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Pathophysiology 2 > Spinal Cord Injury > Flashcards

Spinal Cord Injury Flashcards

1
Q

The Spinal Cord

A

The spinal cord controls all voluntary movement of the body and is supported & is protected by the vertebral column

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2
Q

Cervical Vertrebral Column

A

First 7

C3-C5 is where the nerves run to the diaphragm

“C3 – C5 keeps the diaphragm alive”

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3
Q

How Many Thoracic Vertebrae are There

A

12

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4
Q

How Many Lumbar are There

A

5

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5
Q

Sacral Vertebrae

A

There are five vertebrae that are fused together into one bone

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6
Q

Coccygeal Vertebrae

A

4 Bones fused together as one

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7
Q

Spinal Nerves

A

31 pairsof nerves that are attached to the spinal cord

Cervical-8 Pairs

Thoracic-12 Pairs

Lumbar-5 Pairs

Sacral-5 Pairs

Coccygeal-1 Pair

These nerves will contain motor and sensory divisions

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8
Q

Spinal Cord Injuries

A

May stem from a sudden traumatic impact to the spine that fractures, dislocates, or compresses one or more of the vertebrae

A non-traumatic SCI can be the result of arthritis, cancer, inflammation, infections, or disc degeneration

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9
Q

Incomplete Spinal Cord Trauma

A

Preservation of sensory or motor function below the level of injury including the lowest sacral segments

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10
Q

Complete Spinal Cord Trauma

A

Absence of sensory and motor function in the lowest sacral segments

Paraplegia is the result of thoracic/lumbar injury

Will result in Para or Quadrapalegia

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11
Q

Simple Vertebral Fractures

A

Single break in transverse or spinous process

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12
Q

Compressed Vertebral Fractures

A

Vertebral body has been anteriorly compressed

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13
Q

Comminuted Vertebral Fractures

A

Burst/shattered vertebra

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14
Q

Dislocated Vertebral Fractures

A

Can cause cord injury and cord severing

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15
Q

Types Vertebral Fractures

A

Simple

Compressed

Comminuted

Dislocated

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16
Q

Vertebral Compression

A
  • May be caused by downward pressure from the head through the spine
    • Ex. Diving into shallow water
  • Typically causes T12-L2 comminuted or burst fracture
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17
Q

Hyperextension-Hyperflexion

A

Whiplash type injury

Usually cervical caused by a rapid aceleration /deceleration of the head

Compresses the A/P diameter of the spinal cord

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18
Q

Rotational Spinal Cord Trauma

A

Can effect any part of the spinal column

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19
Q

Spinal Contusion

A

Bruising, local hemorrhage or edema

Can be temporary

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20
Q

Penetrating Injury

A

Knives, GSW, projectiles, explosions

Cord tearing or severing

Bone fragments will also cause vascular injury

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21
Q

High C-Spine Injury

A

Injury to C1-C2

Will result in an almost complete paralysis of the respiratory muscles and only some of the accessory muscle may remain functional

Acutely these parameters are unable to generate significant tidal volume and/or cough

Will require intubation and full ventilatory support.

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22
Q

Mid-Low C-Spine Injury

A
  • Injury to C3-C8
  • Varying degrees of muscle impairment depending on involvement/sparing of the diaphragm
  • Paradoxical breathing pattern (loss of lateral and A/P chest expansion)
    • This is caused by a loss of external intercostal muscles
  • Severely limited cough/expiratory function, as major expiratory muscles are innervated below T6
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23
Q

T-Spine Injury

A
  • There will be varying degrees of inspiratory muscle impairment depending on involvement/sparing of the intercostal muscles
  • Observe patient for lateral and A/P chest expansion of inspiration to assess external intercostal muscle function.
  • Varying degrees of expiratory muscle function depending on the level of injury.
  • Place hands on abdomen and ask patient for a strong cough.
    • Feel for abdominal muscle contraction and observe the force of the cough.
    • Don’t just look for abdominal movement.
  • Associated chest trauma and/or hemothorax are not uncommon.
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24
Q

Sign and Symptons of Spinal Cord Injury

A

Pain or pressure in the neck or back

Weakness or paralysis in any part of the body (may develop immediately or come on gradually as swelling occurs in or around the spinal cord)

