Unit 1: Spinal Cord Injury (SCI) Flashcards
Spinal Cord
-18 inches long
-nerves within the cord carry messages from the brain to the spinal nerves (upper motor neurons) and back
-spinal nerves (lower motor neurons) branch out from the spinal cord to specific areas of the body
-lower motor neurons: have 2 parts
>sensory portion: carries messages from the body to the brain
>motor portion: carries messages back to body parts to initiate actions like muscle movements
-spinal cord does not have to be severed for loss of functioning to occur (ex: neuronal axonal injury)
-protected by vertebral column, spinal meninges, and CSF
Functions of the spinal cord
>Somatic and autonomic reflexes >Motor control centers: -somatic nervous system -autonomic nervous system (ANS); sympathetic and parasympathetic >Sensory/motor modulation
Pathophysiology of SCI
damage to the spinal cord w/ results of functional loss of mobility and/or sensation
- complete or incomplete
- results from concussion, contusion, compression, tearing, laceration, transection, or ischemia of the spinal cord
Acute Spinal Cord Injury
- unexpected, catastrophic event
- loss of function; mobility or sensation
- spinal cord trauma may result from direct injury to the cord
- spinal cord trauma may result from indirect injury from damage to surrounding bones, tissue, and blood vessels; caused by hyperextension, hyperflexion, rotation and vertical compression (axial loading), or penetrating injuries
Risk Factors for SCI
- occur in ages 16 and 18
- high-risk physical activities; speeding and drinking while under the influence of alcohol
- substance use
- not using protective gear in sports or recreational activities
- in older population, increased risk of spinal cord injuries r/t fall related injuries
Where are injuries most commonly located on the spinal cord?
C4, C5, C6 and T12
-half of injuries resulting in paraplegia and half in quadriplegia
Paraplegia
paralysis of the legs and lower body
Quadriplegia
paralysis of all four limbs
Causes of SCI
- leading cause is automobile accidents then,
- falls
- acts of violence/guns
- sports injuries
Secondary Injury
-occurs d/t edema at the site of injury
-leakage of blood w/ decreased flow to the injured area
-and inflammatory processes causing neuronal death and the formation of scar tissue
>this sequelae can result in further functional deficits in the patient
Complete Injury
-total loss of motor and sensory function below the level of injury
Incomplete Injury
incomplete structural damage w/ some function preserved below the primary level of injury >central cord syndrome >anterior cord syndrome >posterior cord syndrome >Brown-Sequard syndrome
Incomplete Injury: Central Cord Syndrome
- most common
- hyperextension injury w/ central cord swelling
- manifestations: functional motor loss greater in arms than legs
- bladder dysfunction
- variable loss of sensation
Incomplete Injury: Anterior Cord Syndrome
-acute anterior compression from bony fragments or acute disk herniation
>Manifestations:
-loss of motor function (paresis or paralysis), pain, temperature, crude touch and pressure below level of injury
-preserved sense of proprioception (position sense), fine touch and pressure, and vibration
Incomplete Injury: Posterior Cord Syndrome
- acute compression
- loss of proprioception (position sense), fine touch and pressure, and vibration
- intact pain, temperature, and crude touch and pressure
Incomplete Injury: Brown-Sequard Syndrome
-hemisection of the spinal cord resulting from penetrating injury (i.e. gunshot, knife)
-also occur as a result of primary ischemia, infection, or hemorrhagic event
-ipsilateral (same side) loss of motor function, proprioception (position sense) and vibration
-contralateral loss of pain and temperature
>you can still have sensation of the affected side, no motor function; have no sensation on opposite side of injury
Clinical Manifestations of SPI
>depends on the level of injury >spinal cord trauma results in motor and sensory loss below the level of injury >clinical manifestations vary depending on the location and severity of the cord damage and are caused by loss of innervation at the affected spinal cord levels -inability to breathe -paraplegia -loss of bowel, bladder, sexual function -chronic pain -hypotension -impaired temperature control
Clinical Manifestations of Cervical Cord Injuries
> cervical cord injuries that occur in the neck result in manifestations that affect the arms, legs, and middle of the body
- difficulty breathing; can result in inability to breathe (above C4) as the phrenic nerve innervates the diaphragm in this area
- quadriplegia
- requires ventilator
