Spinal Injuries Flashcards
Spinal cord
8 cervical nerves (C1-C8) 7 cervical vertebrae 12 thoracic nerves (T1-T12) 5 Lumbar nerves (L1-L5) 5 Sacral nerves (S1-S5) 1 coccygeal pair
Function of the spinal cord
- conduction
- locomotion
- reflexes
What is the function of the cerebral column and spinal column?
Support/protect the spinal cord
What are two reflexes controlled by the spinal cord?
- Micturition - external sphincter contracted to hold urine
- Digestion to defecation - gastrocolic and duodenocolic relflex –> peristalsis
Spinal cord injury is
damage to the spinal cord caused by concussion, contusion, compression, laceration, transection, hemorrhage, damage to blood supply, damage to blood vessels in the cord
SCI can be classified by
- Mechanism of injury
- Skeletal and neurological level of injury
- Degree of injury
Examples of mechanism of injury are
Flexion
Hyperextension
Flexion-rotation
Extension-ratation
What is the most unstable mechanism of injury?
Flexion-rotation recuasse ligaments are torn that stabilize the spine and it usually has the most severe neuro deficits
Skeletal and neurological level of injury
Skeletal - vertebrae and ligaments - level of damage to bones and ligaments
Neurological - lowest segment of spinal cord with sensory and motor function
Degree of injury
How much motor/sensory is lost
Complete = total sensory and motor loss
Incomplete = mix sensory and motor loss
What is the American spinal injury association (ASIA)?
determines the level of impairment for a spinal cord injury
Diagnosis of a spinal cord injury
- CT - gold standard for bone injury
- MRI - gold standard for degree of injury like soft tissue and neural changes
- ASIA - docs use this to determine specific level of injury by assessing sensory and motor level that are affected
Primary SCI
occurs at the time of the impact
Immediate stretch or laceration of spinal cord
Secondary SCI
Ongoing progressive damage that occurs minutes, hours, days after primary
What can secondary SCI cause?
tissue hypoxia and further damage to the spinal cord
Cervical nerves function is
head, neck, breathing, upper arms, wrists, hands
Thoracic nerves function is
chest and abdominal muscles, internal organs
Lumbar nerves function is
legs muscles
Sacral nerves function is
bathroom capabilities, ability to reproduce
C3, 4, 5
“keep a fella alive”
Breathing
C1-4
ventilator and 24 hr/day care
C4
requires mouth stick to use wheelchair
C5
10hr/day care
C6
might be able to use hand control on wheelchair
6hr/day care
T6
non motorized wheelchair with full independence
L1
can ambulate with long leg braces, control of leg and not at risk for AD, flaccid bowel and bladder
L3-4
ambulate completely independently but can’t stand for long periods
C8 and above are…
tetraplegic - can’t move legs or arms
T1 is…
paraplegic - can’t move legs, breath on their own, move move upper back and arms, at risk for AD, spastic bowel and bladder
Phrenic nerve is responsible for
C3-C5
Breathing
Spinal shock
Temporary loss of reflexes and paralysis below level of injury and bowel and bladder dysfunction
Lasts days to weeks
Neurogenic shock
Loss of sympathetic NS tone for someone with a T6 injury or above.
Form of disruptive shock
Hypotension and bradycardia
Warm or cold, dry extremities, not able to auto regulate temp by sweating or shivering
Anterior cord syndorme
Not common
r/t flexion injury
Loss of motor, pain, and temperature below injury
Intact: position, vibration, and touch sense
Central cord syndrome
More common cervical injury
Incomplete loss
Motor and sensory loss in upper and lower extemities
Upper are more weak than lower
Brown-sequard syndrome
Usually from penetrating injuries - knives, GSW, disc rupture
Loss of pain and temp sensation on opposite side
Loss of voluntary motor control , vibration and positioning on same side
Conus medullaris injury
Lowest portion of spinal cord
Function in legs are preserved, weak or flaccid
Decrease in or loss of sensation in perianal area
Bladder and bowel issues
Impotence
Cauda Equine injury
Lumbar and sacral nerve roots Asymetrical distal weakness Flaccid paralysis of lower extremities Complete loss of sensation in saddle area Bladder and bowel issues Severe, radicular, asymmetric pain
Stabilization of the spine immediately after surgery
rigid cervical collar and supportive backboard
How do you change positions of a patient with a SCI
logroll the patient
To stabilize the spine you can use..
Surgery or traction
Decompression laminectomy - remove part of bone to allow swelling
Fusion
Insertion of stabilizing rods, screws, and plates
Downside to cervical traction
can still twist in bed
Halo vest
More strict, nonsurgical procedure
Not good for ligament instability
For both cervical traction and halo vest you should clean the pins by
hydrogen peroxide, alcohol, and water on a cotton pad and then apply antibiotic ointment
Respiratory complications about C4
total loss of respiratory function
Respiratory complications below C4
diaphragmatic breathing if phrenic nerve is functioning
Respiratory complications cervical/thoracic
paralysis of abdominal muscles and intercostal muscles –> not being about to cough
In the first 48 hours swelling occurs, why does that matter in relation to breathing?
