http://www.rexdonald.com/facts.html

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• http//www.rexdonald.com/facts.html
• http//www.cureparalysis.org/statistics/

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Spinal Cord Injuries

• Life expectancy greatly increased since WW II.
• Intermittent catheterization
• Medications, equipment, etc
• Cause of premature death in QUADS is usually
  related to COMPROMISED RESPIRATORY FUNCTION

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Spinal Cord Injuries

• Whos at risk?
• ADULT MEN BETWEEN 15 AND 30 YEARS
• Anyone in a risk-taking occupation or lifestyle
• SCI in older clients increasing largely due to
  MVAs

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Spinal Cord Injuries

• Causes (in order of frequency)
• MVA
• Gunshot wounds/acts of violence
• Falls
• Sports injuries

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Spinal and Neurogenic Shock

• Below site of injury
• Total lack of function
• Decreased or absent reflexes and flaccid
  paralysis
• Lasts from a week to several months after onset.
• End of spinal shock signaled by muscular
  spasticity, reflex bladder emptying, hyperreflexia

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Classification of SCI

• Mechanism of injury
• Flexion (bending forward)
• Hyperextension (backward)
• Rotation (either flexion- or extension-rotation)
• Compression (downward motion)

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Pathophysiology of SCI

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• Insert picture here

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Classification of SCI

• Level or Injury
• Cervical (C-1 through ??)
• Thoracic (T-1through ??)
• Lumbar (L-1through ??)
• Degree of Injury
• Complete
• Total paralysis and loss of sensory and motor
  function although arms or rarely completely
  paralyzed
• Incomplete or partial

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http//www.sci-recovery.org/sci.htm
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Degree of Injury

• Complete transection
• Total paralysis and loss of sensory and motor
  function although arms or rarely completely
  paralyzed
• Incomplete (partial transection)
• Mixed loss of voluntary motor activity and
  sensation
• Four patterns or syndromes

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Incomplete cord patterns

• Insert picture of cord here
• Central cord syndrome More common in older
  clients
• Frequently from hyperextension of spine
• Weakness in upper and lower ext, but greater in
  upper.
• Anterior cord syndrome
• Posterior cord syndrome
• Brown-Sequard syndrome

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Anterior cord syndrome

• Compression of the ant. Cord, usually a flexion
  injury
• Sudden, complete motor paralysis at lesion and
  below decreased sensation (including pain) and
  loss of temperature sensation below site.
• Touch, position, vibration and motion remain
  intact.

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Posterior cord syndrome

• Assoc with cervical hyperextension injuries
• Dorsal area of cord is damaged resulting in loss
  of proprioception
• Pain, temperature sensation and motor function
  remain intact.

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Brown-Sequard syndrome

• Damage to one half of the cord on either side.
• Caused by penetrating trauma or ruptured disk.
  ischemia (obstruction of a blood vessel), or
  infectious or inflammatory diseases such as
  tuberculosis, or multiple sclerosisBSS may be
  caused by a spinal cord tumor, trauma (such as a
  puncture wound to the neck or back),.
• a rare SCI syndrome which results in
• weakness or paralysis (hemiparaplegia) on one
  side of the body and
• a loss of sensation (hemianesthesia) on the
  opposite side.

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Clinical manifestations of SCI

• Depend on the LEVEL and DEGREE of the injury!
• Quadriplegia occurs with C-1 through
• C-8 injuries.
• Paraplegia occurs with T-1 thru L-4.
• SEE TABLE 57-3 ON PAGE 1725!

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Clinical Manifestations of SCI

• Respiratory
• C1 C3 Absence of ability to breathe
  independently.
• C4 poor cough, diaphragmatic breathing,
  hypoventilation
• C5 T6 decreased respiratory reserve
• T6 or T7 L4 functional respiratory system with
  adequate reserve.

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What is the phrenic nerve?

