Spinal Cord Flashcards
SCI: Top Causes
MVC
Falls
Violence (street and veterans)
Sports Injuries
SCI: Level of Injury (Skeletal vs. Neurologic)
skeletal level: injury is at the vertebral level, where there is most damage to vertebral bones and ligaments
neurologic level: lowest segment of spinal cord w/ normal sensory and motor function on both sides of the body
SCI: Level of Injury
C4 Injury: tetraplegia, results in complete paralysis below the neck
C6 Injury: results in partial paralysis of hands and arms as well as lower body
T6 Injury: paraplegia, results in paralysis below the chest
L1 Injury: Paraplegia, results in paralysis below the waist
SCI: Complete vs. Incomplete
complete: total loss of sensory and motor function below the level of injury
incomplete: results in mixed loss of voluntary motor activity and sensation and leaves some tracts intact
Two Functions of Nerves
- Motor: starts from head down
2. Sensory: starts from feet up
Deficits that can occur w/ Level of Injry
C4: Diaphragm C5: Elbow flexion C6: Wrist flexion C7: Elbow and wrist extension C8-T1: Fingers T2-T7: Chest muscles T9-T12: Abdominal muscles L1-L5: Leg muscles S2-S5: Bowel, bladder and sexual fx
Parasthesia
numbness
Quad (tetraplegic)
paralysis of all four extremities
Quadriparesis
numbness of all four extremities
Paraplegic
paralysis of lower extremities
Paraparesis
numbness of two extremities
Diaphragmatic Breathing
- occurs when intercostal muscles are paralyzed (C4 or above)
- abnormal in adults and considered using accessory muscles (common in children under 3YO)
- crucial to re-assess often
- diaphragm will wear out and pt won’t breath so need to secure airway before they get fatigued and go into respiratory failure
*hypoxia increases cerebral edema!
SCI: Types of Injuries
Hyperflexion and Hyperextension Injuries:
- damage to ligaments, discs, cord
- accompany coup/contracoup injuries
Compression Injuries:
-shattered vertebrae, disc/cord compression
Rotation Injuries:
-torn ligaments, fractures
Neurogenic Shock
- systemic
- fx w/ pressure on cord at thoracic level
- affects sympathetic NS - can’t vasoconstrict > running on PSNS
- decreased BP and pulse
- tx: fluids
Spinal Shock
- local: below level of injury
- decreased reflexes
- loss of sensation
- flaccid paralysis below the level of the injury
- loss of thermoregulation
Dermatomes
illustration of the areas where sensory and motor nerves cause loss of sensation or pain (innervation) as a result of nerve root compression
the offending nerve root can often be identified by the distribution (dermatomes) of symptoms
SCI: Primary vs. Secondary Injury
primary:
- immediate effect of the trauma on spinal cord itself
- flexion, compression, rotation
- complete or partial transection of spinal cord
secondary:
- further injury in minutes/hours/days following primary injury
- ischemia, hypoxia, inflammation, edema (of cord from primary injury)
- neuro deterioration can occur in the first 8-12 hours
SCI Clinical Manifestations: Motor and Sensory
ASIA recommends classification for severity of SCI according to sensory deficits
Sensory regions are called dermatomes
SCI Clinical Manifestations: Respiratory
cervical injuries above C4 result in total loss of respiratory muscle function
will require mechanical ventilation for the rest of their life
SCI Clinical Manifestations: Cardiovascular
any cord injury above T6 leads to dysfunction of the SNS (neurogenic shock)
SCI Clinical Manifestations: Urinary
neurogenic bladder:
- flaccid or hypotonic
- or spastic
- or dyssynergia
urinary incontinence
SCI Clinical Manifestations: GI System
neurogenic bowel:
- incontinence
- or retention
SCI Clinical Manifestations: Integumentary
risk for skin breakdown over bony prominences
SCI Clinical Manifestations: Thermoregulation
poikilothermic: adjustment of body temperature to room temperature
decreased ability to sweat or shiver below the level of the injury
SCI Clinical Manifestations: Metabolic Needs
monitor Na+ and K+, especially when NGT suction
increased nutritional needs d/t increased metabolism
SCI Clinical Manifestations: Peripheral Vascular
elevated risk for VTE and DVT > PE b/c they aren’t moving, no venous return back to heart, blood pools in legs
SCI Clinical Manifestations: Pain
- differs in type and severity following injury
- nociceptive pain (phantom pain)
- neuropathic pain
Stages of SCI
- Prehospital
- Acute Care
- Rehabilitation and Home Care
Methylprednisolone
- evidence as to its efficacy to improve neurological outcomes is limited, inconclusive, or conflicting so its use/utility is debated
- clinicians concerned about complication of glucocorticoid use, esp. infections
- contraindicated w/ a pt who has both SCI and TBI
