1.  http://www.rexdonald.com/facts.html http://www.rexdonald.com/facts.html  http://www.cureparalysis.org/statistics/ http://www.cureparalysis.org/statistics/

2. Spinal Cord Injuries  Life expectancy greatly increased since WW II.  Intermittent catheterization  Medications, equipment, etc  Cause of premature death in QUADS is usually related to COMPROMISED RESPIRATORY FUNCTION

3. Spinal Cord Injuries  Who’s at risk?  ADULT MEN BETWEEN 15 AND 30 YEARS  Anyone in a risk-taking occupation or lifestyle  SCI in older clients increasing largely due to MVAs

4. Spinal Cord Injuries  Causes (in order of frequency)  MVA  Gunshot wounds/acts of violence  Falls  Sports injuries

5. Spinal and Neurogenic Shock  Below site of injury:  Total lack of function  Decreased or absent reflexes and flaccid paralysis  Lasts from a week to several months after onset.  End of spinal shock signaled by muscular spasticity, reflex bladder emptying, hyperreflexia

6. Classification of SCI  Mechanism of injury  Flexion (bending forward)  Hyperextension (backward)  Rotation (either flexion- or extension- rotation)  Compression (downward motion)

7. Pathophysiology of SCI  Insert stuff here  Insert picture here

8. Classification of SCI  Level or Injury  Cervical (C-1 through ??)  Thoracic (T-1through ??)  Lumbar (L-1through ??)  Degree of Injury  Complete  Total paralysis and loss of sensory and motor function although arms or rarely completely paralyzed  Incomplete or partial

11. http://www.sci- recovery.org/sci.htm

13. Degree of Injury  Complete transection  Total paralysis and loss of sensory and motor function although arms or rarely completely paralyzed  Incomplete (partial transection)  Mixed loss of voluntary motor activity and sensation  Four patterns or syndromes

14. Incomplete cord patterns  Insert picture of cord here  Central cord syndrome More common in older clients  Frequently from hyperextension of spine  Weakness in upper and lower ext, but greater in upper.  Anterior cord syndrome  Posterior cord syndrome  Brown-Sequard syndrome

16. Anterior cord syndrome  Compression of the ant. Cord, usually a flexion injury  Sudden, complete motor paralysis at lesion and below; decreased sensation (including pain) and loss of temperature sensation below site.  Touch, position, vibration and motion remain intact.

18. Posterior cord syndrome  Assoc with cervical hyperextension injuries  Dorsal area of cord is damaged resulting in loss of proprioception  Pain, temperature sensation and motor function remain intact.

20. Brown-Sequard syndrome  Damage to one half of the cord on either side.  Caused by penetrating trauma or ruptured disk. ischemia (obstruction of a blood vessel), or infectious or inflammatory diseases such as tuberculosis, or multiple sclerosisBSS may be caused by a spinal cord tumor, trauma (such as a puncture wound to the neck or back),.  a rare SCI syndrome which results in  weakness or paralysis (hemiparaplegia) on one side of the body and  a loss of sensation (hemianesthesia) on the opposite side.

22. Clinical manifestations of SCI  Depend on the LEVEL and DEGREE of the injury!  Quadriplegia occurs with C-1 through C-8 injuries.  Paraplegia occurs with T-1 thru L-4.  SEE TABLE 57-3 ON PAGE 1725!

23. Clinical Manifestations of SCI  Respiratory  C1 – C3: Absence of ability to breathe independently.  C4 – poor cough, diaphragmatic breathing, hypoventilation  C5 – T6: decreased respiratory reserve  T6 or T7 – L4: functional respiratory system with adequate reserve.

