Week 3--SPINAL CORD INJURY --(MR. LIEB)

Question 1

initial assessment of SCI

Answer 1

• NEUROVASCULAR ASSESSMENT
  
  • SENSORY (body to brain)
    
    • ex: dull/sharp sensations?
    • checking bilaterally (Spinal cord injuries typically present at bilateral, Stokes typically present at unilateral)
  • MOTOR (brain to body)
    
    • ex: may be weaker in one area
    • ex: “can you wiggle your fingers/toes”
  • DISTAL to PROXIMAL (start farthest away and work in)
  • Feet to head
• PAIN
  
  • absence of pain where you would anticipate pain
• Gastrointestinal (GI)
  
  • Initially, no peristalsis
  • Later-bowel movements may occur randomly
  • May be permanently relaxed “flaccid bowel”
• Genitourinary (GI)
  
  • Initially-flaccid bladder (distended-overfilled)
  • can empty-dribble out without warning
  • distension forces urine back into kidneys d/t incoordination of the bladder and urethral sphincter

Question 2

PRIMARY

INITIAL ASSESSMENT OF SCI

Answer 2

HINT: ABCDE

A-irway ^{(Protect the airway, respiratory support, suction secretions, etc)}

***with cervical spine stabilization ^{(<u><strong>Jaw Thrust</strong></u> for cervical spinal protection)}

B-reathing (and ventilation and ventilation)

Apply High Flow Oxygen

C-irculation (is perfusion adequate)

D-isability (Neurological status?)

E-xposure/Environment (Complete assessment-prevent hypothermia)

Question 3

SCI

INITIAL INTERVENTIONS

Answer 3

M-aintain Oxygenation

^{—Keep SpO2 Between 94-98 %…then titrate down}

^{—15 L/min NRB}

P-ositioning

^{—Maintain inline spinal immobilization at all times}

^{—remains in C-Collar with backboard in place until spine is cleared from injury}

^{—LOG ROLL}

I-V Access

OG/NG tube

^{—Decompression of the stomach –initially no peristalsis}

^{—pt at risk for backing up, obstruction, vomiting, nausea= PT AT RISK FOR ASPIRATION}

F-OLEY/FECAL incontinence tube

P-AIN MANAGEMENT

C-ARDIAC MONITOR / VITAL SIGNS

Question 4

Any loss of respiratory muscle control can______, ________, _________

Answer 4

• Decrease lung capacity
• increased respiratory congestion
• makes coughing difficult

Question 5

Autonomic Dysreflexia

1. ) define
2. ) what causes it?

Answer 5

1. ) abrupt onset of excessively high blood pressure as the result of an overactive autonomic nervous system (ANS). occurs in clients who have injuries above level T5
2. ) triggered by irritation, pain or other stimulus below the level of injury, such as:
   - the urge to urinate/defecate ^{(overdistended bladder is the most common cause)}

-pressure sores

-burns

-pressure from tight clothing

Question 6

S/S of Autonomic Dysreflexia

Answer 6

ABOVE THE LEVEL OF INJURY—–VASODILATION ^{(loss of sympathetic control we can’t get a high HR)}

Hypertension Bradycardia

Flushed face Sweating excessively

Headache Distended Neck Veins

Vision changes Goosebumps

BELOW THE LEVEL OF INJURY—-VASOCONSTRICTION

Pale / Cool

NO sweating

Question 7

TREATMENT FOR AUTONOMIC DYSREFLEXIA

Answer 7

1. sIT PATIENT UP IN BED
2. ASSESS AND FIND STIMULI
   
   1. changing positions
   2. empty bladder or bowels
   3. remove tight clothing
3. REMOVE STIMULI IF POSSIBLE
4. IF BLOOD PRESSURE UNIMPROVED BY REMOVAL OF STIMULI, OR IF STIMULI CANNOT BE FOUND RAPIDLY-–treat with antihypertensives (typically hydralazine 10mg IVP)

Question 8

Two complications associated with the cardiovascular system (for SCI)

Answer 8

1. AUTONOMIC DYSREFLEXIA
2. DVT (stroke or PE)
   
   1. anticoagulant therapy may be needed

Question 9

Epidemiology of SCI

• # of new cases per year in the United States
• Who is most at risk?