Nursing Management: Respiratory Problems
- respiratory failure is leading cause of death in acute and chronic phases
- signs of impending respiratory failure = RR > 30 and/or decreasing vital capacity
- prevent atelectasis and pneumonia (deep breathing and incentive spirometer q2hrs)
Nursing Management: Hemodynamics
neurogenic shock
hypovolemic shock:
- may receive IVF but excess fluids can cause further cord swelling and increase damage
- careful I&O and electrolyte monitoring
- MAP goal: 85-90
- fluids, transfusion, vasopressors as needed
Orthostatic or Postural Hypotension:
- develops cerebral hypoxia and loss of consciousness if moved too fast
- change position slowly
- adequate fluids, elastic stockings, tilt table
DVTs:
- can lead to PEs
- heparin/lovenox
Nursing Management: Thermoregulation
Poikilothermia
- avoid temperature extremes
- person w/ a fever may need a cooling blanket
Nursing Management: Nutrition
- for the immobilized pt, nutritional needs are greater than one would expect
- high calorie, high protein diet to prevent infection, promote wound healing
if pt doesn’t have gag reflex:
- feed via Dobhoff
- move to PEG if missing gag reflex becomes permanent
if pt gut doesn’t work:
-TPN
people w/ SCIs are 4x more likely to develop diabetes b/c of difficulty w/ glucose metabolism
Nursing Management: Mobilization and Skin Care
- big risk for pressure ulcers and foot drop so use splints
- risk of flaccidity and/or spasticity d/t can’t stand or walk > osteoporosis > fractures
- tx for spasticity = ROM and meds (dantrolene, baclofen, tizanidine hydrochloride)
PT/OT
Alteration in Urinary Elimination
- failure to empty > urinary retention
- failure to store > urinary incontinence
Failure to Empty
d/t flaccid bladder or areflexic bladder
can lead to UTIs and then renal failure
tx:
- continuous catheterization early on
- intermittent catheterization later (every 3-4 hours)
Failure to Store
d/t spastic bladder or reflexic bladder
may happen once spinal shock subsides
tx:
- pads
- condom catheters
- urinary diversion (such as a urostomy)
- meds to suppress bladder contractions (oxybutynin, tolterodine)
Neurogenic Bowel
loss of voluntary neurological control over bowel
- early stage of SCI: bowel is areflexive (sphincter tone is decreased and pt is constipated)
- later stage of SCI: if reflexes return, bowel becomes reflexive as sphincter tone is increased (pt has fecal incontinence)
Nursing Management: Alteration in Bowel Elimination
- good hydration and nutrition
- stool softeners and fiber
- elimination planned for 30 min after breakfast to utilize peristalsis
- rectal stimulation and/or suppository may be needed to trigger defecation
Sexual Activity and Fertility
males:
- fewer erections
- tx: ED meds, devices, surgical implants
females:
- lubrication issue
- risk of autonomic dysreflexia
SCI: Meds
- methylprednisolone
- vasopressors or vasodilators
- muscle relaxants/antispasmodics
- analgesics
- antidepressants
- anticoagulatns
- stool softeners
- laxative suppositories
- PPIs
Cord Syndromes
3 major cord syndromes
Central Cord Syndrome:
- paralyzed upper extremities
- some motor loss of chest (including diaphragm)
Anterior Cord Syndrome:
- paralysis from nipple line down
- position sense and touch intact in extremities
Brown-Sequard Syndrome:
- hemiplegic on one side
- loss of sensation on opposite side
Nelson’s Phases of Reintegration
buffering
transcending
toughening
launching
Surgical Options for Fx of Vertebrae
fusion: attach metal hardware to the spline to keep alignment
laminectomy: removal of a portion of the vertebrae that’s damaged and pinching nerves
discectomy: removes damaged portion of disk that’s compressing nerve root, decompresses nerve root
rods: can be inserted to correct curvature of spine
Autonomic Dysreflexia
massive uncompensated cardiovascular reaction mediated by SNS
occurs in response to visceral stimulation once spinal shock is resolved in pts w/ spinal cord lesions
life threatening
Autonomic Dysreflexia: Causes
- full bladder
- full bowel
- local pressure, pressure ulcers
- tight clothing
- catheterization
- labor
Autonomic Dysreflexia: S/Sx
- paroxysmal HTN (BP 280/14)
- major HA
- visual changes (d/t vasoconstriction)
- decreased HR
- cool/pale below lesion level
- vasodilation above lesion
Autonomic Dysreflexia: Tx
- raise HOB
- legs dangle
- tx cause (check catheter, impaction, loosen clothing)
- call providder
- check BP q2-5min
- vasopressors as needed (Nipride, captopril)
- stay w/ pt
Best Way to Manage Airway
- head tilt/chin lift
- modified jaw-thrust/chin lift
- tracheostomy
SCI: Imaging
- c-spine plain films (before c-collar is removed)
- thoracic/lumbar imaging
- CT scan
- MRI if pt is stable enough
