Spinal Cord Injury Flashcards
Injury to the
______ paralysis of lower body
_____ paralysis of all four extremities (formerly called quadriplegia)
Life expectancy continues to increase for patients with SCI due to improvements in health care
spinal cord, vertebral column, the supporting soft tissue, or intervertebral discs caused by trauma
Paraplegia:
Tetraplegia:
Causes & Risk Factors:
Most common causes:
Motor vehicle accidents
Falls
Violence (predominantly gun shot wounds)
Sports related injurie
Risk factors:
Younger age
Male gender (78% of population with spinal cord injury)
Alcohol/drug use
Vertebrae and Spinal Cord Areas
Cervical Vertebrae- C1-C7
Head, neck, diaphragm, deltoids, biceps, wrist extenders, triceps, hand
Thoracic Vertebrae T1-T12
Chest muscles, abdominal muscles
Lumbar vertebrae L1-L5
Leg muscles
Sacral Nerves S1-S5
Bowel, bladder, sexual function
Spinal Cord Injury: Pathophysiology
_______: client fully recovers
_____, _____, _____ of spinal cord tissue (alone or in combination)
__________ (severing of the spinal cord)
Vertebrae most commonly affect:
Transient concussion
Contusion, laceration, compression
Complete transection
C5, C6, & C7, T12, and L1
These vertebrae are more susceptible to injury due to the greater range of mobility
Types of Injuries
Transient concussion
Contusion (bruising)
Laceration (deep cut)
Compression (pressure placed on cord)
Complete transection (severing of cord)
Spinal Cord Injury: Primary & Secondary
Primary Injury: Result of initial trauma or injury, usually permanent
Secondary Injury:
-Result of edema and hemorrhage
-Major concern for critical care nurses
-Early treatment needed to prevent long-term damage or permanent damage
Clinical Manifestations
Depends on the type and level of the injury
Complete spinal cord lesion:
Loss of both sensory and voluntary motor communication from brain to periphery
Results in paraplegia or tetraplegia
Incomplete spinal cord lesion:
Ability of the spinal cord to relay messages to/from the brain is NOT completely absent
Sensory and/or motor fibers are preserved below the injury
Effects of Spinal Cord Injuries:
Central Cord Syndrome
Anterior Cord Syndrome
Lateral Cord Syndrome (Brown-Sequard Syndrome)
Central Cord Syndrome
Characteristics:
Cause:
Characteristics:
motor deficits
–Sensory loss more pronounced in the upper extremities
bowel/bladder dysfunction is variable
–Or can be completely preserved
Cause:
Injury or edema to the central cord (typically cervical area)…hyperextension
Anterior Cord Syndrome
Characteristics
Causes
Characteristics:
Loss of pain, temperature, and motor function below the level of the lesion
Light touch, position, and vibration sensation remain intact
Cause:
Acute disc herniation or hyperflexion injuries with fracture/dislocation of vertebra.
Injury to the spinal artery
Lateral Cord Syndrome(Brown-Sequard Syndrome)
Characteristics:
Ipsilateral paralysis or paresis with ipsilateral loss of touch, pressure and vibration
Contralateral loss of pain and temperature
(Ipsilateral- belonging to or occurring on the same side of the body.)
Cause:
Transverse hemisection of the cord (half of the cord is transected from north to south)
Knife or missile injury (GSW, shrapnel)
Fracture/dislocation of unilateral articular process
Acute ruptured disc
Lateral Cord Syndrome(Brown-Sequard Syndrome)
Loss of _____ and ____ sensation on the opposite side
Loss of _________ on the same side as the cord damage
pain and temperature
voluntary motor control
Assessment & Diagnostics
Full neuro exam with frequent neuro checks
Full head to toe exam
Diagnostics:
Lateral cervical spine x-rays
CT Scan
MRI (if further injury suspected)
If MRI is contraindicated, a myelogram may be used
Continuous ECG monitoring
Bradycardia and asystole are common in acute spinal cord injuries
Emergency Management
ALL the following clients must be ruled out for spinal cord injury:
ANY OF THESE INJURIES … YOU MUST ASSUME THERE IS A SCI UNTIL IT IS RULED OUT
MVC
Diving or contact sports injury
Fall
Direct trauma to head/neck
Emergency Management Cont:
At the scene
Trauma Center:
At the scene:
Immobilization of head/neck must occur
Focus upon maintaining head/neck in neutral position
to prevent flexion, rotation, or extension
Use hands, back board, or cervical immobilizing device-including head blocks working together
Client must be lifted in one movement with all team members
Trauma Center:
Referral to a regional spinal injury or trauma center
Many changes occur within the first 24 hours
It is important to have multiple disciplines working with patient
Medical Management
Respiratory therapy:
____________
Intubation may be required
In high cervical spine injuries, ______ is damaged (which stimulates the diaphragm)
Intramuscular diaphragmatic pacing is currently in clinical trial phase
O2 to maintain paO2
phrenic nerve
Medical Management
Skeletal fracture reduction and traction:
Surgical management indicated:
Skeletal fracture reduction and traction:
Traction (weights are applied)
Halo device (ring fixed to skull by 4 pins)
Surgical management indicated:
Compression is evident
fragmented/unstable vertebral body
wound that penetrates cord
bony fragments in spinal canal
neuro status is deteriorating
Non-Surgical Treatments
Steroid infusion
-Decrease inflammation and swelling
-High dose within 24-48hrs
-Controversial / only slight benefits
Stabilization with cervical (neck) traction/alignment (see next slide):
-Braces
-Halo traction
-Gardner-Wells Tongs traction
Types of Equipment used
Philadelphia collar
Miami J colloar
Aspen cervical thoracic orthosis (CTO)
Halo vest
Gardner with tongs traction
