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Spinal Cord Injuries in Critical Care

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Spinal Cord Injuries in Critical Care How do you manage? INTRODUCTION Almost 50% of all patients with acute traumatic spinal cord injury (SCI) are admitted to a ... – PowerPoint PPT presentation

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Title: Spinal Cord Injuries in Critical Care


1
Spinal Cord Injuries in Critical Care
  • How do you manage?

2
INTRODUCTION
  • Almost 50 of all patients with acute traumatic
    spinal cord injury (SCI) are admitted to a
    Critical Care Unit prior to their transfer to a
    specialist SCI Centre.
  • Therefore, it is not unreasonable to expect
    critical care practitioners to maintain an
    appropriate awareness of the specific care needs
    of SCI patients admitted for critical care.

3
Do I know what we do?
  • Do I understand why do we do it?
  • Should we do it differently?
  • Should we do it for different reasons?

4
Critical Care is Rehabilitation
  • Rehabilitation is a continuous process,
  • beginning at the moment of injury, and is an
  • integral part of Critical Care.
  • If Critical Care and Rehabilitative Care are
  • not combined, people with SCI are subject to
  • serious clinical and economic consequences
  • that could otherwise have been prevented.
  • (Oakes 1990)

5
THE CHALLENGE
  • Acute SCI patients are most at risk of developing
    preventable complications when admitted outside
    of SCI Centres.
  • Critical Illness is the commonest reason for
    delayed transfer to a specialist centre.
  • Pre-transfer complications increase length of
    stay, care costs and long-term quality of life
    for the SCI person.
  • Many unplanned post-admission transfers of SCI
    patients to Critical Care are avoidable

6
EARLY COMPLICATIONS
  • Secondary neurological deterioration
  • Pressure ulcers leading to sepsis
  • HCAIs VAPs
  • Pulmonary oedema (overinfusion)
  • Renal impairment (diuretic use)
  • VTE
  • Gastric bleeding
  • Colorectal dysfunctional morbidity / necrosis
  • Joint contractures
  • Anxiety, Pain, Depression
  • Increased Dependency

7
CRITICAL CARE ISSUES 2000
  • Understanding spinal shock
  • Clearing the cervical spine
  • The use of cervical collars
  • Steroid therapy
  • Turning/positioning patients
  • Head-tilting for SCI patients
  • Thromboprophylaxis
  • Gastric protection
  • Enteral feeding
  • Bowel management
  • Patient transfer guidelines
  • The SCI-LINK scheme
  • www.spinal.co.uk/on-lineshop (With thanks to the
    SCI-LINK Critical Care Forum)

8
Do I know what we do?
  • Do I understand why do we do it?

9
SPINAL SHOCK
  • Within traumatic SCI, we need to remember that
  • Hypotension
  • Bradycardia
  • Oliguria
  • Poikilothermia
  • are normal only for paralysed patients with
    complete lesions above T6
  • We must remember to treat the dynamic trend, not
    the value of these observations

10
(No Transcript)
11
CLEARING THE SPINE
  • Demands a rigorous process involving
  • Accident History
  • Mechanism of Injury
  • Clinical Examination
  • Radiological Interpretation
  • Documentation of clearance by authorised staff
  • 3 Scenarios following diagnosis
  • Actual SCI (Neurological impairment)
  • Potential SCI (Orthopaedic spinal injury)
  • Uncleared SCI (Unconscious / Multi-trauma)

12
CERVICAL COLLARS
  • Raised ICP
  • Limited evidence to suggest any risk if properly
    selected, sized and fitted
  • Range of collars available Aspen model
    preferred
  • Significant ICP is gt20 (Neuro consensus)
  • Pressure sores
  • Limited incidence if properly selected, sized and
    fitted
  • Range of collars available Aspen preferred for
    extended use
  • May be loosened or removed between turning if
    appropriate to clinical scenario
  • Person ordering removal must be a) authorised
    and b) must document decision in patient notes
    before removal with reference to criteria
    evidence used to inform clearance.

13
STEROID THERAPY
  • There is NO credible clinical evidence supporting
    the ROUTINE use of high-dose steroids in human
    traumatic SCI
  • Inappropriate use of steroids increases risk of
    systemic complications, extending time in ICU by
    an average 21 days
  • All steroid use should be discussed with
    specialist centre staff first

14
SURGICAL PRINCIPLES (Bedbrook. 1985)
  • Surgical judgement or surgical balance is of
    much greater importance than surgical technique.
    The advantages or disadvantages of any particular
    method of acute management of spinal injuries
    must be considered before a particular programme
    of management is laid down to suit the
    individual, as well as the individuals
    fractures.
  • This implies informed consent must be satisfied
    before operation including notation of treatment
    options offered to patient / next-of-kin