- loss of bowel and bladder control
- numbness
- weakness or paralysis
- pain
- sensory changes
- spasticity
Clinical Manifestations of Thoracic Cord Injuries
> occur at chest level
- paraplegia
- loss of normal bowel and bladder control (constipation, incontinence, and bladder spasms)
- numbness
- sensory changes
- spasticity (increased muscle tone)
- pain
- weakness, paralysis
Clinical Manifestations of Lumbar and Sacral Cord Injuries
> occur at lower back level
- decreasing control of legs
- altered bowel/bladder function
- sexual dysfunction
- numbness
- pain
- sensory changes
- spasticity
- weakness and paralysis
C1-C4
- quadriplegic (paralysis of all 4 limbs)
- requires ventilator
C5-C6
- quadriplegic (paralysis of all 4 limbs)
- phrenic nerve intact
- gross arm movements, shoulder strength
C7-C8
- quadriplegic (paralysis of all 4 limbs)
- diaphragmatic breathing
- biceps, triceps, wrist extension
- no core strength
T1-T5
- Paraplegic (paralysis of legs and lower body) w/ trunk involvement
- Normal arm/hand movement
T6-T12
- Paraplegic (paralysis of legs and lower body)
- ability to control balance and trunk
- no voluntary bowel/bladder control
Below T12
- variable motor/sensory loss of lower extremities
- reflexive bowel/bladder
How we Diagnose SCI
- time between SCI and tx affects outcome
- if admitted w/ suspected SCI associated w/ trauma to head or neck the spine is immobilized (cervical collar, spine backboard) until exam is performed to identify level of injury b/c any significant movement of the spine can = further damage
- physical and neurological examination; include reflexes
- X-ray to look for damage to the vertebrae
- If patient has clinical manifestations of a SCI (inability to move/feel) a CT scan or MRI to show the location nd extent of damage; to reveal problems like a hematoma
- the level of injury refers to the vertebra closest to the site of injury
Medical Management for SCI
>no way to reverse spinal cord damage >acute stage: focus on -maintain airway patency -adequate breathing and oxygenation -preventing spinal shock -restoring and maintaining BP -preventing further cord damage -spinal immobilization -avoiding possible complications >monitored for vital sign changes that may indicate spinal shock >maintain airway patency, maintain BP, and spinal immbolization
Surgical Management
- w/ no evidence of external pressure on spinal cord transferred to ICU in traction
- evidence of spinal cord compression, progressive deficits, compound vertebral fractures, penetrating spinal cord wounds, or bony fragments in the spinal canal; early surgery for decompression and fusion to stabilize spinal column
- w/ neurological evidence of spinal instability patients are admitted to the ICU for a diagnostic work-up and neurological monitoring
- types of surgery: Decompression Laminectomy, and Posterior Laminectomy
Decompression Laminectomy
using anterior cervical and thoracic approaches with fusion in which one or more laminae are removed to allow for cord expansion b/c of edema
Posterior Laminectomy
and fusion with bone graft to immobilize the neck and prevent further damage to the spinal column
-posterior approach using a bone graft or the insertion of rods or other instruments to correct and stabilize the deformities
Immobilization an Stability
- fracture/dislocation must be reduced early
- spinal immobilization obtained to prevent further loss of function, ischemia, pain, and necrosis
- realignment of the spine w/ traction, a halo device, or surgery to achieve optimal function
Halo Traction Device
used to maintain cervical immobilization
- made up of a ring around head attached to a special vest by 4 rods
- titanium screws are screwed into the skull bone and attached to device; weights connect to the halo at the head of the bed over a pulley system; weights slowly added, with x-rays taken between each additional weight until spinal alignment achieved
Gardner-Wells Tongs
u-shaped tongs used for spinal traction
- pressure-controlled pins are inserted into the skull at opposite ends to permit a longitudinal force to be applied to the axis of the spinal column
- tongs are attached to weights using a pulley system at the HOB
Halo Brace/Traction Complications
- pin infections
- skin breakdown
- loosening or movement of pins
- swallowing problems
- dural tears
Halo Brace/ Traction Care
- sites must be frequently assessed for infection
- site care once a shift and PRN
- kept clean using a clean cotton-tipped applicator or gauze soaked in normal saline
- new clean applicator or gauze used for each pin site
