Spinal Cord Injury Flashcards
Explain the anatomic structure and function of the spinal cord and the peripheral nerves.
Spinal cord is wrapped in tough layers of dura.
Rarely torn or transected by direct trauma
duramater
arachnoid mater
piamater
Describe the classification of spinal cord injuries and associated clinical manifestations.
Divided into traumatic and nontraumatic
Traumatic- external. Physical impact
Nontraumatic- disease, infection, tumour
Traumatic SCI typically occurs in the younger age group, 20–30 years of age, with male to female ratio of 4:1.
-MVA’s and falls
-Cervical spine most common region of injury
Spinal cord injury due to cord compression by
-Bone displacement
-Tumour
-Penetrating trauma (gunshot wound or stab wound
*all cause interruption of blood supply to cord
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Initial Injury
Primary injury-Initial mechanical disruption of axons as a result of stretch or laceration
Secondary injury/response- immune response, sends mediators to site of injury – inflammation, swelling
Apoptosis occurs and may continue for weeks or months after initial injury.
Apoptosis: by 24 hours or less after injury, the development of edema above and below level of injury may cause permanent nerve damage.
Complete cord damage in severe trauma related to autodestruction of cord
-Petechial hemorrhages are in central grey matter of cord shortly after injury.
Resulting _hypoxia_______ reduces oxygen tension below level that meets metabolic needs of spinal cord
Lactate metabolites-a product of anaerobic metabolism
Increase vasoactive substances
-Norepinephrine
-Serotonin
-Dopamine
-released during time of stress -> high levels lead to vasospasm-> subsequent necrosis-> spinal cord has limited ability to adapt to vasospasm
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.
-cord compression increases ischemic damage
basically:
primary injury damage.
Actual physical disruption of axons
secondary damage due to:
1-ischemia
2- hypoxia
3-microhemorrhage
4-edema
Classified by Mechanism of Injury (MOI):
-Skeletal level of injury
-Neurological level of injury
-Completeness or degree of injury
Major mechanisms of injury are:
-flexion
-hyperextension
-flexion–rotation
-most unstable because the ligament structures
that stable are torn resulting in severe
neurological deficits
-extension–rotation
-compression
-from fall, dive (force loading on the spinal
column and is crushed)
-Crush the vertebrae and force bony fragments
into the spinal canal
Describe the clinical manifestations, collaborative care and nursing management of spinal cord injury.
Clinical Manifestations
-Related to level and degree of injury
-a direct result of trauma that causes cord compression, ischemia, edema, and possible cord transection
-The higher the injury = the more serious the sequelae dt Proximity of cervical cord to medulla and brain stem
Immediate post-injury problems include:
-Airway.
- If high c spine, may not have one
-Breathing
-diaphragmatic movement, degree of chest expansion, RR, O2 level
-Adequate circulating blood volume. Did they lose blood? Internal injury? Neurogenic shock below injury (vasodilation, edema)
-Prevent extension of cord damage by secondary injury = reduce disability
Respiratory System
-closely correspond to level of injury
-Above level of C4
-total loss of respiratory muscle function =
mechanical ventilation is required to keep
pt alive.
-Below level of C4
-Diaphragmatic breathing if phrenic nerve is
functioning
-Spinal cord edema and hemorrhage can affect
function of phrenic nerve and cause respiratory
insufficiency
-Hypoventilation almost always occurs with
diaphragmatic breathing.
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 may occur in response to fluid overload.
Cardiovascular System
-Any cord injury above level T6 greatly reduces the influence of the sympathetic nervous system
=bradycardia occurs.
-Peripheral vasodilation ->hypotension, decreased venous return, Decreased CO causing low BP
-Relative hypovolemia exists due to increased venous capacitance.
-Cardiac monitoring is necessary.(heart monitor)
-IV fluids or vasopressor drugs to support BP
-In marked bradycardia (HR <40 bpm) - atropine
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GU
-Bladder is atonic and overdistended
-Urinary retention is common.
-In-dwelling catheter inserted (acute)
(but Increased risk of infection)
-Bladder is atonic because it loses innervation can’t tell when it’s full, can’t relax the sphincter to let out the urine
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)
GI
-injury above T5 = hypomotility
1. paralytic ileus
2.Gastric distension
-Stress ulcers common- tx PPI’s, H2 receptor blockers
Intra-abdominal bleeding may occur.
Difficult to diagnose
-continued hypotension despite tx
-drop in hgb and hct
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
Integumentary
-lack of movement is_skin breakdown over bony prominences =pressure ulcers__ can occur quickly.
