Spinal Cord Injury LPN to RN Track Spring 2004

Significance Result of spinal cord compression Leading cause of death WITH GOOD CARE will be able to live within 5 years of previous life expectancy Nurses caring for spinal cord clients have to be able to encourage independence Many spinal cord clients end up in nursing homes, group homes

Mechanism of Injury Flexion Extension Flexion-rotation Compression

From Pathology For Health-related Professions

From Rehabilitation Nursing

From Rehabilitation Nursing

From Lewis

Degree of Spinal Cord Involvement Complete – Cord is severed and there is no movement below the level of injury Incomplete  Central cord – More common in adults. Compression of anterior horn cells. Motor weakness more in upper limbs Sensory depends on site of injury. Usually has bladder involvement. Recovery will depend on resolution of edema and how intact the spinal tracts are

From Rehabilitation Nursing

Degree of Spinal Cord Involvement Anterior cord syndrome – Often a flexion injury Immediate motor paralysis below level of injury Decreased sensation and loss of temperature below injury Posterior tracts are intact so sense of touch position, vibration and motion are intact

From Rehabilitation Nursing

Degree of Spinal Cord Involvement Brown – Sequard  Half of spinal cord is transected  Usually from penetrating injuries  Motor function, vibratory, and position sense are lost on side that is cut. Opposite side has loss of pain and temperature  These losses are below the level of injury

From Rehabilitation Nursing

Degree of Spinal Cord Involvement Posterior Cord Syndrome  From cervical hyperextension  Has damage to posterior part of the spinal cord with sensory neurons and position-sense  Loss proprioception  Pain, temperature, sensation and motor function remain intact

Pathophysiology Initial injury  Autodestruction – quickly after injury there is bleeding in the cord. Hemorrhage, edema and metabolites contribute to ischemia which leads to necrosis in the cord.  Within 4 hours there is infarction in the gray matter

Pathophysiology Hypoxia interferes with metabolic needs of the spinal cord There is a release of norepinephrine and vasospasms in the spinal cord This causes necrosis, more hypoxia and necrosis of the cord

Pathophysiology The spinal cord cannot increase its blood flow to compensate Damage is permanent in 24 hours Because the spinal cord has nowhere to expand to, edema from the injury will cause compression of the cord 2 vertebral spaces above and 2 spaces below. (If a client presents with an injury at C6 initial swelling will affect C4 though C8

Spinal Shock Damage from edema lasts 72 hours to 1 week Cannot tell extent of injury until edema subsides During spinal shock, the cord does not function below the level of injury Hypotension, bradycardia, and warm, dry extremities

Spinal Shock Peripheral vasodilation, venous pooling and decreased cardiac output Bowel, bladder and musculoskeletal systems are all affected Lasts for 7 to 10 days Hyperreflexia, reflex emptying of the bladder and spasticity mark the end of spinal shock

Complications Patent airway Adequate ventilation Adequate blood volume Prevent further cord damage

Respiratory C1-C4 loss of respiratory function Require being on ventilator Below C4 has diaphragmatic breathing if phrenic nerve is intact. Diaphragmatic breathing causes decrease in vital capacity and tidal volume Abdominal muscles are paralyzed so client cannot cough effectively to clear secretions

Cardiovascular Above T5 decreases the sympathetic system Parasympathetic has control and causes bradycardia, peripheral dilatation that results in hypotension May need medication to raise heart rate Watch for hypoxemia Causes decreased cardiac output

Urinary System Retention is big problem In spinal shock bladder will overfill Post acute bladder will partly empty as reflex and retain residual. Use intermittent cath to control this May have kidney and bladder stones

GI System Above T5 problems are related to hypomobility Risk for paralytic ileus Stress ulcers are common

Skin Big risk for skin breakdown Do pressure relief every 15 minutes when wheelchair Will need special bed Poikilothermism – cannot control body temperature below level of injury Assume temperature of their environment Also have decreased sweating

Metabolic Needs Need proper nutrition for healing May need tube feeding until can take sufficient PO

Peripheral Vascular DVT is a BIG problem Also prone to have PE – is leading cause of death

Drug Therapy Dopamine is used to keep MAP at This helps perfuse the spinal cord Methylprednisone (Solumedrol) is used to control edema and improve blood flow in the spinal cord

Drug Therapy Solumedrol  Reduce spinal cord ischemia  Improve energy balance  Restore extracellular calcium  Improve nerve impulse conduction  Repress release of free fatty acids from spinal tissue

Acute Care Keep head in alignment Protect cervical spine If traction is used must keep on at all times If has tongs, do pin care regularly If pins come loose, you will hear a clicking noise If has a halo vest be sure to do good skin care MUST HAVE WRENCH ATTACHED TO VEST AT ALL TIMES

From Lewis

Respiratory May need ET tube or trach Cannot effectively cough – suction or do quad cough Use incentive spirometry every 2 hours while awake

Cardiovascular Prone to hypotension – move and get up slowly. If BP bottoms out when you get the client up, lean them back in their W/C until this resolves Use TED hose to prevent DVT and help keep BP up. Also abdominal binder May need atropine IV or temporary pacemaker to keep HR up

Fluids and Nutrition In first couple of days is at risk for paralytic ileus May need an NG tube Evaluate swallowing in high cervical client before feeding them (hint: the gag reflex) Encourage roughage to help with bowels

Bowel and Bladder May retain urine Use Foley in acute phase, then use intermittent cathing schedule. Must done on a schedule and not PRN. Encourage fluids – will be prone to kidney stones Give stool softeners, laxatives and enemas to prevent impaction

Reflexes Families see the return of reflexes as a sign that client will recover. In most cases, this is not the case. If spasms are a problem, baclofen can be given either PO or by pump Warm baths might help

Autonomic Dysrreflexia Uncompensated sympathetic response to sympathetic response of autonomic nervous system Caused by visceral stimulation in client with injuries above T7 This is an emergency Aggravated by sensory stimulation for bladder, bowel, skin

Autonomic Dysrreflexia Symptoms:  Hypertension  Blurred vision  Throbbing headache  Diaphoresis above the level of injury (there is an error on your handout)  Bradycardia  Piloerection (gooseflesh)  Nasal congestion  Nausea

Nursing Interventions ELEVATE HOB Check Foley is there is one If no cath and has not been cathed lately cath client using Lidocaine jelly If has not had a BM lately – check for impaction using Lidocaine jelly If you need to give BP med, be aware that the BP will drop when the cause is found and corrected Remember Quads typically have a lower BP if their injury is old

Pediatric Considerations Most common spinal cord damage is from congenital causes Child’s bones don’t fracture as easily and may not show up on x-ray Child with function down to L3 will be able to walk Important to have child walk and be weight bearing to prevent osteoporosis and hypercalcemia

Females Female teen will have menses return in about 6 months. Is possible for quad teen to get pregnant This is a high risk pregnancy with high risk of autonomic dysreflexia during labor Quad may not be able to feel contractions and tell when she is labor

Sexual Function Males with upper motor neuron may have unpredictable erections that cannot be maintained. Ejaculation is not possible Males with a complete lower motor neuron cannot have erection Males with incomplete lower motor neuron have the best chance of erection and ejaculation. Sperm will have decreased number and motility