it can increase the level of dysfunction and a C5 injury may look more like a C3 injury and require ventilation
Respiratory complications r/t SCI
- hypoventilation
- Atelectasis
- Pneumonia
Respiratory assessment with SCI
breath sounds, RR, airway, saturation, ABG, tidal volume, skin color, comments on breathing, color of sputum, use of accessory muscles, can they count to 10 in one breath
Airway assessment with SCI
adequate oxygenation
Chest physiotherapy SCI
positioning, mobilization, manual hyperinflation, percussion, chest vibrations, suction, cough, breathing exercises
Cough and deep breathing SCI
incentive spirometer
assisted/quad coughing - for any patient having trouble coughing, patient takes a deep breath and provider pushes up forcefully as they cough. Should not be done if they just ate
Suction SCI
tracheal or oral
Position SCI
upright and possibly propped
Pani management SCI
medications and massage
Bradycardia due to neurogenic shock can lead to
Cardiac arrest when vagal is stimulated, while turning or suctioning
Bradycardia intervention
Cardiac monitoring, atropine, pacemaker
Hypotension intervention
Iv fluids, vasopressor like dopamine, NE
Orthostatic hypotension intervention
abdominal binder, support stocking, gradual elevation of bed, tailback if event occurs
DVT intervention
compression stockings, ROM, heparin or lovenox
While using compression stocking when should they be removed?
every 8 hours for skin care
Acute urinary issue with SCI
spinal bladder shock –> not able to eliminate –> distention –> needing catheter
Urinary can reflex to kidneys
Chronic urinary issues with SCI
loss of control and reflex of bladder and sphincter
No sensation of fullness or distention
This can cause kidney failure as urine refluxes into kidneys, kidneys stones from bone breakdown, and UTI
Inability to control urine intervention
intermitent cath, regualr bladder emptying 4-6 hours, indwelling Cath, mitrofanoff, ileostomy
UTI interventions
fluid intake fo 2L/day and s/s of UTI
Renal stone intervention
Watch calcium intake
Inability to empty bladder interventions
ultrasound post void, should be less than 500 mL
Bowel complications with SCI acute
decreased GI motility –> gastric distention
Excess Hal acid in stomach —> ulcer
Paralytic ileus
Bowel complications with SCI chronic
dysphagia, neurogenic bowel, hemorrhoids, abdominal distention, constipation, incontinence, poor nutrition intake
Mitrofanoff
part of appendix is removed to create a sphincter to straight cath
Must be at least 1 year out for SCI because complication rate are high especially for infection
injury above T12 and bladder
can’t empty bladder on their own, intermittent catheterization
Injury below T12 and bladder
decreased sensation of bladder fullness and overflow and incontinence is common
intermitent catheterization
Reflex/ spastic bowel
above T12, anal sphincter remains closed
Keep stool soft
Areflexic / flaccid bowel
Below T12, loss of anal sphincter tightness
Keep stool hard
Bowel program
Patient knows what is best for them and what has worked in the best so don’t change what works.
Bowel program is to avoid constipation
Intervention for gastric distention
NG tube with suction, NPO
Ulcer intervention
H2 blocker or PPI (prazole)
Intra-abdominal bleeding intervention
guaiac stool for heme positive and watch H/H, monitor abdominal girth
Constipation interventions
bowel regimen, medications: reglan, cisapride, prucalopride, neostigmine, fampridine, external electrical stimulation
Severe catabolism interventions
high protein, high calories, feeding tube or parenteral
Dysphagia interventions
speech and swallow consult after bowel sounds or flatus is passed
Poor PO intake interventions
assess for depression, make a contract, food they enjoy, how they like to be fed, rewards for eating, calorie count
Complications with skin SCI
pressure ulcers –> infection –> sepsis –> death
Interventions for pressure ulcers
- change positions every 2 hours
- check for any equipment like tubes under patient
- takes weight off of pressure points
- watch out for hot/cold packs
- Special cushions/pad - required for wheelchair bound
Poikilothermism
adjustment of body temperature to room temperature
T6 and above with temperature
interruption of SNS
Cant shiver or sweat to regulate temperature
Reflexes after spinal shock
hyperactive or exaggerated
Spasms below level of lesion peak spacigity after 2 years
Spasms can cause contractors so may need to splint
How to treat spasms
muscles relaxants such as baclofen, botulinum toxin injections of surgery like cordotomy which is cutting a nerve
Autonomic dysreflexia
life threatening condition that can occur in patient with a SCI at T6 and above
Hyperteflexic due to noxious stimuli below level of injury
When can autonomic dyreflexia occur?
after spinal shock because it is a reflex which only come back once spinal shock is gone
Patho of autonomic dysreflexia
- Stimulation below injury
- SNS below injury –> vasoconstriction
- PNS cannot respond
- Baroreceptors in the heart respond to high BP by decrease the HR and dilating peripheral blood vessel above injury
- body is not communicating so above injury, vasodilation. Below injury, vasoconstriction
S/S of autonomic dysreflexia
HTN (240-300), bradycardia, HA, blurred vision, flushing, diaphoresis and red above injury, cold pale skin below injury
Autonomic dysreflexia leads to
status epilepticus
stroke
MI
death
Common precipitating factor of autonomic dysreflexia are?
- Distended bladder or rectum (kinked foley, constipation, impaction)
- tight clothing
- wrinkle in bed sheet
- wounds
Autonomic dysreflexia interventions
Elevated the HOB above 45 degree
Monitor BP every 3-5 minutes
Notify provider
Assess for cause: check bladder drainage, loosen tight clothes/shoes, check skin
Medication: nitroglycerin - drug of choice because short 1/2 life and need to find the cause to fix it, atropine, nifedipine
Teach patient
Before giving nitroglycerin what should you do?
Check BP
Ask about medication like viagra or anything similar to it
Patient with a SCI can have depression because..
- overwhelming sense of loss
- goal adjust instead of accept
- family may need counseling
- sympathy is not helpful
Sexuality and SCI
yes can have sex and you can get pregnant
