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Neuro Rehab 2 > SCI 4 - Acute Management > Flashcards

SCI 4 - Acute Management Flashcards

1
Q

what are the things that need to be done when you arrive on scene at a SCI (4)

A

use of backboard
c collar
neutral alignment of spine
assess respiratory function
- maintain airway
- maintain adequate O2

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2
Q

what imaging and tests are done acutely

A

XR - affect region
CT - assess fx, fresh blood
MRI - assess lesion/cord injury
Hgb/Hct - severity of blood loss

*CT and MRI will look at lesions on SC itself

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3
Q

why is it important for IV fluids acutely

A

manage neurogenic shock
maintain cardiac function

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4
Q

what is a HUGE consideration of acute medical management? what are some examples that are reliant on this factor

A

TIMING

surgical depression
anticoag prophylaxis
baseline MRI

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5
Q

why is the timing of surgical decompression important

A

want to wait for swelling to dec
don’t want to wait too long

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6
Q

why is the use of methylprednisolone sodium succinate and hypothermia controversial and why is it sometimes utilized

A

MSS: steroid, dec inflammation and swelling
- controversy bc of secondary complications (ie cardiac)

hypothermia
- preserve neuro tissue thru dec swelling and metabolism

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7
Q

why is timing a consideration w anticoagulation prophylaxis

A

high risk for DVTs
- don;t want to prevent good clots w healing from injury

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8
Q

what should be considered other than timing w anticoagulation prophylaxis

A

neuro tissue doesn’t like blood and bleeding can cause death

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9
Q

what is the role of baseline MRI in decision making and prognosis

A

similar w stroke - not ab if, but when will get MRI

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10
Q

what are surgical options for management

A

decompression
alignment
spine supported w instruments
bone graft –> fusion

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11
Q

what could be done w a decompression and what are the goals

A

ORIF, might take out disc, decompress or fuse spine

  • want to take pressure off nerves running thru area
  • preserve communication in any viable neuro tissue
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12
Q

what is the goal of a bone graft

A

stabilize the spine

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13
Q

when is cervical traction indicated

A

cervical subluxation
cervical fx
cervical dislocation

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14
Q

what is cervical traction doing, when can it be implemented, and what are the goals

A

closed reduction

before or after surgery

decompress spine and take some pressure off

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15
Q

when are orthoses implemented acutely

A

in conjunction w surgical stabilization or instead of

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16
Q

what are examples of acute orthoses

A

TLSO
halo
c collar
minerva orthosis
miami j collar
jewett brace

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17
Q

how is the orthoses used acutely determined

A

level of SCI
how stable the spine is –> how rigid

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18
Q

why is orthostatic hypotension a common secondary complication post SCI

A

not getting vasoconstriction of ms and natural pumping mechanism from skeletal ms

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19
Q

what are possible secondary complications post SCI

A

respiratory/CV deficiencies
skin breakdown
ms atrophy
dec ROM/contractures
heterotropic ossification
osteoporosis
spasticity
pain
GI complications
UTI
impaired circulation: DVT, OH
autonomic dysfunction
decubitus ulcers

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20
Q

what is the leading cause of death in SCI and why

A

respiratory d/t impaired respiratory ms function

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21
Q

what are 3 common respiratory sequelae in SCI

A

pneumonia
atelectasis
PE

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22
Q

why is there an inc risk of retained secretions inc ICE

A

expiratory ms weakness leading to an ineffective cough

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23
Q

what are the 2 main ms impacted w inspiration and the corresponding SCI

A

neck ms - above C3
diaphragm - C3-5

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24
Q

what are the 2 main ms impacted w expiration and the corresponding SCI

A

intercostal ms - T1-12
ab ms - T7-12

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25
Q

what are causes/ factors that contribute the development of secondary respiratory sequelae

A
  1. expiratory ms weakness
  2. altered level of consciousness w concomitant head trauma or meds
  3. ileus
  4. failure to spontaneously sigh
  5. bronchial mucus hypersecretion
  6. associated rib fx
  7. associated thoracoabdominal surgery
  8. dysphagia and aspiration associated w tracheostomy or cspine surg w ant approach
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26
Q

how can ileus lead to secondary respiratory sequelae

A

ileus - temp lack of intestinal ms

w inc diaphragmatic excursion and inc risk of aspiration of gastric contents

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27
Q

why is bronchial mucus hypersecretion seen in 20% acute cspine SCI

A

impaired peripheral sympathetic nervous system

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28
Q

what can cause a DVT in general

A

dec rate of blood flow
damage to blood vessel wall
inc tendency of blood to clot

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29
Q

why is there an inc risk of DVT in SCI

A

immobilization
unable to move UE or LE d/t:
- absent strength
- impaired vasomotor control*
- fx

