SPINAL CORD INJURY

Spinal Cord Injury Approx 12 thousand new injuries per year 81% of SCI are males 60% of SCI between 16-30 yrs old 4,800 SCI die prior to reaching the hospital 6,000 die in MVA d/t cervical fractures 1/3 are due to no seatbelt use and ejection from car

Annual cost $2.4 billion per year 1st Year $417,067 After $74,707 Usually die within first year After that about a normal life expectancy MVA- 48% Falls- 27% Violence - 15% Sports- 7% Other 8%

Spinal Cord Injury Trauma to the spinal cord of sufficient force to dislocate or fracture the vertebrae and produce damage to the spinal cord resulting in loss of sensory and motor function

Types of injuries Compression fracture- Squashed Burst fracture Vertebral dislocation Fracture

Cord Lesions Total Transection- complete severing of the cord with loss of movement and sensation below the level of the injury Incomplete lesion-partial severing of the cord with loss of either motor or sensory function below the level of the injury. This varies but usually both are not loss

INCOMPLETE LESIONS Anterior Cord- Due to hyperflexion injuries associated with fracture-dislocation of a vertebrae. Loss of pain, temperature and motor function. Light touch, position and vibration sensations intact. Central Cord- Injury or edema of the central cord in the cervical area. Hyperextension injury. More motor loss in the upper extremities than the lower. Sensory varies. Variable bowel and bladder

Posterior cord- Hyperextension (not common) Injury to the posterior spine therefore loss of proprioception but no loss of pain, sensation, temperature or motor function. Brown-Se’quard Syndrome- transection of a portion of the spinal cord but not complete (GSW, Stab, fracture). Ipsilateral paralysis along with loss of touch, pressure, vibration.

Assessment At or above C4=Loss of respiratory control At or above C5=Quadriplegia Between T1-T11=Paraplegia/Loss of bowel and bladder control

Spinal Shock Results in the portion of the cord that is severed, resulting in complete loss of motor, sensory, reflex and autonomic function below the level of the injury. Flaccid paralysis Loss of all spinal reflexes Loss of all sensations Loss of ability to perspire Bowel and bladder dysfunction

Usually lasts for 1-6 weeks after injury but may last longer The earliest indication of end of spinal shock is the anal reflex After Spinal shock, amount of functional recovery can be determined

Neurogenic Shock Results from damage to the neurons that control the blood vessels in the lower abdomen and legs. Temporary disruption of the autonomic nervous system resulting in cardiovascular changes ?

Management of clients with SCI Every Trauma client has a spinal Cord injury until proven otherwise Immobilize Collar, Manual, Spinal Board Move as a unit Cervical Tongs- Immobilization via weights and pulley Halo Traction-skull screws, vest and supporting rods Thoracic and Lumbar stabilization Fiberglass/plastic body jacket Canvass corset

Nursing Care Maintain alignment Pin Care Prevent complications of immobility Kinetic Bed Stryker Frame Halo Traction Allows for the immobilization of the cervical spine with correct alignment on a long term basis Able to mobilize earlier to prevent complications

Halo Traction Care Move client as a unit-NEVER pull by bars Pin Care No Pillow Check edged of vest for roughness Check skin around vest for breakdown Wash skin under jacket daily Allow inner lining to dry completely Do not use powder under jacket

Steroid Therapy Used if injury is less than 8 hours old Lesion is above L2 Possible contraindicated Pregnancy < 13 years Penetrating wounds TB/Infections HIV Diabetes

High Dose methylprednisolone Has resulted in recovery of neurological function. Decreases/prevents edema Bolus 30 mg/kg of body weight administered over 15 min. Wait 45 minutes then begin drip of 5.4 mg/kg/hr over the next 23 hours

Multisystem effects of SCI Respiratory System Respiratory dysfunction related to the level of injury Compromising the diaphragm major factor in respiratory involvement Above C5, Diaphragm involvement C5-T6, diaphragm spared but intercostals are involved Immobilization

Cardiovascular System Vasodilation below the level of injury results in lowered BP Orthostatic Hypotension Bradycardia Vagal stimulation sensitive Treat with anticholinergics Dysrhythmias ? DVT Immobility Hypotension/bradycardia

Gastrointestinal System Gastric Dilation and paralytic ileus Loss of bowel function Constipation Suppository QOD Stool Softeners Hi PRO, Hi Cal, Hi Bulk, Hi CHO Diet Gastric Ulcers Common 6-14 days after injury Stress/ Trauma/High Dose Steroids

GU System Major involvement Atonic Bladder causes urinary retention ? Dysreflexia Foley catheter ASAP progressing to intermittent catheterizations

Integumentary system Pressure ulcers and breakdown Once developed difficult to heal Special beds and appliances

Autonomic Dysreflexia A generalized body reflex response to a local stimuli. There is an intact reflex arch that doesn’t communicate with the brain. Caused by a local stimulation Distended bladder Fecal impaction Decubitus Ulcer Skin irritation Pain

Clinical Manifestations Hypertensive Crisis Bradycardia Severe headache Piloerection below the level of injury Sweating above the level of injury Blurred vision nasal stuffiness Convulsions

Life Threatening Medical Emergency Sit the Client up 45 degrees (decrease BP) Notify MD Remove stimulant Catheterize Check for impaction Remove shoes, covers etc Administer Antihypertensives

Spasticity State of excessive muscular tonus Increases gradually over 1-2 years then begins to decrease Arms are flexed and pronated, legs are extended and adducted Not a return of function

Management Control of aggravating factors Physical Therapy Cold Anxiety Fatigue Emotional Distress Infections Impactions Physical Therapy ROM Antispasmodics Baclofen Dantrolene Possible Cordotomy

Sexual Dysfunction LMN Incomplete lesions- 83% Psychogenic erections and 90% able to have coitus. No ejaculation or orgasm. Females- Lack sensation during intercourse. Can become pregnant. Early C section to prevent dysreflexia Males with UMN Lesions (Rectal Sphincter) 70-80% can consummate coitus. Most cannot ejaculate or have orgasm LMN complete Lesions 25% can have psychogenic erections. No coitus, ejaculation or orgasm

Emotional Support Goes through the grief process Allow them to express feelings Encourage a positive attitude by recognizing Use crisis interventions to mobilize coping mechanisms Assist with families emotional needs Treat Family and client as a unit Counseling and spiritual support Include client in decision making Do not avoid the sexual counseling

Rehabilitation Begin as soon as stable in the hospital Encourage independence for self care needs Use of braces, wheelchairs and other assistance devices Long Term Physical Therapy, Vocational rehab Continued Counseling Community Resources Social Services Home Care Support Groups