Jewett brace- lower thoracic/lumber injuries
Surgical Treatments
Decompression
-Releasing pressure on the spinal cord
Causes: bone, disc, blood clot, tumor
Internal fixation and instrumentation
-Placing metal rods, screw, and/or hooks to prevent further injury
Bone grafting for fusion
Spinal and Neurogenic Shock
Spinal shock:
-Sudden decrease of reflex activity below level of injury with:
-BP and HR may be decreased
-Prolonged hypotension and bradycardia can worsen damage to the spinal cord; therefore, important to keep ______
-Bladder and bowel function affected
-_____ most often occurs within first 2-3 days after SCI and resolves within 3-7 days
Neurogenic shock:
-Loss of ____ function below level of lesion
-Hypotension, bradycardia, decreased CO, pooling in extremities and peripheral vasodialtion
-Patient will not ____ in paralyzed portions of the body…. watch for ____
-_______ problems:
No sensation, paralyzed, flaccid, and reflexes are absent
Paralytic ileus
MAP > 85 mmHg
ANS
perspire…S&S of fever
Respiratory problems: secretion retention, increased paCO2, decreased paO2, respiratory failure, and pulmonary edema
Other complications:
Venous thromboembolism / PE
Respiratory failure / pneumonia
Autonomic dysreflexia
Pressure injuries
Infections
-Urinary
-Local infection at the pin sites
Nursing Interventions
Promoting adequate breathing and airway clearance
Preventing injury
Maintaining skin integrity
Maintaining urinary elimination
Improving bowel function
Providing comfort measures
DVT/PE anticoagulant therapy/SCDs
Recognizing Autonomic Dysreflexia
Autonomic Dysreflexia
Occurs as a result of _______ responses that have an injury above ___
Occurs after _____ is resolved
Triggers:
Signs/symptoms:
exaggerated autonomic
T6
spinal shock
Distention of bladder/bowels
Stimulation of the skin
Pressure ulcers
infection
Causes:
Bladder/organ distention
Urinary tract infection
hemorrhoids
Constrictive clothing
Sexual intercourse
Pregnancy
Scrotal compression
Menstruation
Severe, pounding headache
Profuse diaphoresis above spinal lesion
Nausea
Nasal congestion
Bradycardia
Extreme HTN
Autonomic dysrelexia
See slide
Long-Term Care for Paraplegia/Tetraplegia Patients
Increasing mobility:
-Exercise programs
-Mobilization
Preventing disuse syndrome:
-ROM, repositioning, proper body alignment
Promoting skin integrity:
-Frequent skin assessments and repositioning to decrease risk of pressure ulcers
Improving bladder management:
-Encourage 2.5 liters of intake/day
Establishing bowel control:
-Bowel training program
Long-Term Care (cont.)
Counseling on sexual expression:
Assistance with erectile dysfunction
Enhancing coping mechanisms:
Managing grief and depression
Decreased life expectancy
Long-Term Care
Risk for:
Autonomic dysreflexia
Bladder/kidney infections
Orthostatic hypotension
VTE
Spasticity
Mental health issues
Pressure ulcers…leading to fistulas, osteomyelitis, and sepsis
Autonomic Dysreflexia treatment
Sit up or raise head to 90 degree. Remain upright until BP is normal.
Loosen or remove tight clothing
Check/empty bowel or bladder
Call health care professional, even if symptoms go away
Monitor BP every 5 minutes
Major causes of death for those with SCI are:
*
Pneumonia
* PE
* Sepsis
Transient concussion - disturbance of the spinal cord with or without vertebral damage usually resolves with ______
- eg:
24-48 hours
hyperflexion or hyperextension
- Respiratory dysfunction
- Related to the level of the injury
- C4 controls diaphragm
- T1-T6 intercostal muscles
- T6-T12 abdominals
- Injury to ____ or above causes paralysis of the diaphragm and the patient will need ventilator support ** _____ is the leading cause of death **
C4
acute respiratory failure in
Continuous ECG monitoring
____ and _____ are common in acute spinal cord injuries
Bradycardia and asystole
Best to have at least __ people to move the patient in one movement
During examination in the ED and Xray departments the patient must remain on the transfer board
No twisting or turning
Must be in an ____ position
Will need a rotating specialty bed – if a specialty bed is not available the patient needs to be put on a:
4
extended
firm bed with a cervical collar
Fractures can be reduced and aligned with skeletal traction
Traction – allows the vertebrae to move back into place
Halo device – can be used with traction initially or after traction
* They provide _______
__________ injuries are usually treated with surgery
- Followed by immobilization (fitted brace)
Surgical management
- Early may improve the patients clinical outcome
- Goals are to preserve neurological function
early ambulation
Thoracic and lumbar
Spinal shock
The highest MAP is correlated with greatest degree of neurological recovery
* Induced hypertension helps to enhance spinal cord perfusion
Paralytic ileus – muscles that move your food are temporarily paralyzed
* Treated with ____________
Neurologic shock
ANS (autonomic nervous system) Vital organs affected
* Controls involuntary actions (heartbeat, breathing, narrowing or widening of vessels)
Vital organs are affected:
* Hypotension
* Bradycardia
* Decreased cardiac output
* Pooling of blood in extremities
* Peripheral vasodilation
intestinal decompression
* Insertion of NG tube
Autonomic dysreflexia – is a sudden onset of _________
Only way to resolve is to change the situation
E.g.: ___________
Can cause hemorrhagic stroke, retinal hemorrhage, MI, seizures
Treatment:
high blood pressure
SCI patients cannot restore their BP because of damage
remove tight clothing, empty bladder
Sit up immediately
Alleviate cause
Empty bladder, check for fecal impaction
Skin assessment for any sores or ulcers
Cold air
Antihypertensive