Answer 9

• 12,000 new cases each year in the US
• Males account for 80% of SCI
• Ages: Between 16-30 = more than half of the new injuries

Question 10

MECHANISM OF INJURY (PERCENTAGE)

(4)

Answer 10

1. MVC (36.5 %)
2. FALLS (28.5 %)
3. SPORTS/ WORK RELATED (18 %)
4. vIOLENCE (14 %)

Question 11

Initial physical trauma to the Spinal cord produces a series of events

Answer 11

• Neurons are killed (cannot regenerate)
• Demyelination of axons
• Hemorrhages
• ischemia
• edema

Question 12

4 types of primary injuries that can occur with SCI

Answer 12

• CONCUSSION
  
  • ^{Transient (short term) dysfunction lasting 24-48 hrs}
  • ^{**USUALLY OCCURS WITH PRIOR HX OF VERTEBRAL ABNORMALITIES (ie, spinal stenosis)}
• CONTUSION
  
  • ^{Bruising of neural tissue in grey matter}
  • **CAUSED BY CORD COMPRESSION-POSSIBLE PRESENCE OF NECROSIS
  • ^{often no long term complications}
• COMPRESSION
  
  • ^{Pressure on the cord by anything (bone, bullet, disc, etc)}
• TRANSECTION (most serious injury)
  
  • ^{complete or incomplete disruption of neural elements}

Question 13

Damage to C1 - T1

Tetraplegia

or Paraplegia

Answer 13

TETRAPLEGIA

Question 14

DAMAGE TO T2 - T12

(tetraplegia or paraplegia?)

Answer 14

paraplegia

Question 15

what type of signals does the ANTERIOR cord carry?

POSTERIOR?

Answer 15

ANTERIOR = MOTOR

POSTERIOR = SENSORY

Question 16

Anterior cord syndrome

• LOCATION OF INJURY
• Symptoms
• prognosis

Answer 16

• Injury to the anterior 2/3 of both the gray/white matter of spinal cord
• LOSS of MOTOR, PAIN, TEMP (below injury)
• PRESERVATION of POSITION, VIBRATORY
• WORST PROGNOSIS FOR RECOVERY
  
  • long rehabilitation times
  • only 10-20% experience motor recovery

Question 17

COMPLETE SPINAL CORD INJURY

• WHAT IS IT?
• SIGNS/SYMPTOMS?

Answer 17

• NO motor or sensation below the level of the injury (S4/S5 region)

S/S

• Loss of SNS functioning ^{(sympathetic stimulates htn, tachycardia)}
  
  • ​Poikilothermia -^{inability to regulate body temperature}
  • Bradycardia
  • Hypotension
• Priapism
  
  • ​extended erection-loss of parasympathetic
• Respiratory Depression
• Loss of voluntary bowel/bladder
• Paralytic Ileus
  
  • ​intestinal blockage in the absence of an actual physical obstruction

Question 18

Injury of C3 and above

(2)

Answer 18

• loss of phrenic nerve control
  
  • NO CONTROL OF DIAPHRAGM
• Long term ventilatory support

Question 19

iNJURY OF C4 to C5

(2)

Answer 19

• Diaphragm functional-NO intercostal functioning = RESPIRATORY INSUFFICIENCY
• Respirations are typically fast/shallow b/c the pt is only breathing with their diaphragm ===high levels of CO2 (hypercapnia)

Question 20

Injury between C6 and T12

(2)

Answer 20

• Weakened intercostal muscle function
• Weakened abdominal muscle and cough (inability to clear secretions)

Question 21

The risk for RESPIRATORY complications can occur with any injury from the C1 thru ______

Answer 21

T12

Question 22

What level do we lose control of the phrenic nerve ..which means we have NO control of the diaphragm?

Answer 22

C3 and above

Question 23

What is the #1 cause for morbidity/mortality with respect to the patient with an SCI is ________

Answer 23

RESPIRATORY COMPLICATIONS

(Pneumonia)

Question 24

• The only medication approved for the treatment of SCI?
• “4” important facts to know about this medication?

Answer 24

HIGH DOSE CORTICOSTEROIDS

Methylprednisolone (Solu-Medrol) IV

1. MUST be given in the first 8 hours after injury to be effective
2. Found to increase motor and sensory improvements over time
3. Weight-based dosing
4. NOT FOR PENETRATING INJURIES–d/t the risk for infection form

Question 25

NEGATIVE effects that steroid administration may have on our patient with an SCI.

Answer 25

Hint: WIMP-HA

W-eight Gain

I-nfection

M-ood swings

P-eptic Ulcers

H-yperglycemia

A-vascular Necrosis

Question 26

What is Spinal shock?

Due to what…….

How long does it last…….?

S/S……?