- if crusting; wrap a gauze soaked w/ normal saline around pin site for 15 minutes; after removing gauze, use a clean cotton-tipped applicator to gently remove crust from pin site
- ointments and solutions like hydrogen peroxide should not be used b/c they can irritate the skin and cause breakdown at the pin site
Safety Alert: Halo Brace Pin Site Loosening
leads to cervical instability and infection
>manifestations = pins are loose:
-redness
-swelling
-drainage
-site pain
-areas where the skin has pulled away from the site
-pt complains of neck pain and that “the vest does not fit correctly/feel the same”
-some pts may notice ability to move their neck; notify provider immediately; place pt in a hard cervical collar; prepare for radiological imaging to assess for change in spinal alignment
>if no infection, provider may tighten pins
>if pins remain loose = halo ring may migrate = loss of immobilization
>perform a neurological exam to determine if new or worsening deficits
>halo will be reapplied using new pin sites
Halo Brace/Traction Complications: Skin Breakdown
> Pressure injuries from vest portion of halo brace result from improper vest size, poor application, or insufficient padding
- meticulous skin care
- assessment for early signs of skin irritation
- turn and position q 2 hours and PRN
- vest fits properly; padded sufficiently
Halo Brace/Traction Complications: Swallowing Difficulties
dysphagia may occur w/ brace
- the head and neck are placed in an exaggerated extension position
- notify provider if complaints of swallowing difficulty
- adjust halo
- speech or language pathologist can be consulted
Spinal Cord Injury Complications
- Spinal Shock
- Neurogenic Shock
- Autonomic Dysrelfexia
Complications: Spinal Shock
-occurs immediately after injury; temporary
-temporary suppression of all reflexes below the level of cord injury
-complete but temporary loss or depression of sensory, motor, and autonomic activity below injury level
-hypotension possible
-brain is unable to transmit signals to muscles and organs = loss of sensation, movement, and other body function
-manifestation can start within 30 minutes and last days/months
-reappearance reflex activity signals the end of spinal shock (“anal wink”); contraction of anal sphincter
-Clinical Manifestations:
>flaccid paralysis of all skeletal muscles
>absence of deep tendon reflexes
>impaired proprioception (position sense)
>decreased visceral and somatic sensations
>penile reflex
>urinary and fecal retention
>anhidrosis (absence of sweating)
>paralytic ileus
Complications: Neurogenic Shock
- distributive shock
- causes vasodilation and relative hypovolemia
- threatens underlying acute conditions d/t hypoperfusion if not recognized and treated
- disruption in sympathetic nervous system stimulation causes an inability of vascular smooth muscle to constrict, resulting in decreased blood return to the heart and decreased cardiac output
- sympathetic nervous system interruption w/ unopposed parasympathetic action, may result in transient profound bradycardia
-Clinical Presentation:
>bradycardia (give atropine)
>Hypotension (fluids/vasoactive drugs)
>Change in LOC
>Metabolic acidosis -Manifestations: >vasodilation >bradycardia >body temperature instability >hypotension >can lead to organ dysfunction or organ death if not tx >tx = increase fluids, vasopressors
Complications: Autonomic Dysreflexia
massive imbalanced reflex sympathetic discharge occurring above T5-T6 level
-occurs up to 1 year after injury
-BP 20-40 mmHg above patients baseline
-triggered by noxious stimulus
>a strong sensory input (pain, distended bladder, rapid temperature changes, infection, or full rectum) is carried into the spinal cord via intact peripheral nerves
>input travels up the spinal cord and evokes a massive sympathetic surge from the intact thoracolumbar sympathetic nerves which = widespread vasoconstriction = peripheral arterial hypertension
>brain detects this hypertensive crisis through intact baroreceptors; uses 2 methods to stop its progression
1. Brain attempts to shut down the sympathetic surge by sending descending inhibitory impulses; these impulses are blocked in the injured spinal cord
2. Brain attempts to lower BP by slowing the HR via vagus nerve (parasympathetic); bradycardia is inadequate; hypertension continues
>once stimulus has been removed, reflex hypertension resolves
>Clinical Manifestations:
-severe headache
-hypertension
-bradycardia
-tachycardia
-flushing above the injury level
-pallor below injury level
Nursing Care for Autonomic Dysreflexia
-observing for a rapid rise in BP (20 to 40 mmHg above baseline)
>observe for:
-bradycardia
-diaphoresis
-flushing of the skin above level of lesion
-chills
