Spinal cord injury Flashcards
What are the two categories of spinal cord injuries?
traumatic (result of external physical impact)
non-traumatic (result of disease, infection, or tumour)
Initial injury
Spinal cord is wrapped in tough layers of dura.
Rarely torn or transected by direct trauma
Compression (bone displacement, interruption of blood supply to cord, tumor)
Penetrating trauma (gunshot wound or stab wounds)
Primary injury (Initial mechanical disruption of axons as a result of stretch or laceration)
Secondary injury (Ongoing, progressive damage that occurs after initial injury (swelling))
Resulting hypoxia reduces oxygen tension below level that meets metabolic needs of spinal cord (needs o2)
Lactate metabolites (anaerobic metabolism)
Increase vasoactive substances (from stress)
- Norepinephrine
- Serotonin
- Dopamine
By ≤24 hours, permanent damage may occur because of edema.
Edema secondary to inflammatory response is harmful because of lack of space for tissue expansion.
Results in compression of cord and extension of edema above and below injury which increases ischemic damage.
What is apoptosis
happens in initial injury
death of cells, after 24 hours development of edema above and below the level of injury results due to ischemic damage and can cause permanent cord damage
may continue for weeks or months after initial injury
identified by petechial hemorrhages are in central grey matter of cord shortly after injury
Extent of neurological damage caused by spinal cord injury results from
primary injury damage.
- Actual physical disruption of axons
secondary damage due to:
1 ischemia
2 hypoxia
3 microhemorrhage
4 edema
Spinal shock
Temporary neurological syndrome
Characterized by:
1 decreased reflexes
2 loss of sensation
3 flaccid paralysis below level of injury
may last days - mos
may masks pts ability to return to normal functioning
Neurogenic shock
Caused by SCI at T5 or above
Loss of vasomotor tone by injury
Characterized by hypotension, hypothermia and loss of sympathetic innervation (important clinical cues)
Characterized by
1. hypotension
2. hypothermia
3. loss of sympathetic innervation
causes…
1 peripheral vasodilation (edema)
2 venous pooling
3 decreased CO
How are spinal cord injuries classified?
Classified by Mechanism of Injury (MOI):
Skeletal level of injury
Neurological level of injury
Completeness or degree of injury
Major MOIs
flexion.
hyperextension.
flexion–rotation. (most unstable b/c ligamented structures of the spine are torn, severe neurologic deficits occur)
extension–rotation.
compression.
Skeletal level of injury
Injury is at the vertebral level, where there is most damage to vertebral bones and ligaments.
Neurological level of injury
Lowest segment of spinal cord with normal sensory and motor function on both sides of the body
Level of injury may be..
- cervical - paralysis of all 4 extremities (tetraplegia) occurs
- thoracic - paraplegia
- lumbar - paraplegia
Why not sacral - spinal cord ends b/w L1/L2
Degree of Injury
Degree of spinal cord involvement may be
Complete cord involvement
- Results in total loss of sensory and motor function below level of injury (equal on both sides)
Incomplete (partial) cord involvement
- Results in mixed loss of voluntary motor activity and sensation and leaves some tracts intact
- More complicated to assess as S+S are different between L and R sides
ASIA impairment Scale
American Spinal Injury Association (ASIA) impairment scale
Commonly used for classifying severity of impairment resulting from spinal cord injury
used for (recording changes in neurologic status, identifying appropriate functional goals for rehab)
Clinical manifestations for spinal cord injury
Generally a direct result of trauma that causes cord compression, ischemia, edema, and possible cord transection
Related to level and degree of injury
Clients with an incomplete lesion may demonstrate a mixture of symptoms.
The higher the injury, the more serious the sequelae.
- Proximity of cervical cord to medulla and brain stem
Movement and functional goals are related to specific location of spinal cord injury.
What are immediate post-injury problems of a spinal cord injury include
1 A – airway, patency
2 B – adequate ventilation, diaphregmatic movement, degree of chest expansion, respirate, o2 level
3 C – adequate circulating blood volume, is peripheral vasodilation occuring
4 D – prevent extension of cord damage by secondary injury, decrease disability
Respiratory system manifestations
Above level of C4
- Presents special problems because of total loss of respiratory muscle function = Mechanical ventilation is required to keep client alive.
Below level of C4
- Diaphragmatic breathing if phrenic nerve is functioning (resulting in hypoventilation)
- Spinal cord edema and hemorrhage can affect function of phrenic nerve and cause respiratory insufficiency.
