient needs to stay on medical floor SCI Service will help with:Prognostication and classification of SCIRehabilitation evaluationBowel programBladder managementSpasticity managementSkin/Wound issuesRespiratory issuesTreatment of Autonomic Dysreflexia
10KEY POINTSPrognostication – 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.)
11EMERGENCIES IN SPINAL CORD INJURY There are two common SCI emergenciesAUTONOMIC DYSREFLEXIA (AD)IS AN ACUTE HYPERTENSIVE EVENTMUCUS PLUGSCAN CAUSE ACUTE RESPIRATORY DISTRESS OR RESPIRATORY FAILURE
12Areas of Autonomic Dysfunction after Spinal Cord Injury Cardiovascular FunctionRespiratory FunctionGI functionLower Urinary Tract FunctionSexual FunctionSudomotor FunctionThermoregulation
14AUTONOMIC 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
20AUTONOMIC DYSREFLEXIA: CAUSES Distended bowel or bladderUTI, Kidney stonesMenstruation, pregnancy, labor, deliveryGastric ulcerSunburn or insect bitesSexual intercourse, ejaculationScrotal compressionDVT and PEConstrictive clothingIngrown toenailHeterotrophic Ossification, FracturesInfection, Pressure ulcers, Pain
21SIGNS 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’sAD Symptoms:BradycardiaPounding headacheNasal stuffinessProfuse sweating usually above the LOIGoose bumps usually above the LOIFlushing or blotches usually above the LOIBlurred vision or spotsFeelings of anxietyCardiac arrythmiasAND THEN THERE IS SILENT AD
22TREATMENT 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).
26THE SCI CENTER AD PROTOCOL Developed from Spinal Cord Consortium CPG & SCI Model Center guidelines and local policy.Protocol basicsCHECK BLOOD PRESSURE + PULSE Q2-5MINUTESSIT THE PATIENT UP / LOOSEN CLOTHINGREMOVE SPLINTS + SHOES / CHECK SKIN +TUBES + BODY POSITIONCHECK BLADDER / CATHETERSCHECK BOWEL LASTUSE MEDS: LIDOCAINE GELfor changing caths or bowel checksNITROPASTE 1 INCH:when BP is above 150
29WRAP 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!
30Case Study54 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?
31Case Study54 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
32Somatic 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 ventilationC6-8 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.
33Respiratory Dysfunction following SCI PneumoniaAtelectasisBronchitisRestrictive Airway SyndromeSleep ApneaRespiratory InsufficiencyDyspnea on ExertionLeading Cause of Death
34MUCUS PLUGS Mucus plugging may present with acute dyspnea. Patient may be misdiagnosed with pulmonary embolism or pneumoniaAggressive pulmonary toilet by RT is essential to assist withremoving mucus plugsChest vestMetanebs (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.