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30
Q

what are considerations for PT since population has inc risk of DVTs

A

TEDS, ace wraps, venodyn boots
see if IVC filter placed
on anti-coag therapy

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31
Q

what is the concern of DVTs in this population

A

it traveling and becoming PE
- partial or complete lung obstruction

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32
Q

what are sx of the onset of a PE

A

sudden sx of:
SOB
tachycardia
chest pain
blue tinge to fingers, toes, lips

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33
Q

what is heterotopic ossification (HO) and what can this be d/t

A

inc bone growth/calcification around joint (aka inc bone where shouldn’t be)

d/t trauma or hit to bone

34
Q

when does heterotopic ossification present in SCI

A

3-12wks post injury

35
Q

sx of heterotopic ossification

A

swelling
changes in end feel (-> bony)
dec ROM
inc in temp around area
redness

36
Q

where are the 4 most common sites of heterotopic ossification

A

most

hips
knees
shoulders
elbows

least

37
Q

what are common causes of UTIs in SCIs

A

common w voiding dysfunction
- bacteria enters bladder while catheterizing
- delayed use of toilet
- incomplete emptying of urine

38
Q

what are first signs of a UTI in SCI

A

fever
chills
pain w urination
acute cog changes
inc spasticity (UTI = nox stim)

39
Q

why is OH common in SCI

A

interruption of CV sensory input to brainstem and sympathetic nervous system in SC
-> loss of vasomotor control -> blood vessels not able to vasoconstrict effectively to counteract change in pressure –> venous pooling –> inc in HR w pressure change isn’t enough to counterbalance drop in BP

40
Q

what are PT interventions/considerations with OH

A

wear compression stockings and abdominal binder

tilt table and monitor VS

41
Q

when would we see an order for Midodrine and why is this helpful for PT

A

treats low bp / HoTN
admin prior to therapy

only in people whos low bp severely limits ADLs

OH can limit progression in therapy if dropping every time we do activity

42
Q

what is the most costly and frequent secondary complicaiton

A

pressure sores

43
Q

what are common sites of pressure sores

A

bony prominences
- sacrum/coccyx
- heels
- greater troch
- ischial tub
- scap

44
Q

what impacts does pressures sores have

A

mobilty
positioning / off loading
QOL

45
Q

where does sympathetic vs parasympathetic system live

A

sympathetic - tspine
para - brain

46
Q

what is the cause of autonomic dysreflexia

A

SCIs above T6
- interrupts sympathetic splanchnic outflow and the pathological autonomic reflex

–> leads to an abnormal response to noxious stim and sends body into fight or flight

47
Q

what are examples of a noxious stim that may trigger autonomic dysreflexia and what is the most common

A

***bowel/bladder distention/irritation **
pressure sore
restrictive clothing
cutaneous stim
DVT
sex
labor
sunburn
bug bite
estim
fx

48
Q

what are s/sx of autonomic dysreflexia

A

HTN
bradycardia
pounding HA
red/blotchy face
blurry vision
constricted pupils

49
Q

what do you do if someone goes into autonomic dysreflexia

A

find and correct source of noxious stim
sit person upright if possible
- trying to dec BP
- call for assistance ASAP this is a red flag

50
Q

why is autonomic dysreflexia a red flag

A

can be fatal bc can stroke out when goes into HTN as HR slows down

51
Q

what are 4 common causes of death post SCI

A
  1. respiratory complications
    - pneumonia / PE
  2. CV dz and autonomic dysfunction
  3. external causes - subsequent injuries, homicide, suicide (most common)
  4. wound infection
52
Q

what are spinal precautions

A

no excessive bending/twisting
maintain log roll always
- spine in neutral alignment for mobility, no segmental
no lifting >10# or what indicated by MD
c collar worn always or per MD order

53
Q

what is an important part of following spinal precautions w pts

A

vary MD to MD and depending on pt
- ask when they need the brace/collar on and when is it okay not to

54
Q

what are acute care PT priorities

A

pain
respiratory / ventilation
integument
sensation
ms performance
ROM
ms tone and DTR
functional status

55
Q

nociceptive vs neuropathic pain

A

nociceptive:
- msk and visceral
- from activation of nerve endings or nociceptors in peripheral tissues

neuropathic:
- direct consequence of lesion or dz affecting somatosensory system / injury to nerves themselves
- very common in SCIs