Cervical and thoracic injuries cause paralysis of:
- abdominal muscles.
- intercostal muscles.
= client cannot cough effectively (leads to atelectasis or pneumonia)
Artificial airway provides direct access for pathogens (ie trach)
Important to reduce infections
Neurogenic pulmonary edema may occur.
Pulmonary edema (increase in pulmonary and alveolar fluid) may occur in response to fluid overload.
Cardiovascular system manifestations
Any cord injury above level T6 greatly reduces the influence of the sympathetic nervous system
bradycardia occurs.
Peripheral vasodilation results in hypotension.
Relative hypovolemia exists due to increased venous capacitance.
Cardiac monitoring is necessary, IV fluids, vasopressors to support BP
What does peripheral vasodilation cause?
1 decreased venous return
2 decreased cardiac output
Urinary system manifestations
Urinary retention is common.
Bladder is atonic and overdistended.
In-dwelling catheter inserted (acute)
- Increased risk of infection
Bladder may become hyper-irritable (post-acute phase)
- Loss of inhibition from brain
- Results in reflex emptying
Indwelling catheter should be removed, and intermittent catheterization should begin as early as possible (once med stable) – maintains bladder decreases risk of infection
Gastrointestinal system manifestations
If cord injury is above T5, primary GI problems are related to hypomotility.
Stress ulcers common
Intra-abdominal bleeding may occur.
Expanding girth may also be noted.
Less voluntary control over bowel results in a neurogenic bowel.
Injury level of T12 or below, or in spinal shock:
- Bowel is areflexic
- Decreased sphincter tone
As reflexes return,
- bowel becomes reflexic.
- sphincter tone is enhanced.
- reflex emptying occurs.
What does decreased GI motor activity contribute to?
1 deceased motor activity paralytic ileus
2 gastric distension
Intra-abdo bleeding indications
Difficult to diagnose
1 continued hypotension despite treatment
2 drop in hemoglobin and hematocrit
Integumentary system manifestations
Consequence of lack of movement is skin breakdown.
Pressure ulcers can occur quickly.
Can lead to major infection or sepsis.
Thermoregulation manifestations
Poikilothermism
Def’n: Adjustment of body temperature to room temperature
Occurs d/t SNS interruption preventing peripheral temperature sensations from reaching hypothalamus
Ability to sweat or shiver is decreased below the level of injury
Metabolic manifestations
Nasogastric suctioning may lead to metabolic alkalosis.
Reduced tissue perfusion may lead to acidosis.
Monitor electrolyte levels until suctioning is discontinued and normal diet is resumed.
Loss of body weight is common.
Nutritional needs much greater than expected for immobilized person
High-protein diet:
1 helps ward off skin breakdown and infection
2 reduces rate of muscle atrophy
Peripheral Vascular manifestations
Deep vein thrombosis (DVT) a common problem
Pulmonary embolism is a leading cause of death.
DVT assessments
- Doppler examination
- Measurement of legs and thigh girth
Patients will not be able to notice pain in the lower legs so they wont know they have a DVT
Diagnostic studies for spinal cord injuries
CT scan may be used to assess stability of injury, location, and degree of bone injury.
MRI is gold standard for imaging neurological tissues.
Comprehensive neurological examination (CT with contrast)
Care for spinal cord injuries
Immediate goals are to sustain life and prevent further cord damage.
1 A patent airway
2 B adequate ventilation
3 C adequate circulating volume
Systemic and neurogenic shock must be treated to maintain BP. (MAP > 65) – fluids and vasopressives
Care for thoracic and lumbar injuries
Systemic support less intense than cervicle injury
Respiratory compromise not as severe
Bradycardia is not a problem.
Specific problems treated symptomatically
What happens with care after stabilization has happened?
history is obtained
- Emphasis on how injury occurred
- Extent of injury as perceived by client immediately after event
Assessment of SCIs
Test muscle groups with and against gravity, alone and against resistance, and on both sides of the body.
Note spontaneous movement.
