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High Acuity > Spinal Cord Injury > Flashcards

Spinal Cord Injury Flashcards

1
Q

Define spinal cord injury

A
  • A sudden traumatic injury that either results in a bruise, partial injury or a complete injury to the spinal cord
  • Can occur at any level of the spine
  • Leading cause of paralysis and always results in a physical disability
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2
Q

Causes of spinal cord injury

A

Trauma > MVC, falls, violence (gunshot wounds), sports/recreation-related accidents, assault

Non-traumatic > degenerative disease, vertebral #, tumors, infections, etc.

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3
Q

The spinal cord provides ________ between the brain and PNS

A

2 way communication

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4
Q

Describe the matter of the spinal cord

A

H-shaped gray matter (neuron cell bodies) is surrounded by white matter (myelinated axons)

> Opposite to brain (white is inside in brain, gray on outside)

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5
Q

White matter contains:

A

White matter has
* ascending (sensory/afferent)
* descending (motor/efferent) tracts

Myelination = communication

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6
Q

Describe the composition of a spinal nerve

A

Each spinal nerve has a posterior and an anterior branch

  • Posterior/dorsal: carries sensory perception information to the cord (afferent pathway)
  • Anterior/ventral: transmits motor impulses to the peripheral target cells (efferent pathway)
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7
Q

How many spinal nerves are there + list their divisions

A

31 pairs of spinal nerves exiting the spinal cord below correlating vertebrae
- C1-C8: 8 cervical nerves, 7 vertebrae – most prone to injury due to increased ROM; C5 most common for quad
- T1-T12: 12 thoracic nerves and vertebrae– T12/L1 most common for para
- L1-L5: 5 lumbar nerves and vertebrae
- S1-S5: 5 sacral nerves and vertebrae
- 1 coccygeal nerve and vertebrae

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8
Q

What portion of the vertebral canal does the spinal cord span?

A

Upper 2/3 of vertebral canal; doesn’t span whole length of spine
- Usually ends at L1-L2 in adults
- Cauda equina: sack of nerve roots (nerves that leave the spinal cord between spaces in the bones of the spine to connect to other parts of the body) at the lower end of the spinal cord. These nerve roots provide the ability to move and feel sensation in the legs and the bladder.

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9
Q

Describe the respiratory innervation responsible for inhalation

A

C3-C5: diaphragm

C2-C7: accessory muscles - sternocleidomastoid, scalene, upper trapezius

T1-11: external intercostals

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10
Q

Describe the respiratory innervation responsible for exhalation

A

T1-11: internal intercostals

T6-12: abdominal muscles

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11
Q

Hyperflexion MOI

A

Forward, head on vehicle motor collision, whiplash

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12
Q

Hyperextension MOI

A

Backward, vehicle collisions from behind, falls

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13
Q

Axial loading MOI

A

(vertical compression)

Diving into shallow water, falling straight on butt

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14
Q

Rotational MOI

A

Laterally

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15
Q

Penetrating MOI

A

Enters spinal area; direct injury

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16
Q

Tetraplegia

A

Complete or partial loss of sensation and/or movement in all 4 extremities and torso
Cervical and upper thoracic injuries

Injury to C1-T1

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17
Q

Paraplegia

A

Complete or partial loss of sensation and/or movement in the legs (often also includes torso)

Lower thoracic & lumbosacral injuries/lesions

Injury to T2-T12

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18
Q

Describe the 2 ways level of injury is assessed:

A
  1. Vertebral (anatomic) level of injury: where the injury occurred
  2. Neurological level of injury: lowest level with intact motor and sensory function
    > Usually the same, but not always: secondary injury causing ischemia/inflammation to areas higher up in the cord
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19
Q

Complete vs Incomplete SCI

A

Complete:
- Spinal cord damaged in a way that eliminates all innervation below the level of the injury
- Loss of all voluntary motor and sensory function below the level of injury

Incomplete:
- Allow some function or movement below the level of the injury.
- More common than complete injuries
- Usually still present as complete at time of injury due to swelling/inflammation. As it subsides, ability to classify increases.