Answer 26

• Rapid to immediate onset of symptoms following a SCI. TEMPORARY LOSS of MOTOR, SENSORY and REFLEX functions below the level of the lesion
• due to inhibition of impulses in the spinal cord
• LASTS for days to weeks
• CAUSES Flaccid Paralysis

RESOLUTION IS NOTED WITH RETURN OF REFLEXES AND MUSCLE SPASTICITY

^{​Lo<span>ss of motor and sensory functions can occur with any SCI, but loss of REFLEX is unique to SPINAL SHOCK. Deep Tendon Reflexes are NOT affected by SCI, unless the patient is in SPINAL SHOCK. </span>}

Question 27

What is NEUROGENIC SHOCK…?

Answer 27

• Pt is at risk for POOR PERFUSION
• Damage to T6 or higher
• Causes disruption of sympathetic regulation of vagal tone (fight/flight)==WE HAVE ABUNDANCE OF PARASYMPATHETIC STIMULATION

–Results in massive VASODILATION and decreased Vascular tone (resistance)

ASSESSMENT FINDINGS:

• BRADYCARDIA
• HYPOTENSION
• WARM, NORMAL COLOR SKIN-(b/c vasolation causing skin to get warm)
• CORE TEMPERATURE INSTABILITY

Question 28

Can a patient with an injury at T 7 or below be in Neurogenic Shock?

Answer 28

NO.

must be at T 6 or higher

Question 29

We recognize that the patient is bradycardic and hypotensive and is showing manifestations of Neurogenic shock.

What medications would be given for the bradycardia?

the Hypotension?

Answer 29

Atropine ….for the bradycardia

vasopressors and fluids ….for the hypotension

Question 30

“5” indications for SURGICAL intervention with SCI

Answer 30

HINT: CUP BD

C-ord Compression

U-nstable/fragmented vertebral body

P-enetrating Injury

B-one fragments in cord

D-ecline in neuro status

Question 31

CERVICAL TRACTION CAN BE USED WHICH IS CALLED _________

Answer 31

GARDNER-WELLS TONGS

Question 32

COMMON BRACE OFTEN USED TO STABILIZE A CERVICAL FRACTURE

Answer 32

HALO TRACTION BRACE

Question 33

How is the weight of the traction determined?

Answer 33

5 lbs of weight for each level

EXAMPLE: C7 x 5 lbs = 35 pounds of traction

Question 34

“3” things that are important for a nurse to assess and help prevent

(with a SCI)

Answer 34

• DVT
  
  • Occurs in over 67%
  • DVT’s can lead to a PE
• ORTHOSTATIC HYPOTENSION ^{(d/t inability to control vasoconstriction)}
  
  • Can be low for up to 2 weeks
  • Often required medication to increase BP with movement/rehab
  • abdominal binder/compression stocking to assist in “shunting” the blood back up to the heart/brain
• Pneumonia ^{(d/t inability to clear secretions)}
  
  • Lung Sounds
  • ISB
  • Assess for fever

Question 35

A _________ is used to maximize functioning and recovery of ADL

Answer 35

REHAB

Question 36

HIGH-level Spinal cord injury ^{(T-5 or higher)} patients are at RISK for a lifelong complication known as _____________

Answer 36

Autonomic Dysreflexia

Question 37

PARTIAL LOSS OF MOTOR AND/OR SENSORY FUNCTIONING BELOW THE LEVEL OF THE INJURY

Answer 37

INCOMPLETE LESIONS

(ABCC)

A-nterior cord syndrome

B-rown sequard syndrome

C-entral Cord Syndrome

C-onus Medullaris Syndrome

Question 38

weak upper extremities with increasing strength as you get lower

WHICH SPINAL CORD INJURY IS THIS?

Answer 38

Central cord syndrome

Question 39

______ occurs when clients change position due to the interruption in functioning of the automatic nervous system and pooling of blood in lower extremities when in an upright position.

“2” nursing interventions for this…

Answer 39

ORTHOSTATIC HYPOTENSION

1. Change the client’s position slowly and place the client in a wheelchair that reclines
2. apply SCD/compression hose to increase venous return. May need to extend the compression to the abdomen using an abdominal binder

Question 40

This is the spinal cords response to inflammation caused by injury. Manifestations include:

1. flaccid paralysis
2. loss of reflexes
3. activity below the level of injury
4. paralytic ileus
5. loss of autonomic function\
6. hypotension
7. bradycardia

Answer 40

SPINAL SHOCK

**KEEP MEAN ARTERIAL PRESSURE (MAP) AT LEAST 85MM hG CAN PREVENT FURTHER DAMAGE TO THE SPINAL CORD.