Spinal Cord Injuries Flashcards
Primary Injury
SCI due to cord compression by Bone displacement Interruption of blood supply Traction from pulling on cord Penetrating trauma 🡪 tearing and transection
Secondary Injury
Ongoing progressive damage that occurs after initial injury
Due to vascular changes, free radical formation, inflammation
Apoptosis (programmed cell death) for weeks after injury
Leads to:
Neuronal cell death
Reduced spinal cord blood flow
Scar tissue formation
Irreversible nerve damage and extension of paralysis to higher levels
Permanent neurologic deficits
Within 24 hours: permanent damage may occur because of edema
72 hours+ after injury: extent of damage and prognosis for recovery most accurately determined
3-6 months following injury: greatest improvement occurs
Spinal Shock
Characterized by: Loss of reflexes Loss of sensation Absent thermoregulation Flaccid paralysis below level of injury Lasts days to weeks
Neurogenic Shock
T6 injury or higher Characterized by Hypotension 🡪 give fluids then pressors Bradycardia 🡪 give atropine then might try to pace Loss of SNS innervation Peripheral vasodilation Venous pooling Decreased CO
Mechanism of SCI
Flexion Hyperextension Flexion-rotation Extension-rotation Compression
Level of SCI
Skeletal and neurologic level
Level of injury may be: cervical, thoracic, lumbar, sacral
Tetraplegia (C8) (quadriplegia)
Paraplegia (T1)
- Phrenic @ C3-5 think breathing
Complete SCI
Total loss of sensory and motor function below level of injury
Incomplete SCI
Mixed loss of voluntary motor activity and sensation
Some tracts intact
Degree of sensory and motor loss depends on level of injury and specific damaged nerve tracts
Clinical Manifestations of SCI
Manifestations are related to level and degree of injury
Incomplete lesion results in a mixture of symptoms
Higher the injury 🡪 more severe the sequelae
Proximity of the cervical cord to the medulla and brainstem
C4 Injury
Tetraplegia, complete paralysis below the neck
C6 Injury
partial paralysis of hands and arms as well as lower body
T6 Injury
Paraplegia, paralysis below the waist
L1 Injury
paraplegia, paralysis below the waist
Respiratory (Edema)
Spinal cord edema may increase during first 48h 🡪 potential for respiratory distress
Risk for neurogenic pulmonary edema: flash pulmonary edema from inflammatory response
May need intubation and mechanical ventilation
Increased risk for pneumonia, atelectasis
Respiratory (Above C4)
total loss of respiratory muscle function
Respiratory (Below C4)
diaphragmatic breathing
respiratory insufficiency
Cervical and Thoracic Injuries
Paralysis of abdominal and intercostal muscles ineffective cough
risk for aspiration, atelectasis, pneumonia
Respiratory Management
Regular assessment Intervene to maintain ventilation Administer O2 Provide ventilatory support Chest physiotherapy Assisted (augmented) coughing: nurse acts as “muscle” pushing on chest to help pt cough Tracheal suctioning Incentive spirometry Appropriate pain management
Neurogenic shock
Injury above T6
Dysfunction of sympathetic nervous system
Bradycardia
Peripheral vasodilation
Hypotension
Relative hypovolemia because of increase in capacity of dilated veins
Reduced venous return decreasing CO
Cardiovascular
Increased risk for DVT
Dysrhythmias may occur
Chronic low BP with postural hypotension
Risk for cardiac arrest
Cardiovascular Management
Frequent assessment of VS Anticholinergic drug/pacemaker Fluid replacement, vasopressor agent Only suction as needed (vagus response) If blood loss occurred Monitor hgb, hct Possible blood administration *signs of DVT *monitor for orthostatic BP
Gastrointestinal
Injury above T5
Hypomotility
Risk for paralytic ileus
Gastric distention (NG tube as long as no facial injury)
Excessive release of HCl may cause stress ulcers
Risk of aspiration, esp. high injuries
Dysphagia may be present
Intraabdominal bleeding may be difficult to diagnose
Gastrointestinal Management
Monitor F&E Nutrition should be started within 72h High protein, high cal diet Possible parenteral nutrition (ileus) Prevent skin breakdown, reduce infection, decrease muscle atrophy Stress ulcer prophylaxis Increased risk secondary to severe trauma and physiologic stress Monitor stool, gastric contents, and hct
Bowel Management
Neurogenic bowel initially Bowel program started during acute care Daily rectal stimulant Suppository or small-volume enema Digital stim or manual evac Adequate fluid, fiber intake Increased activity and exercise
GU
Neurogenic bladder: bladder dysfunction related to abnormal or absent bladder innervation
Acute phase (spinal shock)
Urinary retention
Bladder atonic, overdistended, fails to empty
Indwelling catheter
Bladder Management
Post-acute phase – bladder may become hyperirritable
Once stable: remove indwelling urinary catheter
Intermittent cath program
4-6x daily
Monitor for S/S UTI
High risk UTI, bladder stones, kidney infections
Integumentary System
Potential for skin breakdown Poikilothermism Interruption of SNS Decreased ability to sweat or shiver below the level of injury More common with high cervical injury Temp control is external Monitor environment and body temp Do not use excessive covers or unduly expose patient
Skin Care
In from field 🡪 try to log roll as soon as level of injury known to decrease skin breakdown
Decreased sensory/motor 🡪 at risk skin breakdown for rest of life
Comprehensive visual and tactile exam
Careful positioning and repositioning q2h; wheelchair tilts q30m
Specialty mattresses, pressure-relieving cushions
Careful temp control
Assess nutritional status
Nociceptive pain
musculoskeletal pain – dull or aching, worsens with movement; visceral pain in thorax, abdomen, pelvis – dull, tender, or cramping
-treat with anti-inflammatories and opioids
Neuropathic pain
at or below level of injury; hot, burning, tingling, pins and needles, cold, shooting; may be extremely sensitive to stimuli
-Gabapentin (Neurontin) or pregabalin (Lyrica)
Teach about pain triggers and relaxation therapy