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20
Q

Primary vs Secondary Injury SCI

A

Primary
- neurological damage that occurs at impact
- The immediate mechanical damage to the cord and/or vertebrae
- Solid structures crack; hollow structures pop; fixed points tear

Secondary
- worsens the primary injury, may result in death. A result of vascular injury to the cord
> Ischemia- control spinal shock
> Inflammation (local edema to the cord)
> Hemorrhage
> Impaired tissue perfusion (neurogenic shock)
> hypovolemia

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21
Q

Describe the Primary Survey in SCI

A

Done with all trauma patients
1. Airway, Alertness, C-Spine
* C-spine immobilization
* Early intubation & ventilation
* Concurrent trauma putting patient at risk for airway compromise
2. Breathing, Ventilation
* BVM or ventilator
3. Circulation and Control of Hemorrhage
* Hemodynamic instability> shock
4. Disability
* GCS < 8 = intubate
5. Environment and Exposure
* Other injuries
* Temperature management

22
Q

4 Devices used for C-Spine Immobilization

A
  1. C-collar: what patient is brought in with; put on at scene
  2. Philly collar: unsure if injury present; more comfortable, can be sized to patient
  3. Vista Collar: confirmed injury; provided by OT
  4. Halo Device: skeletal traction with burr holes - injuries that required surgical intervention/unstable fractures – pin-site care important for infection rx

> Backboards no longer best practice

23
Q

Describe the Secondary Survey in SCI

A
  1. Get adjuncts & give comfort
    * CT scan: identification of injury
    * ABG: impact on physical ventilation
    * Continuous oximetry and etCO2
    * Cardiac monitor: for additional trauma
  2. History: What might you want to know?
    * PMH, MOI, immediate symptoms post-injury (how does it differ from presentation now), treatment that has occurred, when was spine mobilized
  3. Head-to-toe
24
Q

Describe the head to toe done in the secondary survey of patient with SCI

A
  1. Mobility and sensation
    * muscle weakness
    * loss of voluntary muscle movement in chest, arms or legs
    * loss of sensation in chest, arms or legs
  2. Deep tendon reflexes
    * biceps- C5; triceps- C7; patella- L3; ankle- S1
  3. Cardiopulmonary
    * Sympathetic nerve impairment = cardio
    * C3-C5 = diaphragmatic innervation
  4. GI/GU
    * Paralytic ileus: secondary to spinal shock; gastric mobility can return following return
25
Q

Bicep reflex shows ____ innervation

A

C5

26
Q

Tricep reflex shows _____ innervation

A

C7

27
Q

Patellar reflex shows ________ innervation

A

L3

28
Q

Ankle reflex shows _____ innervation

A

S1

29
Q

Dermatome vs Myotome

A

Dermatome: area of skin in which sensory nerves derive from a single spinal nerve root – afferent/dorsal

Myotome: set of muscles innervated by a spinal nerve – efferent/anterior

30
Q

Explain process of logroll

A
  • 4 people minimum
  • Leader at patient’s head maintains cervical stabilization and team direction
  • 2 people on one side of patient; support torso, hips, and lower extremities
  • Maintain vertebral column alignment during turning
  • Avoid rolling onto side of injured extremities
  • Logroll away from examiner
31
Q

Priorities for SCI in first 24 hours

A
  1. ABCs
  2. Stabilize: manage damage to the spinal cord
  3. Prevent secondary injuries
    * Control ischemia: leads to further necrosis and injury
    * Inflammation: control with corticosteroids
    * Manage shock (spinal, neurogenic, etc.)
    * Maintain MAP 85 for spinal perfusion
32
Q

Long term priorities for SCI

A
  1. Maximize potential for neurological recovery
  2. Prevent/minimize complications
  3. Regain life skills and independence
33
Q

Prevention of respiratory complications

A

Monitor respiratory status
* Airway
* Respiratory drive
* Ventilation
* Ability to cough
* Pulse oximetry
* ABGs

Above C5: diaphragm innervation

34
Q

Why are cervical and high thoracic SCI at risk for cardiovascular complications

A

T1-T5 innervate the autonomic nervous system

If effected - SNS response not regulated leading to impaired vessel control (dilation/constriction)

PNS intact leading to low resting responses (AD and orthostatic hypotension)

35
Q

What cardiovascular complications are SCI patients at risk for?

