SCI 4 - Acute Management Flashcards
what are the things that need to be done when you arrive on scene at a SCI (4)
use of backboard
c collar
neutral alignment of spine
assess respiratory function
- maintain airway
- maintain adequate O2
what imaging and tests are done acutely
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
why is it important for IV fluids acutely
manage neurogenic shock
maintain cardiac function
what is a HUGE consideration of acute medical management? what are some examples that are reliant on this factor
TIMING
surgical depression
anticoag prophylaxis
baseline MRI
why is the timing of surgical decompression important
want to wait for swelling to dec
don’t want to wait too long
why is the use of methylprednisolone sodium succinate and hypothermia controversial and why is it sometimes utilized
MSS: steroid, dec inflammation and swelling
- controversy bc of secondary complications (ie cardiac)
hypothermia
- preserve neuro tissue thru dec swelling and metabolism
why is timing a consideration w anticoagulation prophylaxis
high risk for DVTs
- don;t want to prevent good clots w healing from injury
what should be considered other than timing w anticoagulation prophylaxis
neuro tissue doesn’t like blood and bleeding can cause death
what is the role of baseline MRI in decision making and prognosis
similar w stroke - not ab if, but when will get MRI
what are surgical options for management
decompression
alignment
spine supported w instruments
bone graft –> fusion
what could be done w a decompression and what are the goals
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
what is the goal of a bone graft
stabilize the spine
when is cervical traction indicated
cervical subluxation
cervical fx
cervical dislocation
what is cervical traction doing, when can it be implemented, and what are the goals
closed reduction
before or after surgery
decompress spine and take some pressure off
when are orthoses implemented acutely
in conjunction w surgical stabilization or instead of
what are examples of acute orthoses
TLSO
halo
c collar
minerva orthosis
miami j collar
jewett brace
how is the orthoses used acutely determined
level of SCI
how stable the spine is –> how rigid
why is orthostatic hypotension a common secondary complication post SCI
not getting vasoconstriction of ms and natural pumping mechanism from skeletal ms
what are possible secondary complications post SCI
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
what is the leading cause of death in SCI and why
respiratory d/t impaired respiratory ms function
what are 3 common respiratory sequelae in SCI
pneumonia
atelectasis
PE
why is there an inc risk of retained secretions inc ICE
expiratory ms weakness leading to an ineffective cough
what are the 2 main ms impacted w inspiration and the corresponding SCI
neck ms - above C3
diaphragm - C3-5
what are the 2 main ms impacted w expiration and the corresponding SCI
intercostal ms - T1-12
ab ms - T7-12
what are causes/ factors that contribute the development of secondary respiratory sequelae
- expiratory ms weakness
- altered level of consciousness w concomitant head trauma or meds
- ileus
- failure to spontaneously sigh
- bronchial mucus hypersecretion
- associated rib fx
- associated thoracoabdominal surgery
- dysphagia and aspiration associated w tracheostomy or cspine surg w ant approach
how can ileus lead to secondary respiratory sequelae
ileus - temp lack of intestinal ms
w inc diaphragmatic excursion and inc risk of aspiration of gastric contents
why is bronchial mucus hypersecretion seen in 20% acute cspine SCI
impaired peripheral sympathetic nervous system
what can cause a DVT in general
dec rate of blood flow
damage to blood vessel wall
inc tendency of blood to clot
why is there an inc risk of DVT in SCI
immobilization
unable to move UE or LE d/t:
- absent strength
- impaired vasomotor control*
- fx
what are considerations for PT since population has inc risk of DVTs
TEDS, ace wraps, venodyn boots
see if IVC filter placed
on anti-coag therapy
what is the concern of DVTs in this population
it traveling and becoming PE
- partial or complete lung obstruction
what are sx of the onset of a PE
sudden sx of:
SOB
tachycardia
chest pain
blue tinge to fingers, toes, lips
what is heterotopic ossification (HO) and what can this be d/t
inc bone growth/calcification around joint (aka inc bone where shouldn’t be)
d/t trauma or hit to bone
when does heterotopic ossification present in SCI
3-12wks post injury
sx of heterotopic ossification
swelling
changes in end feel (-> bony)
dec ROM
inc in temp around area
redness
where are the 4 most common sites of heterotopic ossification
most
hips
knees
shoulders
elbows
least
what are common causes of UTIs in SCIs
common w voiding dysfunction
- bacteria enters bladder while catheterizing
- delayed use of toilet
- incomplete emptying of urine
what are first signs of a UTI in SCI
fever
chills
pain w urination
acute cog changes
inc spasticity (UTI = nox stim)
why is OH common in SCI
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
what are PT interventions/considerations with OH
wear compression stockings and abdominal binder
tilt table and monitor VS
when would we see an order for Midodrine and why is this helpful for PT
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
what is the most costly and frequent secondary complicaiton
pressure sores
what are common sites of pressure sores
bony prominences