56
Q

how does neuropathic pain present

A

tingling
burning
electric shock
cold
pricking
pins and needles
squeezing
sharp/shooting

57
Q

what are 2 ways to assess pain

A

VAS - visual analog scale
NPS - neuropathic pain scale

58
Q

what are treatments for neuropathic pain and what is the challeng w them

A

difficult to treat

pharm: antileptics (gabapentin), tricyclic antidepressants, anticonvulsants, opioids, cannabinoids, baclofen

non-pharm: positioning, surgical (ie nerve block), TENS, acupuncture

59
Q

how can TENS help to treat neuropathic pain and what is limitation

A

stimulating nerve endings
TENS units are like bandaids
- helps them function while it is on and dec pain
- doesn’t carryover when you take off

60
Q

what are characteristics of respiratory/ventilation PT addresses acutely

A

function of respiratory ms
chest expansion
breathing pattern
cough
vital capacity

61
Q

what impact does the position have on breathing in higher level SCI and why

A

more difficult in sitting
- diaphragm when innervated sits in a biomechanically advantaged position
- however if higher injury, diaphragm sinks down and pushes organs down and out in sitting

in supine - gravity pulls organs in and up & provides support for diaphragm for breathing and makes it easier

62
Q

what are 4 considerations that impact skin integrity

A
  1. absent or impaired sensation
  2. loss of normal motor function
    - dec ability to self reposition
  3. loss of normal sensation
    - disrupts feedback of discomfort/pain w position
  4. impaired circulation and ms atrophy
    - edema
    - less protection/padding at bony prominences
63
Q

what are 3 external causes of skin breadown

A

trauma
moisture
friction

64
Q

what sensation info do we want to test / collect

A

detailed exam of both superficial and deep sensations
- LT
- pin prick
- proprioception

65
Q

what are the 2 types of sensation testing that are especially used to classify sensory level of lesion

A

LT and pin prick

66
Q

what is key to assessing ms performance and why

A

palpation
common ms substitutions used

(make sure mobilizing prox joint)

67
Q

what ms should be tested

A

other than “key ms” in ASIA:
- ms groups throughout myotomes w intact innervation

68
Q

what are ROM considerations

A

pt positioning
pain limitations
other trauma
sensory integ
tone
functional impact

69
Q

where should extreme caution be used when performing MMT and PROM exam and why

A

neck and shoulders in tetraplegia
lower trunk and hips in parapleg

could causes secondary trauma to soft tissues (esp after surgery) if pushing PROM into end range too much

70
Q

who is an important interprofessional team member to work w for ROM and on what

A

OT

facilitating and maintaing optimal positioning
- & tenodesis grasp in above C6

71
Q

what is documented with regard to the ms tone assessment

A

quality, involved ms groups, factors that inc or dec tone
use modified ashworth

72
Q

what are recovery considerations with examining ms tone

A

time since injury
spinal shock
- dec tone during those phases
emerging tone
- may inc over time

pt can also experience spasms throughout continuum of care which can be very painful

73
Q

what 5 DTRs are most commonly examined

A

biceps (C5)
ECRL (C6)
triceps (C7)
quads (L3)
gastroc (S1)

74
Q

when is the detailed functional exam usually performed and why

A

often deferred until acute rehab phase when pt is medically stable and cleared for activity (depends on medical status)

75
Q

what is the goal w assessing and intervening on functional status

A

get pt to tolerate verticality and have proper hemodynamic response (aka not OH) to that position

76
Q

what is assessed in the functional status exam

A

ability of pt to tolerate upright and OOB mobility with:
- head of bed
- chair position of bed
- OOB lift to loaner chair w cushion

77
Q

what is an important consideration to be aware of with a functional status assessment

A

any contraindications or precautions to mvmt

78
Q

what is the purpose of dependent, non-skilled transfers via lift or body slide boards (3)

A

get pt out of bed to:
- inc tolerance for upright
- for skin integ
- optimize pulm function

79
Q

how does the SCI level impact the bladder/bowel dysfunction seen

A

spastic = higher lesion
areflexic = lower lesion

80
Q

what type of postural deformity is often seen in SCI and why is this problematic

A

post pelvic tilt

problematic bc inc pressure on sacrum and ischial tubs
- also problematic for sliding out of chair

81
Q

what are other complications seen along the continuum of care

A

CV impairments
edema
OP and skeletal fx
bladder/bowel dysfunction
postural deformity
overuse injuries
thermoregulation abnormalities
depression
sexual dysfunction

Neuro Rehab 2 (48 decks)

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