Sensory examination
Position sense and vibration
Brain injury may have occurred—assess history for:
1 unconsciousness
2 Signs of concussion
3 increased ICP
Musculo-skeletal injuries
Trauma to internal organs
Non-operative stabilization
Focused on stabilization of injured spinal segment and decompression
Through traction or realignment
Eliminates damaging motion at injury site
Intended to prevent secondary damage
Surgical therapy
Criteria for early surgery
1 cord decompression may result in decreased secondary injury
2 evidence of cord compression
3 progressive neurologic deficit
4 compound fracture
5 bony fragments
6 penetrating wounds of the spinal cord or surrounding structures
Common surgical procedures
Include decompression (reducing pressure), realignment (stabilizing spinal cord and structures surrounding), and stabilization with instrumentation.
If instability is considered severe enough, both anterior and posterior stabilization may be considered.
Drug therapy
Methylprednisolone (MP) is a steroid
- When administered early and in large doses, recovery of neurological function is greater.
- May be used as a treatment option
- No benefit after 8 hours post injury
Vasopressor agents
- Used in acute phase to maintain blood pressure
- Maintain MAP
Drug interactions may occur.
Pharmacological agents
- Used to treat specific autonomic dysfunctions
Subjective data with assessment
Past health history
Current medication history
Symptoms
- Loss of strength, movement and sensation below level of injury
- Dyspnea, “air hunger”
- Pain
- Fear, denial, anger, depression
Objective data with assessment
General: poikilothermism
Integumentary: neurogenic shock
Respiratory: lesions at C1-C3, C4 and C5-T6
Cardiovascular: lesions above T5
GI: decreased or absent bowel sounds
Urinary: retention, flaccid bladder
Reproductive: priapism, loss of sexual function
Neurological: Complete, incomplete
Musculo-skeletal: atony, contractures
Possible findings
Nursing dx
Ineffective breathing pattern
Imbalanced nutrition: less than body requirements
Ineffective peripheral tissue perfusion
Impaired skin integrity
Constipation
Impaired urinary elimination
Risk for autonomic dysreflexia
Nursing planning goals
1 maintain optimal level of neurological function
2 minimal to no complications related to immobility
3 learn skills and gain knowledge and acquire behaviors to care for themselves
4 return home to their community
Immobilization interventions
Proper immobilization involves maintenance of a neutral position.
Stabilize neck to prevent lateral rotation of cervical spine.
- A blanket or towel
- Hard cervical collar
- Backboard
Body should always be correctly aligned.
Turn client so that he or she is moved as a unit to prevent movement of spine (log rolling).
Skeletal traction
- Realignment or reduction of injury
- Provided by rope over a pulley that has weights attached at end
- Traction must be maintained at all times.
- Stabilize head if dislodged, and then call for help.
- Sites of pin insertion can become infected.
- Clean twice daily.
Cervical collars for postsurgical stabilization are used on the basis of surgeons’ preference (ie Aspen) – more padded
With new techniques and better surgical stabilization, a collar is not required postoperatively.
Halo traction is the most commonly used method of stabilizing cervical injuries.
- Hanging weights may be incorporated.
- May be attached to a body vest that allows ambulation.
Thoracic or lumbar spine injuries
- Custom thoracolumbar orthosis (TLSO brace)
- Meticulous skin care is critical.
Respiratory Dysfunction interventions
During first 48 hours, spinal cord edema increases level of dysfunction.
Respiratory distress may occur.
Injury at or above C3
- Client is exhausted.
- Laboured breathing/ABGs deteriorate.
- Endotracheal intubation/tracheostomy
- Mechanical ventilation
Respiratory arrest a possibility
Other potential problems
- Pneumonia and atelectasis
- Nasal stuffiness and bronchospasms
Aggressive chest physiotherapy
Adequate oxygenation
Proper pain management
What to regularly assess with respiratory dysfunction?
1 breathing sounds
2 breathing patterns
3 ABGs
4 Tidal volume
5 skin colour
6 amount and colour of sputum
7 subjective comments
8 vital capacity
Cardiovascular instability interventions
Heart rate is slow (<60 beats per minute) because of unopposed vagal response.
Any increase in vagal stimulation can result in cardiac arrest. Vagal stimulation can happen with;
1 suctioning
2 turning
Bearing down
Frequently assess vital signs.
Anticholinergic for bradycardia
Temporary/permanent pacemaker
Compression gradient stockings
- Remove every 8 hours for skin care.
Prophylactic low-molecular-weight heparin
Fluid and nutritional maintenance interventions
During first 48–72 hours, GI tract may stop functioning.
Nasogastric tube may be inserted.
Fluid and electrolyte needs must be carefully monitored.
Oral foods and liquids can be given once bowel sounds are present or flatus has passed.