15
AVOIDABLE ADMISSIONS A Critical Care Tale of Two
Hospitals
  • ST ELSEWHERES
  • Admits 11 SCI patients
  • 6 were operated on 2-14 days after admission and
    all after prior discussion with SCI Centre
  • 2 patients were already in ITU and 2 ward-based
    patients underwent pre-planned 48-hour admission
    to ITU
  • These 4 patients totalled 70 bed nights between
    them
  • ST ALLSORTS
  • Admits 13 SCI patients
  • 11 are operated on within 24 hours of admission
    and all before referral to SCI Centre
  • 3 patients already in ITU but 3 HDU and 5 ward
    patients required unplanned ITU admission
  • These 11 patients totalled 379 ITU bed nights
    between them

16
TURNING AND HANDLING
  • 2-4 hourly turning is recommended to prevent
    fluid stasis as well as pressure relief
  • Manual turning is staff intensive but mechanical
    turning beds are available
  • Never use dynamic pressure relieving mattresses
    for acute SCI patients
  • Spinal logrolling should be familiar to CCU staff
  • Failure to implement regular turning increases
    risk of multiple complications of bedrest
  • Flat-lifter scoop stretchers are also available
    for transfers

17
REALITY BITES
  • Despite requests from SCI Centre team, a 22
    year-old male paraplegic patient was not turned
    during first 10 days of his ward admission to
    hospital for the following reasons quoted in
    notes
  • lack of staff
  • fear of further compromising spinal cord
  • unnecessary because he is now on a dynamic
    pressure relieving mattress
  • He subsequently developed hydrostatic pneumonia
    (requiring ITU admission intubation and
    ventilation for 21 days) and 3 x Grade 3 pressure
    ulcers requiring surgical repair (extending his
    stay in the SCI Centre by 90 days).

18
HEAD-TILTING
  • All requests to raise patients head / tilt bed
    should be referred to SCI Centre staff
  • Refer to ICS ventilation care bundle
  • Preserving brain takes priority over protecting
    spinal cord
  • Start with 10-15 degrees, increase slowly
  • Do not exceed 30 degrees head-up
  • Keep collar in situ if possible

19
THROMBOPROPHYLAXIS
  • Anticoagulation and full-length TED / PCD
    supported by BD physiotherapy exercise of
    paralysed limbs must commence within 24 hours of
    injury exceptions must be documented with
    rationale
  • Thromboembolism is silent but usually preceded by
    pyrexia, SVT or bizarre behaviour

20
GASTRIC PROTECTION
  • 10 of post-injury SCI deaths due to gastric
    bleeding
  • Chemical prophylaxis must commence within 24
    hours of admission
  • And continue until transfer to SCI Centre

Question How do you diagnose A cute abdomen
in a SCI patient?
21
ENTERAL FEEDING
  • All SCI patients present with loss of peristalsis
    as part of spinal shock
  • Usually lasts 2-5 days
  • Keep patient Nil enterally for first 48 hours,
    then review (British Dietetic Association 2007)
  • Give TPN during this time if nutritionally
    compromised
  • Paralytic ileus leads to splinting of diaphragm,
    gastric reflux and necrotising bowel distension,
    usually requiring surgical intervention

22
BOWEL MANAGEMENT
  • All SCI patients present with neurogenic bowel
    dysfunction
  • Most require digital bowel procedures
  • Digital removal of faeces is a safe and
    legitimate technique for a patient with a
    flaccid bowel
  • Bowel distension in patients with lesions above
    T6 can trigger autonomic dysreflexia
  • Failure to provide appropriate bowel care may
    constitute clinical negligence (RCN/NPSA/ACA)

23
New MASCIP Publication www.mascip.co.uk
24
PATIENT TRANSFER
  • National Training for Transfer programme
    includes patient with actual or potential SCI
  • Must liaise with SCI Centre
  • Fit for Transfer criteria must be met
  • Appropriate mode of transport
  • Provide TOD and ETA
  • Spinal protection as agreed
  • Provision of an informed escort
  • ALL notes, images and test results
  • Inform centre of any change in condition en route

25
SUPPORTING PRE-TRANSFER CARE ENVIRONMENTS
  • SCI Centre liaison information via telephone,
    fax, e-mail or websites
  • SCI Centre outreach for serious delays to
    transfer, centre staff may visit CCU to advise or
    teach care
  • SCI-LINK a scheme to train and support SCI
    Link-Workers within local hospitals
  • www.mascip.co.uk
  • Peer Support SIA outreach scheme for patients
    and families
  • www.spinal.co.uk

26
CRITICAL CARE NEEDS
  • Common practices between CCUs
  • (The SCI Integrated Care Pathway)
  • Informed underpinning knowledge
  • (Why we do what we do in-house education)
  • Core skills and competencies
  • SCI Link-Workers / Skills for Health
  • Confidence in our own abilities
  • Auditable performance standards

27
Do I know what we do?
  • Do I now understand why we do it?
  • Should we do it differently?
  • Should we do it for different reasons?
  • Do we have a care pathway?

28
What if I dont work in Critical Care?
  • Do I understand what we do?
  • Should we do it differently?
  • Should we do it for different reasons?
  • Do we have a care pathway for our clinical area?

29
  • www.mascip.co.uk
  • www.spinal.co.uk
  • www.bascis.pwp.blueyonder.co.uk
  • www.spinal-research.org
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