-pallor below level of lesion
-severe headache w/ nasal congestion, anxiety, blurred vision, chest pain, or a sense of impending doom
-if episode of autonomic dysreflexia is not treated = seizures, pulmonary edema, MI, cerebral hemorrhage, and death
Nursing Interventions for Treatment of Autonomic Dysreflexia
> Monitor BP closely; q 5 minutes
-to evaluate treatments; see if source of the episode has been found + removed
> Antihypertensive meds as ordered
> HOB at 45 degrees; sit patient up
-reduces BP by allowing blood to pool in lower extremities
> Loosen restrictive clothing
- remove braces, antiembolism stocking, shoes; look for sources of pain from these items
- allows for pooling of blood in lower extremities to decrease BP
> Check Bladder
- indwelling catheter- check patency + adequate drainage
- no catheter- intermittent catheterization or place indwelling catheter per order; collect sample for UA
- urinalysis sent to assess for a UTI or kidney infection
> Check bowel for impaction
- assess for possible source and remove to terminate episode
- digital rectal exam delayed until cardiovascular condition stabilized b/c this can exacerbate hypertension
> Check patients body for other sources of noxious stimuli
- assess for possible source
- remove to terminate autonomic dysreflexia episode
Nursing Management: Assessment and Analysis
- spinal cord trauma = motor and sensory loss below level of injury
- manifestations vary on location and severity of cord damage
- manifestations are caused by loss of innervation at affected spinal cord levels
Assessment and Analysis: Cervical Cord Injuries
-occur in the neck
-manifestations that affect arms, legs, and middle of body
>difficulty breathing
>loss of bowel and bladder control
>numbness
>weakness or paralysis
>pain
>sensory changes
>spasticity
Assessment and Analysis: Thoracic Cord Injuries
-occur at chest level >loss of normal bowel and bladder control (constipation, incontinence, and bladder spasm) >numbness >sensory changes >spasticity (increased muscle tone) >pain >weakness, paralysis
Assessment and Analysis: Lumbar, Sacral Injuries
-occur at lower back level >loss of normal bowel and bladder control >numbness >pain >sensory changes >spasticity (increased muscle tone) >weakness and paralysis
Nursing Diagnoses For SCI
- alterations in respiratory function r/t paralyzed muscles, hypoventilation secondary to loss of diaphragm function d/t denervation of phrenic nerve
- decreased cardiac output r/t loss of vasomotor tone secondary to spinal/neurogenic shock
- impaired physical mobility r/t neuromuscular impairment secondary to loss of nerve cells at injured level
- fear/anxiety secondary to loss of motor function and potential for permanent damage
Nursing Assessments for Spinal Cord Injury
- Respiratory Function
- Vital Signs
- Motor function/Sensory Level
- Pain
- Intake + Output
- Surgical and/or Pin Sites
- Bowel Sounds
Assessments: Respiratory Function
- loss of intercostal muscle function = decreased tidal volume and may lead to hypoventilation
- C4 and higher injuries may result in complete loss of diaphragmatic effort
Assessment: Vital signs
- depending on level of injury, b/c loss of sympathetic input, may experience spinal shock, neurogenic shock, respiratory or cardiac arrest, or autonomic dysreflexia
- unable to regulate temperature
- hypothermia may result b/c of loss of control of blood vessels
Assessments: Motor Function/Sensory Level
- locate specific injury level used to choose and evaluate treatment
- used to see if deficits increase or decrease over time
Assessments: Pain
-there may be increased pain above the level of injury as a result of damage to spinal cord or nerve roots
Assessments: Intake + Output
- fluid volume status in evaluating effectiveness of therapies
- w/ decreased renal perfusion = decreased urine output
Assessment: Surgical and/or Pin Sites
sites frequently assessed for infection, bleeding, and CSF leak
Assessments: Bowel Sounds
decreased perfusion to the GI tract = decreased motility and paralytic ileus
Nursing Actions for Spinal Cord Injury (SCI)
- Suction Equipment
- Facilitate cough effectiveness
- Maintain spinal immobilization
- Passive ROM
- Reposition and maintain good alignment
- Perform Routine Pin Site Care
- Intermittent Catheterization/ Bowel Regimen
Nursing Actions: Maintain suction equipment at bedside
w/ decreased cough effectiveness, may require suctioning to clear airway
Nursing Actions: Facilitate Cough Effectiveness
b/c of muscle weakness or lack of diaphragmatic innervation, assistance is needed to remove secretions
Nursing Actions: Maintain Spinal Immobilization
