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
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
Spinal Cord Injuries Causes (in order of frequency) MVA Gunshot wounds/acts of violence Falls Sports injuries
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
Classification of SCI Mechanism of injury Flexion (bending forward) Hyperextension (backward) Rotation (either flexion- or extension- rotation) Compression (downward motion)
Pathophysiology of SCI Insert stuff here Insert picture here
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
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
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
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.
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.
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.
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!
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.
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
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.).
Cardiovascular system C1 – T5 shows decreased or absent SNS influence. BRADYCARDIA AND HYPOTENSION (due to vasodilation)
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
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!
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
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
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?)
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
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
Surgical Therapy Reduces injury and stabilizes the SC Done for Compression Bony fragments in the cord Compound fracture Penetrating trauma
Drug Therapy Vasopressors (Dopamine) to keep mean arterial pressure greater than 80mm to 900mm/Hg so that PERFUSION TO CORD is improved.
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
Other drug therapy Symptom-reducing drugs for GI problems - zantac, tagamet, pepcid Bradycardia - atropine Hypotension - vasopressors bladder spasticity - anticholinergics autonomic dysreflexia – blood pressure reduction
Function of Motor Neurons Upper motor neurons
Function of Motor Neurons Lower motor neurons
Diagnoses and Interventions Impaired Gas Exchange r/t muscle fatigue and weakness Decreased Pao2, increased PaCO2 Fatigue Diminished breath sounds
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
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
Decreased cardiac output Related to venous pooling of blood and immobility as evidenced by Hypotension Tachycardia Restlessness Oliguria Decreased pulmonary artery pressures
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
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
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
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
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!!!
Urinary Retention Related to injury and limited fluid intake as evidenced by Decreased output Bladder distention Involuntary emptying of bladder
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
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!
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!
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
Acute intervention Immobilization Crutchfield tongs Halo vest Stryker bed Roto-rest bed (side to side) Motion sickness a problem with these.
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
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!
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
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