24. What is the phrenic nerve?  The phrenic nerve stimulates the diaphragm to contract.  Two phrenic nerves (right and left) - injury to one or the other paralyzes contraction of only one half of the diaphragm but even hemi- (half) paralysis can significantly interfere with breathing for patients with lung disease.  The nerve arises from branches of the C3,4, and 5 nerve roots.  The phrenic nerve can be damaged by procedures exploring the neck & upper back

25.  Loss of the phrenic nerve on either side results in paralysis of the diaphragm on that side.  Paralysis of the diaphragm on one side results in less inflation of the lung on that side.  Whether this is physiologically significant (producing respiratory distress, hypoventilation/hypercapnia) depends on other aspects of a patient's pulmonary physiology (namely underlying chronic obstructive pulmonary disease [emphysema, bronchitis], pneumonia, etc.).

26. Cardiovascular system  C1 – T5 shows decreased or absent SNS influence.  BRADYCARDIA AND HYPOTENSION (due to vasodilation)

27. What is the VAGUS nerve?  The longest of the cranial nerves- exits out of the medulla and ends in the abdomen  It supplies sensory and motor function to the pharyngx  Supplies motor function to the muscles of the abdominal organs  Provides parasympathetic activity to the heart, lungs, and most of the digestive system

28. Urinary System  Atonic bladder with RETENTION in spinal shock.  Post acute phase – irritability causing dribbling or frequent urination.  Urinary infection and calculi from retention and distention.  INTERMITTENT CATHETERIZATION!

29. GI system  Decreased motility  Paralytic ileus  Gastric distention – intermittent NG suctioning  Increased H2 – administer H2 inhibitors such as Zantac or Pepcid in initial stages  Carafate and antacids later as prophyaxis  Intraabdominal bleeding! Remember, no pain or tenderness to warn you.  Watch for H/H decrease and impactions

30. Integumentary System  Pressure ulcers!  Muscle atrophy in flaccid paralysis  Contractures in spastic paralysis  Poikilothermism – the adjustment of body temp to room temperature  Decreased ability to sweat below lesion

31. Peripheral vascular system  DVT common but not detected easily  Pulmonary embolism a significant cause of death.  Doppler studies, measurement of extremity girth, impedance plethysmography (what the heck is this?)

32. Post Injury Assessment  Goals are to  Sustain life  Prevent further cord damage  Assessment of muscle groups; motor status  Against gravity  Against resistance  Both sides of the body  Ask to move legs, hands, fingers, wrists, then shrug shoulders

33. Post injury assessment (p.1726)  Thorough motor examination including position sense and vibration.  Sensory examination  Pinprick starting at toes and working upward  ALWAYS HAVE CLIENT CLOSE EYES OR LOOK AWAY! If he can see what you’re doing, he will answer accordingly.  Assess for head injury and ICP  X-ray, CT scan, EMG

34. Surgical Therapy  Reduces injury and stabilizes the SC  Done for  Compression  Bony fragments in the cord  Compound fracture  Penetrating trauma

35. Drug Therapy  Vasopressors (Dopamine) to keep mean arterial pressure greater than 80mm to 900mm/Hg so that PERFUSION TO CORD is improved.

36. Methylprednisolone (Solu-medrol)  Increases the recovery of function and is the SOC! IV bolus then continuous IV over a 23 hour period.  Improves blood flow and reduces edema in the SC

37. Other drug therapy  Symptom-reducing drugs for  GI problems - zantac, tagamet, pepcid  Bradycardia - atropine  Hypotension - vasopressors  bladder spasticity - anticholinergics  autonomic dysreflexia – blood pressure reduction

38. Function of Motor Neurons  Upper motor neurons

39. Function of Motor Neurons  Lower motor neurons

40. Diagnoses and Interventions  Impaired Gas Exchange r/t muscle fatigue and weakness  Decreased Pao2, increased PaCO2  Fatigue  Diminished breath sounds

41. Impaired gas exchange  Maintain patent airway  Assess respiratory status q 2 hours  Monitor ABGs  Provide aggressive pulmonary toilet; chest PT and quad-assist coughing  Assess strength of cough  Suction secretions