Numbness, tingling, or loss of sensation in hands, fingers, feet or toes

Loss of bladder or bowel control

Impaired breathing after injury

Hypotension with bradycardia

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25
Spinal Shock
Can occur immediately or within several hours Occurs with SCI above t6
26
Spinal Shock Signs and Symptons
Loss of motor, sensory, reflex, and autonomic function below the level of injury
27
Spinal Shock Results
Instant flaccid paralysis
28
Spinal Shock Duration
Variable R/t severity of insult May last up to 6 weeks Resolved when there is a return of bulbcavernous reflex activity
29
Neurogenic Shock
Neurogenic shock and spinal shock go hand in hand It is a form of distributive shock
30
Neurogenic Shock Pathophysiology
Loss of sympathetic input to the heart and decreased peripheral vascular resistance (loss of vasomotor tone)
31
Neurogenic Shock Clinical Signs
Hypotension and bradycardia Loss of ability to sweat below the level of injury
32
Neurogenic Shock Treatment
IV fluids and inotropes to maintain goal MAP
33
Initial Management of Spinal Cord Injury
Emergent-Spinal precautions/logroll for the removal of the spinal board CAB --- CPR Manage hypotension and risk of neurogenic shock
34
Confirming Spinal Cord Injury
Visual Inspection of spine Initial Neurological Assessment
35
Long Term Management
* ASIA Scale * SCI Respiratory Complications * Pulmonary Function * Vital Capacity (VC) * Peak Cough Measurement * NIF * Respiratory Interventions
36
Long Term Management Respiratory Interventions
MIE LVRM Assisted Cough BIPAP/CPAP Mechanical Ventilation
37
Vital Capacity
A baseline VC measure should be done on all C or T spine patients ASIA categories A, B, or C If VC is equal or less than 10-12 ml/kg then the patient is at high risk of ventilatory failure
38
Vital Capacity and Postural Dependance
In quadriplegics VC increases about 49% when changed from sitting to lying position. In paraplegics VC increases by 28% when changed from sitting to lying position. Increase in VC due to mechanical advantage of the diaphragm. VC should be measured in supine position.
39
Peak Cough
Measuring peak cough flow Different than Peak Expiratory flow because patient’s glottis is closed (allows the patient to generate high thoraco-abdominal pressures and flows)
40
Peak Cough Flow \>160 LPM
Peak Cough Flow \>160 LPM for successful **extubation/decannulation**
41
Peak Cough Flow \>300 LPM
\>300 LPM - normal value, should be enough to generate an effective cough
42
Peak Cough Flow 160-129 LPM
160-290 LPM –Cough will likely be ineffective and will need to be augmented in the presence of increased secretions with MIE/LVRM
43
Peak Cough Flow \<160 LPM
\<160 LPM –Cough will likely be ineffective to mobilize secretions, cough augmentation therapy should be initiated
44
Mechanical Insufflation-Exsufflation (MIE)
Indicated when peak cough is \<290 LPM Will deliver a deep breath then assist with cough by “sucking” the air out of the lungs Often accompanied by chest PT and assisted cough Set pressures: start low and increase up to 40 cmH20 based on patient comfort.
45
Manually Assisted Cough Patient Position
Supine or sitting with head of bed (HOB) at the desired angle
46
Manually Assisted Cough Assister hand Position
Standing beside the patient (or straddling the patient and placing the heel of 1 hand over the abdomen midline 2” below bottom of the breast bone Place second hand on top and interlock fingers
47
Manually Assisted Cough Action
Patient takes a deep breath and tries to cough At the beginning of the cough the assister will push in and up evenly frimly and quickly
48
Other Respiratory Management
Chest PT CPAP/BIPAP Mechanical Ventilation
49
ASIA Impairment Scale Score A
**Complete** No Sensory or motor function present in sacral segemnts S4-5
50
ASIA Impairment Scale Score B
**Sensory Incomplete.** ## Footnote Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-5 (light touch or pin prick at S4-5 or deep anal pressure) AND no motor function is preserved more than three levels below the motor level on either side of the body.
51
ASIA Impairment Scale Score C
**Motor Imcomplete** ## Footnote Motor function is preserved at the most caudal sacral segments for voluntary anal contraction (VAC) OR the patient meets the criteria for sensory incomplete status (sensory function preserved at the most caudal sacral segments (S4-S5) by LT, PP or DAP), and has some sparing of motor function more than three levels below the ipsilateral motor level on either side of the body. (This includes key or non-key muscle functions to determine motor incomplete status.) For AIS C – less than half of key muscle functions below the single NLI have a muscle grade ≥ 3.
52
ASIA Impairment Scale Score D
Motor Incomplete. Motor incomplete status as defined above, with at least half (half or more) of key muscle functions below the single NLI having a muscle grade ≥ 3.
53
ASIA Impairment Scale Score E
Normal. If sensation and motor function as tested with the ISNCSCI are graded as normal in all segments, and the patient had prior deficits, then the AIS grade is E. Someone without an initial SCI does not receive an AIS grade.
54
Function of Accessory Muscles
Expands upper rib cage
55
Abdominals Innervation and Function
T6-12 Tone supports diaphragm Abdominal pressure for cough
56
Internal Intercostals Innervation and Function
T1-7 Pulls rib cage down and in Decrease intrathoracic volume
57
External Intercostals Innervation and Function
T1-7 Pulls rib cage up and forward Increases lateral diameter Increase AP diameter
58
Diaphragm Innervation and Function
C3-5 Increases Vertical Diameter
59
Scalene Innervation and Function
C2-8 Elevates Ribs
60
Trapezius Innervation and Function
C3-4 Elevates Rib Cage
61
Sternocleidomastoid Innervation and Function
C1-3 Elevates Sternum
62
T11 or Below Level of Injury Cough and VC
**Cough:** Normal **Vital Capacity:** Normal
63
T5-T10 Level of Injury Cough and VC
**Cough:** Poor **Vital Capacity:** 75-100%
64
T2-T4 Level of Injury Cough and VC
**Cough:** Weak **Vital Capacity:** 40-50%
65
C5-T1 Level of Injury Cough and VC
**Cough:** Non-Functional **Vital Capacity:** 30-40%
66
C5-T1 Level of Injury Cough and VC
**Cough:** Non-Functional **Vital Capacity: 30-40**%
67
C4 Level of Injury Cough and VC
**Cough:** Non-Functional **Vital Capacity:** 10-15%
68
C1-3 Level of Injury Cough and VC
**Cough:** Absent **Vital Capacity:** 0-5%
69
Theories on Why there is a Postural Change in VC
There are 2 theories on why there is the change in VC 1. The increase is due to the mechanical advantage of the diaphragm. When these patient lie down their abdominal content will push up on the diaphragm, placing it in a position where it can generate more force. When the patient is upright the diaphragm is in a lower resting position as the abdominal content sag out and therefore there is less volume change per contraction 2. The increase in VC is due to the reduction in RV in the recumbent state
70
How to Assess PResence of Diaphram Use
Observe patient’s abdominal excursion during tidal breathing for presence of diaphragm use

Pathophysiology 2 (9 decks)

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