High-protein, high-calorie diet (or TPN)
Evaluate swallowing in high cervical cord injuries before starting oral feedings.
If client is not eating, cause should be thoroughly assessed.
Bladder and bowel management interventions
Immediately after injury
- Urine is retained.
- Loss of autonomic and reflex control of bladder and sphincter
- Bladder overdistension can result in reflux into kidney with eventual renal failure >
- Intermittent catheterization program (Urinary tract infections)
Constipation
- Problem during spinal shock
- No voluntary or involuntary evacuation of bowels occurs.
- Rectal stimulant (suppository or mini-enema) inserted daily
Temperature control interventions
Below level of injury
- Vasoconstriction
- Piloerection
- Heat loss through perspiration
Temperature is largely external to client.
Nurse must monitor environment and body temperature.
Stress ulcer interventions
Physiological response to severe trauma or physiological stress
High-dose corticosteroids (w antacids and food)
Peak incidence occurs 6–14 days after injury.
Sensory deprivation interventions
Stimulate client above level of injury.
Conversation, music, strong aromas, and interesting flavours
Every effort should be made to prevent client from withdrawing.
Reflexes intervetions
Return of reflexes may complicate rehabilitation.
- Hyperactive
- Exaggerated responses
- Penile erections
- Spasms
Client or family may see this as return of function.
Autonomic Dysreflexia
Serious complication of spinal cord injury when injury is above T 6.
a massive, uncompensated CV reaction mediated by the CNS
occurs in response to visceral stimulation once spinal shock is resolved with spinal cord lesions
pathway involves the stimulation of sensory receptors below cord lesion, the intact ANS below level of lesion responds to the stimulation with a reflex arteriolar vasoconstriction that increases BP. Baroreceptors in carotid sinus and the aorta detect HTN and stimulate parasympathetic system. Results in decreased HR, but the visceral and peripheral vessels do not dilate because of efferent impulses can not pass through cord lesions
impulses are cut off between brain and area of stimulus so body does not respond
Signs and symptoms of autonomic dysreflexia
Severe hypertension (>300mgHg)
Pounding headache
Flushing
Piloerection
Diaphoresis (hairs standing on end)
Dilated pupils
Nasal stuffiness
Bradycardia (pulse <60 bpm) – vagal nerve is trying to respond
Nausea
Why does autonomic dysreflexia
Most common precipitating factor is distended bladder or rectum.
Can also occur with stimulation of skin or pain receptors (ie pants too tight, etc)
NOTE: It is important to measure BP (looking for a source) when a client with a SCI c/o headache
Autonomic dysreflexia interventions
Elevate head of bed at 45 degrees, or sit client upright.
Notify physician.
Assess cause.
Provide immediate catheterization.
Teach client and family causes and symptoms. (bladder, bowel, restricted clothing)
Rehabilitation and home care of SCI
Organized around individual client’s goals and needs
Client should expect:
- To be involved in therapies
- To learn self-care
Can be very stressful
Frequent encouragement
Respiratory rehab for SCI
Phrenic nerve stimulators or electronic diaphragmatic pacemakers increase mobility.
Teach cervical level injury clients who are not ventilator dependent.
- Assisted coughing
- Regular use of spirometry or deep breathing exercises
Neurogenic bladder
Any type of bladder dysfunction related to abnormal or absent bladder innervation (most patients with spinal cord injury)
Common problems
- Urgency, frequency, incontinence, inability to - void, and high bladder pressures resulting in reflux of urine into kidneys
Neurogenic bowel
Voluntary control may be lost.
High-fibre diet and adequate fluid intake
Suppositories, small-volume enemas, or digital stimulation by client or nurse
Carefully record bowel movements.
Neurogenic skin
Prevention of pressure ulcers and other types of injury to insensitive skin is essential.
Teach these skills and provide information about daily skin care.
Careful positioning and repositioning should be done every 2 hours with gradual increase in time
Pressure-relieving cushions must be used in wheelchairs.
Protect skin by avoiding thermal injury.
Teach family members skin care as well.
Sexuality
Important issue regardless of client’s age or gender
Nurse must
- have an awareness and an acceptance of personal sexuality.
- have knowledge of human sexual responses.
- use medical terminology.
Grief and depression
May feel an overwhelming sense of loss
May believe they are useless and burdens to their families
Response and recovery differ from those experiencing loss from amputation or terminal illness.