42. Inability to sustain spontaneous ventilation  Related to diaphragmatic fatigue or paralysis evidenced by  Dyspnea  Use of accessory muscles  Abnormal ABGS  Provide chest PT  Assist with mechanical ventilation  Provide emotional support

43. Decreased cardiac output  Related to venous pooling of blood and immobility as evidenced by  Hypotension  Tachycardia  Restlessness  Oliguria  Decreased pulmonary artery pressures

44. Decreased cardiac output  Monitor blood pressure, pulse and cardiac rhythm  Administer vasopressors to maintain MAP at 800mm/Hg or above  Apply pneumatic compression boots or stockings  Perform ROM at least q8h to aid in muscle contraction and venous return

45. Impaired skin integrity  Related to immobility and poor tissue perfusion  Inspect skin and areas around pins or tongs  Turn at least q2h and use kinetic table or other specialty care devices.  Insure adequate nutritional intake  INFORM family and client about risk of pressure ulcers

46. Constipation  Related to location of injury,  fluid intake, diet, immobility AEB  Lack of BM in over 2 days   bowel sounds  Palpable impaction  Hard stool or incontinence

47. Constipation  Auscultate bowel sounds and monitor abdominal distention  Note and report any nausea and vomiting  Begin bowel program when BS return and teach to client and family  Administer suppositories and stool softeners  Ensure appropriate fluid and fiber intake

48. Bowel program for SCI  Needs to be consistent  Give suppository after meal and place on toilet approx 30 minutes after.  Do this at same time each day!  Fiber, fluids and activity are important  Constipation leads to AUTONOMIC DYSREFLEXIA!!!

49. Urinary Retention  Related to injury and limited fluid intake as evidenced by  Decreased output  Bladder distention  Involuntary emptying of bladder

50. Urinary Retention  Palpate bladder every shift  During acute phase, insert indwelling catheter  Begin intermittent cath program when appropriate  Keep I and O and end fluids  Monitor BUN and creatinine  Crude (pronounced croo-DAY) manuever when voiding/cathing

51. Risk for AUTONOMIC DYSREFLEXIA  Assess for HTN, bradycardia, headache, sweating, blurred vision, flushing, nasal stuffiness/congestion  Reduce or eliminate noxious stimuli such as impaction, urine retention, tactile stimulation and skin lesions or pain!

52. Autonomic dysreflexia  Elevate HOB 43 degrees  Identify cause and eliminate  Take BP and pulse  Administer antihypertensives as ordered if hypertensive.  Call physician if interventions not effective  TEACH CLIENT AND CARGIVERS HOW TO PREVENT THIS!

53. Other diagnoses  Impaired physical mobility  Altered nutrition: < body requirements  Sexual dysfunction  Risk or injury r/t sensory deficits  Altered family processes  Risk for ineffective individual coping  Body image disturbance

54. Acute intervention  Immobilization  Crutchfield tongs  Halo vest  Stryker bed  Roto-rest bed (side to side)  Motion sickness a problem with these.

55. Respiratory dysfunction  Intubation if injury is high  Decreased tidal volume and shallow breathing lead to pneumonia and atelectasis  CPT and pain management  Prone position may be risky  Count to 10 test  QUAD COUGH technique to assist with ineffective abdominal muscles

56. Fluids and nutrition  Paralytic ileus common in 48-72 hours  When bowel sounds return:  High calorie, high protein, high fiber diet  Evaluate SWALLOWING before feeding!  EATING CAN BECOME A POWER STRUGGLE!

57. Bowel and Bladder mgmt.  Indwelling catheter initially  Intermittent catheterization when able  Monitor pH of urine (should be acetic!)  Ascorbid acid and Mandelamine (an antiseptic) given to keep down bacteria

58. Temperature control  NO vasoconstriction, piloerection or heat loss through sweating below level of injury  Do not over cool or over heat client. They only have the remaining upper portion of their bodies, generally, for temperature adjustment