Can lead to major infection or_sepsis
Thermoregulation
Poikilothermism-Adjustment of body temperature to room temperature dt sympathetic nervous system interruption preventing peripheral temperature sensations from reaching hypothalamus
Metabolic Needs
-Nasogastric suctioning may lead to metabolic alkalosis
-NG suctioning gets rid of K = alkalosis high pH
-Reduced tissue perfusion may lead to acidosis
-Reduced tissue perfusion = cell breakdown = H ions released = low pH
-Monitor electrolyte levels until suctioning is discontinued and normal diet is resumed
-Nutritional needs much greater than expected for immobilized person
-High-protein diet:
1 skin breakdown, infection
2 muscle atrophy
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Peripheral Vascular Problems
-Deep vein thrombosis (DVT) a common problem
-Pulm embolism_____is a leading cause of death.
DVT assessments
-Doppler examination-pedal pulses
-Measurement of legs and thigh girth (edema)
-Cant feel pain, so pts cant report DVT pain
COLLABORATIVE CARE
Immediate goals are to sustain life and prevent further cord damage.
A-Ensure patent airway
B– adequate ventilation
C- adequate circulating volume
MAP > 65mmHg
Systemic and neurogenic shock must be treated to maintain BP.
-Manage BP it fluids and/or vasopressors like atropine
Thoracic/lumbar vertebrae injuries-
-Respiratory compromise not as severe
-Bradycardia is not a problem.
-Specific problems treated symptomatically
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AFTER ABC stabilization, take hx of event;
-MOI- to look for other evidence of injury elsewhere
-Assessment-
-Test muscle groups with and against gravity, alone and against resistance, and on both sides of the body.
-Note spontaneous movement.
-Sensory examination
-light touch and pain (pin prick) start at toes
and work upwards, both sides
-Position sense and vibration
Brain injury may have occurred—assess history for:
-unconsciousness
-sings of concussion
-increased ICP
Musculo-skeletal injuries
Trauma to internal organs
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Collaborative CareNonoperative Stabilization
-stabilization of injured spinal segment and decompression through traction or realignment
-Eliminates damaging motion at injury site
-Intended to prevent secondary damage
examples:
-clam shell brace & hard collar
-immobilize
-logroll
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Surgical Therapy
1. cord decompression
2. evidence of Cord compression
3. progressive neurologic deficit
4. compound fracture
5. boney fragments pushing on spinal cord
6. penetrating wounds on the SC or surrounding structures
All these necessitate surgery
Common surgical procedures:
-decompression “laminectomy” opens the boney canals to create more space for SC and nerves
-realignment- stabilizing bony structures with rods
-stabilization with instrumentation
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Drug Therapy
-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
-Steroids
-Vasopressors
-ex dopamine, norepinephrine in acute phase to maintain BP and MAP
Contract blood vessels
however no impact if nothing in the vessles to squeeze SO fluids, then vasopressors
NURSING ASSESSMENT
Symptoms:
-Loss of strength, movement and sensation below level of injury
-Dyspnea, “air hunger”
-Pain
-Fear, denial, anger, depression
General: poikilothermism
Neurological: Complete, incomplete
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
Musculo-skeletal: atony, contractures
Reproductive: priapism, loss of sexual function
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NURSING DIAGNOSES
Ineffective breathing pattern
Imbalanced nutrition: less than body requirements
Ineffective peripheral tissue perfusion
Impaired skin integrity
Constipation
Impaired urinary elimination
Risk for autonomic dysreflexia
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acute interventions:
1. Immobilization
2. Resp dysfunction
3. Cardiovascular instability
4. Fluid and Nutritional Maintenance
5. Bladder and Bowel Management
6. Temperature Control
7. Stress Ulcers
8. Sensory Deprivation
9. Reflexes
- ACUTE INTERVENTIONS: Immobilization
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
log roll
Skeletal traction
-Pins go into bone and are attached to a pulley
-Sites of pin insertion can become infected.
-Clean twice daily.
-Stabilize head if dislodged, and then call for help
-Halo traction is the most commonly used method of stabilizing cervical injuries.
-Custom thoracolumbar orthosis (TLSO brace)-Jewett brace
- Acute Interventions: Respiratory Dysfunction
-During first 48 hours, spinal cord edema increases level of dysfunction.