- sacrum/coccyx
- heels
- greater troch
- ischial tub
- scap
what impacts does pressures sores have
mobilty
positioning / off loading
QOL
where does sympathetic vs parasympathetic system live
sympathetic - tspine
para - brain
what is the cause of autonomic dysreflexia
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
what are examples of a noxious stim that may trigger autonomic dysreflexia and what is the most common
***bowel/bladder distention/irritation **
pressure sore
restrictive clothing
cutaneous stim
DVT
sex
labor
sunburn
bug bite
estim
fx
what are s/sx of autonomic dysreflexia
HTN
bradycardia
pounding HA
red/blotchy face
blurry vision
constricted pupils
what do you do if someone goes into autonomic dysreflexia
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
why is autonomic dysreflexia a red flag
can be fatal bc can stroke out when goes into HTN as HR slows down
what are 4 common causes of death post SCI
- respiratory complications
- pneumonia / PE - CV dz and autonomic dysfunction
- external causes - subsequent injuries, homicide, suicide (most common)
- wound infection
what are spinal precautions
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
what is an important part of following spinal precautions w pts
vary MD to MD and depending on pt
- ask when they need the brace/collar on and when is it okay not to
what are acute care PT priorities
pain
respiratory / ventilation
integument
sensation
ms performance
ROM
ms tone and DTR
functional status
nociceptive vs neuropathic pain
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
how does neuropathic pain present
tingling
burning
electric shock
cold
pricking
pins and needles
squeezing
sharp/shooting
what are 2 ways to assess pain
VAS - visual analog scale
NPS - neuropathic pain scale
what are treatments for neuropathic pain and what is the challeng w them
difficult to treat
pharm: antileptics (gabapentin), tricyclic antidepressants, anticonvulsants, opioids, cannabinoids, baclofen
non-pharm: positioning, surgical (ie nerve block), TENS, acupuncture
how can TENS help to treat neuropathic pain and what is limitation
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
what are characteristics of respiratory/ventilation PT addresses acutely
function of respiratory ms
chest expansion
breathing pattern
cough
vital capacity
what impact does the position have on breathing in higher level SCI and why
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
what are 4 considerations that impact skin integrity
- absent or impaired sensation
- loss of normal motor function
- dec ability to self reposition - loss of normal sensation
- disrupts feedback of discomfort/pain w position - impaired circulation and ms atrophy
- edema
- less protection/padding at bony prominences
what are 3 external causes of skin breadown
trauma
moisture
friction
what sensation info do we want to test / collect
detailed exam of both superficial and deep sensations
- LT
- pin prick
- proprioception
what are the 2 types of sensation testing that are especially used to classify sensory level of lesion
LT and pin prick
what is key to assessing ms performance and why
palpation
common ms substitutions used
(make sure mobilizing prox joint)
what ms should be tested
other than “key ms” in ASIA:
- ms groups throughout myotomes w intact innervation
what are ROM considerations
pt positioning
pain limitations
other trauma
sensory integ
tone
functional impact
where should extreme caution be used when performing MMT and PROM exam and why
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
who is an important interprofessional team member to work w for ROM and on what
OT
facilitating and maintaing optimal positioning
- & tenodesis grasp in above C6
what is documented with regard to the ms tone assessment
quality, involved ms groups, factors that inc or dec tone
use modified ashworth
what are recovery considerations with examining ms tone
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
what 5 DTRs are most commonly examined
biceps (C5)
ECRL (C6)
triceps (C7)
quads (L3)
gastroc (S1)
when is the detailed functional exam usually performed and why
often deferred until acute rehab phase when pt is medically stable and cleared for activity (depends on medical status)
what is the goal w assessing and intervening on functional status
get pt to tolerate verticality and have proper hemodynamic response (aka not OH) to that position
what is assessed in the functional status exam
ability of pt to tolerate upright and OOB mobility with:
- head of bed
- chair position of bed
- OOB lift to loaner chair w cushion
what is an important consideration to be aware of with a functional status assessment
any contraindications or precautions to mvmt
what is the purpose of dependent, non-skilled transfers via lift or body slide boards (3)
get pt out of bed to:
- inc tolerance for upright
- for skin integ
- optimize pulm function
how does the SCI level impact the bladder/bowel dysfunction seen
spastic = higher lesion
areflexic = lower lesion
what type of postural deformity is often seen in SCI and why is this problematic
post pelvic tilt
problematic bc inc pressure on sacrum and ischial tubs
- also problematic for sliding out of chair
what are other complications seen along the continuum of care
CV impairments
edema
OP and skeletal fx
bladder/bowel dysfunction
postural deformity
overuse injuries
thermoregulation abnormalities
depression
sexual dysfunction