prevents further injury from an unstable spinal column
Nursing Actions: Passive ROM
- prevents contractures and loss of muscle tone
- strengthens unaffected muscles
- minimizes risk of developing DVT
Nursing Actions: Reposition and maintain good alignment
- prevents pressure injuries
- decreases risk of DVT d/t immobility
Nursing Actions: Perform routine pin site care
- pin sites kept clean using a clean cotton-tipped applicator or gauze soaked w/ normal saline
- new clean applicator/ gauze used for each pin site
- if crusting, wrap a gauze soaked w/ normal saline around pin site for 15 minutes; after removing gauze, use a clean cotton-tipped applicator to gently remove the crust
Nursing Actions: Intermittent Catheterization/ Bowel Regimen
- patients may not have innervation to the bladder or bowel
- urinary retention and constipation not only present problems but can trigger autonomic dysreflexia
Nursing Teachings
- Clinical manifestations of Respiratory Distress; b/c pts w/ high cervical injuries are at risk of ineffective breathing and coughing
- Clinical manifestations of Autonomic Dysreflexia; life-threatening emergency
- Skin care/management; help identify causes of and prevent breakdown; w/ wheelchair, taught to refrain from sitting in one position too long b/c it can lead to decreased perfusion
- Management of bowel and bladder elimination
- Monitor for signs of infection
Nursing Interventions for Neurogenic Shock
> Raise HOB slowly:
- 10-15 degrees/ hour in a systematic manner
- b/c of loss of systemic vasomotor tone, raising HOB may cause orthostatic hypotension b/c of an inability of the peripheral blood vessels to constrict upon change
- orthostatic hypotension may cause hemodynamic instability (lowered BP and cardiac output)
> Assist w/ insertion of hemodynamic monitoring devices:
- an arterial line for continuous BP monitoring
- arterial line enables continuous monitoring of BP and the ability to set alarm parameters so that hypotension is identified
- frequent blood sampling for ABGs and other lab tests facilitated by presence of arterial line
> Assist w/ insertion of pulmonary artery catheter in situations where cardiovascular dysfunction severe
-allows for frequent monitoring of preload (CVP and PAOP), afterload (SVR), and contractility in order to optimize medical therapies
> Administer IV fluids as ordered
-fluid resuscitation is undertaken in order to increase vascular volume, which is inadequate compared to the increase in the size of vascular space d/t vasodilation
> Administer Medications as ordered; (sympathomimetic agents (phenylephrine [NeoSynephrine], norepinephrine [Levophed])
-aids in increasing vasomotor tone, which is reflected as an increase in systemic vascular resistance
> Administer Atropine
-inhibit the action of the vagal nerve, causing the HR to increase and treat bradycardia
> Prepare for Pacing
- a temporary pacemaker may be required to manage bradycardia in patients w/ neurogenic shock b/c of sympathetic nervous system dysfunction
- if sympathetic nervous system dysfunction is irreversible, a permanent pacemaker may be required
> VTE prophylaxis
- w/ neurogenic shock at high risk for VTE, especially when etiology is spinal cord injury
- pharmacological methods or mechanical devices
Evaluating Care Outcomes
- support through acute phase of spinal cord trauma and prevent complications
- prevent muscle wasting and contractures
- emotional support
- airway management
- cardiopulmonary support
- maximizing spinal cord perfusion and oxygen delivery
- pain relief
- pulmonary care (suctioning/ assisting w/ cough)
- turning to prevent pressure injuries
- DVT prophylaxis
- Bowel/Bladder training
- Management of nutrition
- Management of limb edema
- Management of orthostatic hypotension
- once stable = rehabilitation phase and optimal recovery of neurological function
- physical therapy to minimize muscle wasting and prevent contractures
Pharmacological and Fluid Management
-loss of autoregulation and reduced sympathetic stimulation = cardiac dysrhythmias, hypotension, decreased blood vessel tone, and reduced cardiac output
-interruptions to the cardiac accelerator nerves from a cervical SCI = heart to beat dangerously slow or pound rapidly and irregularly; medications or pacemaker used to control irregular heart beat
-loss of vasomotor tone = blood to pool in vessels = low BP; IV fluids, vasopressors and inotropes to provide fluid resuscitation, increase tone, and increase cardiac output
>high doses of vasopressors can cause decreased perfusion in GI tract, kidneys, and extremities = decreased GI motility, impaired renal function, and ineffective peripheral perfusion; monitor