-Injury at or above C3 = laboured breathing, no chest expansion, quick shallow breaths, ABG’s deteriorate, EET/trach for. Mech ventilation
-potential problems- Pneumonia and atelectasis
Nasal stuffiness and bronchospasm
-Aggressive chest physiotherapy
Adequate oxygenation
Proper pain management
assess:
-resp sounds, pattern
-ABG’s
-Tidal volume - lung volume in normal inhalation and exhalation
-Vital capacity -using a spirometer (air in and out max capacity)
-Skin colour
-Amount, colour of sputum
-Subjective comments
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3. ACUTE INTERVENTIONS: cardiovascular instability
-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. turning
2. suctioning
(Spinal cord injury causes disruption of descendant pathways from central control centers to spinal sympathetic neurons originating in T1-L2 sc segments =Loss of supraspinal control over the sympathetic nervous system = reduced overall sympathetic activity below the level of injury AND unopposed parasympathetic outflow through the intact vagal nerve)
-Frequently assess vital signs.
-Anticholinergic for bradycardia ex atropine
-Temporary/permanent pacemaker
-Compression gradient stockings
Remove every 8 hours for skin care
-Prophylactic low-molecular-weight heparin
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- ACUTE INTERVENTIONS: Fluid and Nutritional Maintenance
-During first 48–72 hours, GI tract may stop functioning.
-NG tube insertion prn
-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
-Evaluate _swallowing________ in high cervical cord injuries before starting oral feedings.
-If client is not eating, cause should be thoroughly assessed.
-TPN temporarily
- ACUTE INTERVENTIONS: Bladder and Bowel Management
-Immediately after injury - urine retention
dt 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!
Insert foley asap
Best method of preventing UTI- Regular and complete bladder drainage
Constipation
-Problem during spinal shock
-No voluntary or involuntary evacuation of bowels occurs.
-Rectal stimulant (suppository or mini-enema) inserted daily
-Done in sidelying position
-As soon as pt can sit up, do it in an upright
position on a commode
-Digital rectal stimulation + gravity ---------------------------------------------------- 6. ACUTE INTERVENTIONS: Temperature Control
-Below level of injury
-Vasoconstriction
-Piloerection
-Heat loss through perspiration
-Temperature is largely external to client.
-No ability to thermoregulate below level of injury
SO nurse must monitor environment and body temperature.
- ACUTE INTERVENTIONS: Stress Ulcers
-Physiological response to severe trauma or physiological stress
-Peak incidence occurs 6–14 days after injury.
-Stress ulcers are likely if giving high dose corticosteroids SO give with antacids or with food ex PPI
-Trend hemoglobin and hematocrit for decreases, pay attention to stool colour
———————————————————- - ACUTE INTERVENTIONS: Sensory Deprivation
-Stimulate client above level of injury.
-Conversation, music, strong aromas, and interesting flavours
-Every effort should be made to prevent client from withdrawing.
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9. ACUTE INTERVENTIONS: Reflexes
-Return of reflexes may complicate rehabilitation.
-Hyperactive
-Exaggerated responses
-Penile erections
-Spasms
NURSING GOALS
Maintain optimal level of neurological functioning
Have minimal to no complications rt immobility
Learn skills, gain knowledge, aquire behaviours to care for themselves
Return home into the community
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NURSING IMPLEMENTATION
Health promotion
Identify
high-risk populations.
counselling.
education.
Support legislation on seat belt use, helmets for motorcyclists/bicyclists, and child safety seats.
NURSING INTERVENTIONS
Nursing interventions
Education
Counselling
Maintaining appointments
Referral to programs
Recreation and exercise programs
Alcohol treatment programs
Smoking cessation program
NURSING EVALUATION
-Establishes a bladder management program based on neurological function, caregiver status, and lifestyle choices
-Develops no complications of immobility
-Experiences no episodes of dysreflexia
Diagnostic Studies
gold standard - MRI
for neuro tissue imaging
CT-CT scan may be used to assess stability of injury, location, and degree of bone injury
Ct with contrast for vascular injury
Explain the correlation between the severity and location of spinal cord injury and disruption of bodily function.
Symptoms depend on the degree of paralysis
Rehab depends on the level of the damage
Degree of spinal cord involvement may be
-COMPLETE cord involvement
Results in total loss of sensory and motor
function below level of lesion (injury)
-INCOMPLETE/partial cord involvement
Results in mixed loss of voluntary motor activity
and sensation and leaves some tracts intact
Level of Injury
Skeletal level
-Injury is at the vertebral level, where there is most damage to vertebral bones and ligaments.
-T5, T4, 3, 2, 1 ect. With most damage
-cervical
thoracic
lumbar
Not sacral because the spinal cord ends between L1 and L2
(hence why Spinal blocks are inserted between L3 and 4 or L4 and 5)
-paralysis of all four extremities occurs (“tetraplegia or quadriplegia”) if the __cervical______ cord is involved
Neurological level
-the LOWEST segment of SC with NORMAL sens/motor func on both sides of the body
Phrenic nerve C3-C5 – diaphragm paralysis, breathing
ASIA Impairment Scale
-Commonly used for classifying severity of impairment resulting from spinal cord injury
-Combines assessment of motor and sensory function
-Determines neurological level and completeness of injury
Useful for:
-recording changes in neurological status.