• The phrenic nerve stimulates the diaphragm to
  contract.
• Two phrenic nerves (right and left) - injury to
  one or the other paralyzes contraction of only
  one half of the diaphragm but even hemi- (half)
  paralysis can significantly interfere with
  breathing for patients with lung disease.
• The nerve arises from branches of the C3,4, and 5
  nerve roots.
• The phrenic nerve can be damaged by procedures
  exploring the neck upper back

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• Loss of the phrenic nerve on either side results
  in paralysis of the diaphragm on that side. 
• Paralysis of the diaphragm on one side results in
  less inflation of the lung on that side. 
• Whether this is physiologically significant
  (producing respiratory distress,
  hypoventilation/hypercapnia) depends on other
  aspects of a patient's pulmonary physiology
  (namely underlying chronic obstructive pulmonary
  disease emphysema, bronchitis, pneumonia,
  etc.). 

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Cardiovascular system

• C1 T5 shows decreased or absent SNS influence.
  
• BRADYCARDIA AND HYPOTENSION (due to vasodilation)

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What is the VAGUS nerve?

• The longest of the cranial nerves- exits out of
  the medulla and ends in the abdomen
• It supplies sensory and motor function to the
  pharyngx
• Supplies motor function to the muscles of the
  abdominal organs
• Provides parasympathetic activity to the heart,
  lungs, and most of the digestive system

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Urinary System

• Atonic bladder with RETENTION in spinal shock.
• Post acute phase irritability causing dribbling
  or frequent urination.
• Urinary infection and calculi from retention and
  distention.
• INTERMITTENT CATHETERIZATION!

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GI system

• Decreased motility
• Paralytic ileus
• Gastric distention intermittent NG suctioning
• Increased H2 administer H2 inhibitors such as
  Zantac or Pepcid in initial stages
• Carafate and antacids later as prophyaxis
• Intraabdominal bleeding! Remember, no pain or
  tenderness to warn you.
• Watch for H/H decrease and impactions

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Integumentary System

• Pressure ulcers!
• Muscle atrophy in flaccid paralysis
• Contractures in spastic paralysis
• Poikilothermism the adjustment of body temp to
  room temperature
• Decreased ability to sweat below lesion

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Peripheral vascular system

• DVT common but not detected easily
• Pulmonary embolism a significant cause of death.
• Doppler studies, measurement of extremity girth,
  impedance plethysmography (what the heck is
  this?)

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Post Injury Assessment

• Goals are to
• Sustain life
• Prevent further cord damage
• Assessment of muscle groups motor status
• Against gravity
• Against resistance
• Both sides of the body
• Ask to move legs, hands, fingers, wrists, then
  shrug shoulders

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Post injury assessment (p.1726)

• Thorough motor examination including position
  sense and vibration.
• Sensory examination
• Pinprick starting at toes and working upward
• ALWAYS HAVE CLIENT CLOSE EYES OR LOOK AWAY! If
  he can see what youre doing, he will answer
  accordingly.
• Assess for head injury and ICP
• X-ray, CT scan, EMG

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Surgical Therapy

• Reduces injury and stabilizes the SC
• Done for
• Compression
• Bony fragments in the cord
• Compound fracture
• Penetrating trauma

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Drug Therapy

• Vasopressors (Dopamine) to keep mean arterial
  pressure greater than 80mm to 900mm/Hg so that
  PERFUSION TO CORD is improved.

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Methylprednisolone (Solu-medrol)

• Increases the recovery of function and is the
  SOC! IV bolus then continuous IV over a 23 hour
  period.
• Improves blood flow and reduces edema in the SC

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Other drug therapy

• Symptom-reducing drugs for
• GI problems - zantac, tagamet, pepcid
• Bradycardia - atropine
• Hypotension - vasopressors
• bladder spasticity - anticholinergics
• autonomic dysreflexia blood pressure reduction

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Function of Motor Neurons

• Upper motor neurons

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Function of Motor Neurons

• Lower motor neurons

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Diagnoses and Interventions

• Impaired Gas Exchange r/t muscle fatigue and
  weakness
• Decreased Pao2, increased PaCO2
• Fatigue
• Diminished breath sounds

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Impaired gas exchange

• Maintain patent airway
• Assess respiratory status q 2 hours
• Monitor ABGs
• Provide aggressive pulmonary toilet chest PT and
  quad-assist coughing
• Assess strength of cough
• Suction secretions

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Inability to sustain spontaneous ventilation