A
  1. Impaired Cardiac Output
    > Orthostatic hypotension
    > Blood pooling
  2. Clots
    >VTE prophylaxis anticoagulants
    > Anti-embolic stockings
    > Abdominal binders: promote venous return when up in chair
    > Muscles not engaged; belly protrudes
    > Promotes blood return
  3. Shock
  4. Autonomic Dysreflexia
36
Q

Precipitating Injury for Neurogenic Shock

A

High thoracic or cervical cord (T6 or higher)

37
Q

Pathophysiology of Neurogenic shock

A

Temporary loss of vasomotor tone and sympathetic innervation (= massive vasodilation)
Systemic

38
Q

Duration of neurogenic shock

A

Temporary (often <72hrs)

39
Q

Signs and Symptoms of Neurogenic Shock

A

Decreased CO:
- Hypotension
- Bradycardia
- Loss of ability to sweat below level of injury (= warm dry skin)

40
Q

Treatment of neurogenic shock

A

Support airway; fluids; vasopressors; atropine; keep warm

41
Q

Precipitating injury for spinal shock

A

SCI at any level

42
Q

Pathophysiology of spinal shock

A

Transient loss of reflex and muscle tone (flaccidity) result of secondary injury
Below the level of injury

43
Q

Duration of spinal shock

A

Occurs relatively immediately after injury
Variable duration (usually <48hrs- several weeks one edema decreases)

44
Q

Signs and symptoms of spinal shock

A

Below level of injury:
Flaccidity
Loss of reflexes
Loss of sensation
Bowel & bladder dysfunction

45
Q

Treatment of spinal shock

A

Supportive care

46
Q

Autonomic dyreflexia occurs in injuries:

A

Occurs in T6 SCI and above

47
Q

Autonomic dysreflexia is a result of

A

hyperactive reflex to stimulus (visceral or cutaneous) below the level of the lesion
* Bladder distention, UTI
* Bowel distention, constipation/impaction
* Skin stimulation (heat, sunburn)
* Labor
* Sexual activity
* Contact with hard/sharp object

48
Q

What occurs above and below the level of the SCI in autonomic dysreflexia?

A

Stimulus sends signal activating SNS (increase BP)

BELOW: dysregulated SNS response resulting in massive vasoconstriction
INCREASE BP

ABOVE: PNS responds (Neuronally intact) to increased BP
BRADYCARDIA w MASSIVE VASODILATION

49
Q

Bowel + Bladder Management upper vs lower SCI

A

Upper SCI = spastic bowel and bladder
> Voiding patterns may be uncontrollable
> Long-term indwelling/external catheters
> Rectal suppositories to promote regular bowel elimination

Lower SCI = flaccid bowel and bladder
> Intermittent urinary catheterization
> Manual pressure over bladder
> Bowel disimpaction regularly

50
Q

Male sexual function SCI

A
  • Erectile dysfunction (75%)
  • Reflex erections  direct stimulation independent of erotic stimuli
  • Preserved with injury above L2
  • Ejaculation problems (95%)
  • Requires parasympathetic, sympathetic, and somatic neural components
  • Risk of autonomic dysreflexia
51
Q

Female sexual function SCI

A
  • Orgasm is possible
  • Decreased lubrication produced
  • Pregnancy is possible (rates similar to non-injured population)
  • Risk of autonomic dysreflexia
  • Menstrual periods usually stop due to the shock from the injury; usually start in 3-6 months

High Acuity (20 decks)

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