Spinal Cord Injury Flashcards
The Spinal Cord
The spinal cord controls all voluntary movement of the body and is supported & is protected by the vertebral column
Cervical Vertrebral Column
First 7
C3-C5 is where the nerves run to the diaphragm
“C3 – C5 keeps the diaphragm alive”
How Many Thoracic Vertebrae are There
12
How Many Lumbar are There
5
Sacral Vertebrae
There are five vertebrae that are fused together into one bone
Coccygeal Vertebrae
4 Bones fused together as one
Spinal Nerves
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
Spinal Cord Injuries
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
Incomplete Spinal Cord Trauma
Preservation of sensory or motor function below the level of injury including the lowest sacral segments
Complete Spinal Cord Trauma
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
Simple Vertebral Fractures
Single break in transverse or spinous process
Compressed Vertebral Fractures
Vertebral body has been anteriorly compressed
Comminuted Vertebral Fractures
Burst/shattered vertebra
Dislocated Vertebral Fractures
Can cause cord injury and cord severing
Types Vertebral Fractures
Simple
Compressed
Comminuted
Dislocated
Vertebral Compression
- 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
Hyperextension-Hyperflexion
Whiplash type injury
Usually cervical caused by a rapid aceleration /deceleration of the head
Compresses the A/P diameter of the spinal cord
Rotational Spinal Cord Trauma
Can effect any part of the spinal column
Spinal Contusion
Bruising, local hemorrhage or edema
Can be temporary
Penetrating Injury
Knives, GSW, projectiles, explosions
Cord tearing or severing
Bone fragments will also cause vascular injury
High C-Spine Injury
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.
Mid-Low C-Spine Injury
- 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
T-Spine Injury
- 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.
Sign and Symptons of Spinal Cord Injury
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
Spinal Shock
Can occur immediately or within several hours
Occurs with SCI above t6
Spinal Shock
Signs and Symptons
Loss of motor, sensory, reflex, and autonomic function below the level of injury
Spinal Shock
Results
Instant flaccid paralysis
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
Neurogenic Shock
Neurogenic shock and spinal shock go hand in hand
It is a form of distributive shock
Neurogenic Shock
Pathophysiology
Loss of sympathetic input to the heart and decreased peripheral vascular resistance (loss of vasomotor tone)
Neurogenic Shock
Clinical Signs
Hypotension and bradycardia
Loss of ability to sweat below the level of injury
Neurogenic Shock
Treatment
IV fluids and inotropes to maintain goal MAP
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
Confirming Spinal Cord Injury
Visual Inspection of spine
Initial Neurological Assessment
Long Term Management
- ASIA Scale
- SCI Respiratory Complications
- Pulmonary Function
- Vital Capacity (VC)
- Peak Cough Measurement
- NIF
- Respiratory Interventions
Long Term Management
Respiratory Interventions
MIE
LVRM
Assisted Cough
BIPAP/CPAP
Mechanical Ventilation
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
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.
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)
Peak Cough Flow
>160 LPM
Peak Cough Flow >160 LPM for successful extubation/decannulation
Peak Cough Flow
>300 LPM
>300 LPM - normal value, should be enough to generate an effective cough
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
Peak Cough Flow
<160 LPM
<160 LPM –Cough will likely be ineffective to mobilize secretions, cough augmentation therapy should be initiated
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.
Manually Assisted Cough
Patient Position
Supine or sitting with head of bed (HOB) at the desired angle
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
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
Other Respiratory Management
Chest PT
CPAP/BIPAP
Mechanical Ventilation
ASIA Impairment Scale
Score A
Complete
No Sensory or motor function present in sacral segemnts S4-5
ASIA Impairment Scale
Score B
Sensory Incomplete.
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.
ASIA Impairment Scale
Score C
Motor Imcomplete
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.
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.
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.
Function of Accessory Muscles
Expands upper rib cage
Abdominals Innervation and Function
T6-12
Tone supports diaphragm
Abdominal pressure for cough
Internal Intercostals Innervation and Function
T1-7
Pulls rib cage down and in
Decrease intrathoracic volume
External Intercostals Innervation and Function
T1-7
Pulls rib cage up and forward
Increases lateral diameter
Increase AP diameter
Diaphragm Innervation and Function
C3-5
Increases Vertical Diameter
Scalene Innervation and Function
C2-8
Elevates Ribs
Trapezius Innervation and Function
C3-4
Elevates Rib Cage
Sternocleidomastoid Innervation and Function
C1-3
Elevates Sternum
T11 or Below Level of Injury
Cough and VC
Cough: Normal
Vital Capacity: Normal
T5-T10 Level of Injury
Cough and VC
Cough: Poor
Vital Capacity: 75-100%
T2-T4 Level of Injury
Cough and VC
Cough: Weak
Vital Capacity: 40-50%
C5-T1 Level of Injury
Cough and VC
Cough: Non-Functional
Vital Capacity: 30-40%
C5-T1 Level of Injury
Cough and VC
Cough: Non-Functional
Vital Capacity: 30-40%
C4 Level of Injury
Cough and VC
Cough: Non-Functional
Vital Capacity: 10-15%
C1-3 Level of Injury
Cough and VC
Cough: Absent
Vital Capacity: 0-5%
Theories on Why there is a Postural Change in VC
There are 2 theories on why there is the change in VC
- 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
- The increase in VC is due to the reduction in RV in the recumbent state
How to Assess PResence of Diaphram Use
Observe patient’s abdominal excursion during tidal breathing for presence of diaphragm use