• Related to diaphragmatic fatigue or paralysis
  evidenced by
• Dyspnea
• Use of accessory muscles
• Abnormal ABGS
• Provide chest PT
• Assist with mechanical ventilation
• Provide emotional support

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Decreased cardiac output

• Related to venous pooling of blood and immobility
  as evidenced by
• Hypotension
• Tachycardia
• Restlessness
• Oliguria
• Decreased pulmonary artery pressures

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Decreased cardiac output

• Monitor blood pressure, pulse and cardiac rhythm
• Administer vasopressors to maintain MAP at
  800mm/Hg or above
• Apply pneumatic compression boots or stockings
• Perform ROM at least q8h to aid in muscle
  contraction and venous return

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Impaired skin integrity

• Related to immobility and poor tissue perfusion
• Inspect skin and areas around pins or tongs
• Turn at least q2h and use kinetic table or other
  specialty care devices.
• Insure adequate nutritional intake
• INFORM family and client about risk of pressure
  ulcers

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Constipation

• Related to location of injury, ? fluid intake,
  diet, immobility AEB
• Lack of BM in over 2 days
• ? bowel sounds
• Palpable impaction
• Hard stool or incontinence

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Constipation

• Auscultate bowel sounds and monitor abdominal
  distention
• Note and report any nausea and vomiting
• Begin bowel program when BS return and teach to
  client and family
• Administer suppositories and stool softeners
• Ensure appropriate fluid and fiber intake

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Bowel program for SCI

• Needs to be consistent
• Give suppository after meal and place on toilet
  approx 30 minutes after.
• Do this at same time each day!
• Fiber, fluids and activity are important
• Constipation leads to AUTONOMIC DYSREFLEXIA!!!

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Urinary Retention

• Related to injury and limited fluid intake as
  evidenced by
• Decreased output
• Bladder distention
• Involuntary emptying of bladder

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Urinary Retention

• Palpate bladder every shift
• During acute phase, insert indwelling catheter
• Begin intermittent cath program when appropriate
• Keep I and O and end fluids
• Monitor BUN and creatinine
• Crude (pronounced croo-DAY) manuever when
  voiding/cathing

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Risk for AUTONOMIC DYSREFLEXIA

• Assess for HTN, bradycardia, headache, sweating,
  blurred vision, flushing, nasal
  stuffiness/congestion
• Reduce or eliminate noxious stimuli such as
  impaction, urine retention, tactile stimulation
  and skin lesions or pain!

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Autonomic dysreflexia

• Elevate HOB 43 degrees
• Identify cause and eliminate
• Take BP and pulse
• Administer antihypertensives as ordered if
  hypertensive.
• Call physician if interventions not effective
• TEACH CLIENT AND CARGIVERS HOW TO PREVENT THIS!

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Other diagnoses

• Impaired physical mobility
• Altered nutrition lt body requirements
• Sexual dysfunction
• Risk or injury r/t sensory deficits
• Altered family processes
• Risk for ineffective individual coping
• Body image disturbance

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Acute intervention

• Immobilization
• Crutchfield tongs
• Halo vest
• Stryker bed
• Roto-rest bed (side to side)
• Motion sickness a problem with these.

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Respiratory dysfunction

• Intubation if injury is high
• Decreased tidal volume and shallow breathing lead
  to pneumonia and atelectasis
• CPT and pain management
• Prone position may be risky
• Count to 10 test
• QUAD COUGH technique to assist with ineffective
  abdominal muscles

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Fluids and nutrition

• Paralytic ileus common in 48-72 hours
• When bowel sounds return
• High calorie, high protein, high fiber diet
• Evaluate SWALLOWING before feeding!
• EATING CAN BECOME A POWER STRUGGLE!

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Bowel and Bladder mgmt.

• Indwelling catheter initially
• Intermittent catheterization when able
• Monitor pH of urine (should be acetic!)
• Ascorbid acid and Mandelamine (an antiseptic)
  given to keep down bacteria

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Temperature control

• NO vasoconstriction, piloerection or heat loss
  through sweating below level of injury
• Do not over cool or over heat client. They only
  have the remaining upper portion of their bodies,
  generally, for temperature adjustment

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