-identifying appropriate functional goals for rehabilitation
Explain associated functional goals for rehabilitation based on severity/ location of SCI and disruption of bodily function.
Movement and functional goals are related to specific location of spinal cord injury.
C1-4 - loss of innervation to diaphragm, no independent resp function
-needs ventilator and max living assistance
-motorized WC
C5- decreased resp reserve, can’t roll over
-assistance for personal care, mobilization w/ motorized or manual WC
C6- weak grasp of thumb
-minimal assistance, assistive devices for care
-WC
C7 -T1 good grasp w/ decreased strength
-independent
T2-6 upper extremities fine, lower extremities may need leg brace for stability
T7-12 same as above, functional intercostal muscles
L1-2 may need assistance with bowel and bladder func, independent use of wheelchair
L3-4 independent for care, independent ambulation with assistive devices
Describe the nursing management of the major physical and psychological problems of patients with spinal cord injury.
Spinal cord injury has 2 states of shock: spinal and neurogenic shock
SPINAL SHOCK
-a temporary neurological syndrome
1.Decreased reflexes
2.loss of sensation
3.Flacid paralysis below level of injury
-very common in acute spinal cord injuries (50%)
-This can last from days-months
-may mask post-injury neuro functioning (what the patient is capable of returning to)
-active rehab can begin during spinal shock
NEUROGENIC SHOCK
-Caused by SCI at T5 or above
-Massive vasodilation without compensation caused by the loss of vasomotor tone caused by SCI
Characterized by:
-hypotension
-hypothermia
-loss of sympathetic innervation
(important clinical cues)
-caused by:
-1) peripheral vasodilation = peripheral vascular
volume decrease= edema
2) venous pooling
3) decreased CO
*Neurogenic shock is acute and depends on the level of injury
Vs
Spinal shock is common 1 out of 2 patients get it, temporary, function is regained
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 teaching:
-Urgency, frequency, incontinence, inability to void, and high bladder pressures resulting in reflux of urine into kidneys
-most common in quad pt
-Itermittent catheter.
Depend amount of volume they retain between
cath. Usually q4h. If retaining close to 600 ml, q3h
Neurogenic Bowel teaching:
-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 teaching:
-Prevention of pressure ulcers
-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.
Women of child-bearing age remain fertile and have the ability to become pregnant or to deliver normally through birth canal.
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.
Be able to describe the physiologic mechanism behind autonomic dysreflexia and its treatment.
Autonomic Dysreflexia
a life-threatening complication of spinal cord injury when injury is above T 6.
overreaction of the autonomic nervous system to painful sensory input
Pathway:
-pt w/ T6 + SCI has a sympathetic stimulation and sympathetic arc has an overreaction can’t tell the brain
-Reflex arc gets picked up in the baroreceptors,
causes vasoconstriction = BP goes up BUT there is no parasympathetic system to react and bring BP down. -Vasoconstriction leads to headache
-Only thing to do is stop the reflex arc
Severe hypertension (>300mmHg)
(normal SBP for pt with spinal cord injury is 90-100mmhg)
Pounding headache
Diaphoresis, Flushing
Piloerection
Dilated pupils
Nasal stuffiness
Bradycardia (pulse <60 bpm)
Nausea
causes:
-common- bladder distention, catheter tube blocked, overdistended rectum (impacted, stool retention), or something is too tight on their skin.
Can only occur after spinal shock has resolved and reflexes have returned. Only occurs with pts with injury T5 and above.
=more likely quads
-as SBP increases suddenly= vasoconstriction = risk of stroke
-over SBP 90-100 mmHg = hypertension
-EMERGENCY when pt complains of headache = take BP. Without a source, gets iv antihypertensive
The priority intervention is to identify and remove any noxious stimuli. Monitor vital signs, especially BP, and immediately place the patient in high Fowler’s position with legs dangling to help lower BP. Remove any tight or restrictive clothing.
INTERVENTIONS
BP
sit pt upright or raise HOb 45
identify stimuli
Bladder- licodaine in urethrea, insert i/out cath OR if foley blocked, irrigate with 10-15 ml NS
Bowels- lidocaine gel, digital removal of stool
Skin- remove tight clothes, stimulus
if none of those and S/s persist - admin an adrenergic blocker or vasopressor ex. CCB nifedipine,
ex nitrate Nitroglycerine 2% Paste
