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Traumatic Spinal Cord Injury

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Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN – PowerPoint PPT presentation

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Title: Traumatic Spinal Cord Injury


1
Traumatic Spinal Cord Injury
  • Marnie Quick, RN, MSN, CNRN

2
A. Pathophysiology/etiologyNormal spinal cord as
it relates to SCI
  • Spinal cord begins at the foramen magnum in the
    cranium
  • Cord ends at the L1-L2 vertebra level
  • Spinal nerves continue to the last sacral
    vertebra

3
Normal protection of spinal cord from injury
Bones- vertebral column
4
Protection of spinal cord from injury
  • Disc between vertebra
  • Internal and external ligaments

5
Protection of Spinal Cord from Injury
  • Meninges
  • CSF in subarachnoid space allow for movement
    within spinal canal

6
Normal spinal cord as relates SCI
Autonomic Nervous System Cord
  • ANS can be affected by SCI
  • Sympathetic chains on both sides of the spinal
    column
  • Parasympathic nervous system is the
    cranial-sacral branch

7
Normal spinal cord White tracks send messages to
and from the brain
  • Pyramidal- Voluntary movements
  • Posterior column (Dorsal)- touch, proprioception,
    and vibration sense
  • Lateral spinothalamic tract- pain and temperature
    sensation (only tract that crosses within the
    cord)

8
Normal spinal cord Reflex ark in center
of the spinal cord
  • Where sensory and motor nerves arise from cord
  • Sensory fibers enter posterior
  • Motor fibers leave from anterior
  • Once outside cord join form spinal nerve

9
Normal spinal cord Dermatones skin innervated
by sensory nerves
10
Normal spinal cord
Spinal cord level
  • When referring to spinal cord level, it the
    reflex arc level not the vertebral or bone level.
  • Note that the thoracic, lumbar sacral reflex
    arcs are higher than were the spinal nerves
    actually leave through the opening of there
    respective vertebral bone

11
Upper and Lower Motor Neurons
  • Upper motor deficits results in spastic paralysis
  • Lower motor deficits are flaccid paralysis and
    muscle atrophy

12
Etiology of traumatic spinal cord injury
  • MVA- most common cause
  • Other falls, violence, sport injuries
  • Typically occurs from indirect injury from
    displaced vertebral bones compressing cord
  • Frequently occurs with head injuries
  • Less frequent cord torn/cut, as from direct
    trauma from knives or bullets

13
  • Hemorrhage/edema occurs secondary in cord post
    injury, causing more damage to cord
  • Extension of cord injury from cord edema can
    occur over 1st few days- watch the phrenic nerve!
  • Initially SCI experience spinal shock- depression
    of all cord ANS function below injury. Lasts
    from few min to wks
  • Risk factors- male, 16-30 yr, risk taker
  • 90 discharged home 10 chronic care facility

14
Events leading to spinal cord ischemia and
hypoxia of 2nd injury
15
Classification of SCI 1. Mechanism of
Spinal Cord Injury
16
Mechanism of Injury SCI
Flexion (hyperflexion)
  • Most common because of natural protection
    position.
  • Generally cause neck to be unstable because
    stretching of ligaments
  • Flexion with rotation can also occur

17
Mechanism of SCI
Hyperextention
  • Caused by chin hitting a surface area, such as
    dashboard or bathtub
  • Usually causes central cord syndrome symptoms

18
Mechanism of SCI
Compression
  • Caused by force from above, as hit on head
  • Or from below as landing on butt
  • Usually affects the lumbar region

19
Classification of SCI 2. Level of
skeletal injury
20
Classification of spinal cord injury-3. Level of
Injury to the spinal cord
Neurologic level of Injury
  • Neurologic level or the lowest cord segment
    (reflex) or dermatone level functioning
  • Such as C6 L4 SCI
  • Prefix Para-, quad-
  • Suffix-paresis,-plegia

21
Classification of SCI Level of SCI
Neurologic level
22
Classification 4. Degree of completeness inj
Complete (transection) spinal cord inj
  • After spinal shock
  • Motor deficits- spastic paralysis below level of
    injury
  • Sensory- loss of all sensation perception
  • Autonomic deficits- vasomotor failure
    (orthostatic hypotension, poikilothermic) and
    spastic bladder

23
Classification of SCIIncomplete spinal cord
injury- what white tracks are working after
spinal shock is over?
24
Classification of SCI Degree of completeness
Incomplete spinal cord injury
25
Incomplete spinal cord injury
Central cord Syndrome
  • Injury to the center of the cord by edema and
    hemorrhage
  • Weakness in both upper extremities- legs are
    spared
  • Varied loss of sensation

26
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27
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28
Incomplete spinal cord injury
Anterior Cord Syndrome
  • Injury to anterior cord
  • Loss of voluntary motor (Pyramidal track) below
  • Loss of pain and temperature perception
  • Retains posterior column function

29
Incomplete spinal cord injury
Brown-Sequard Syndrome
  • Hemisection of cord
  • Ipsilateral paralysis
  • Ipsilateral superficial sensation, vibration and
    proprioception loss
  • Contralateral loss of pain and temperature
    perception

30
Classification of SCI5. American Spinal Injury
Association
Impairment Scale
31
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32
Clinical Manifestations Complications
Spinal Cord Injury
  • Depends on extent and level of injury
  • Higher cord injury more serious sequelae
  • Resp decrease chest expansion (intercostals)
    decrease cough reflex Vital capacity diaphragm
    function controlled by phrenic nerve (C3-5) may
    need mechanical ventilation

33
Clinical Manifestations Complications
Spinal Cord Injury continued
  • Cardio dysrhythmias bradycardia loss SNS
    control bl vessels spinal shock loss of
    sympathetic nervous system control over blood
    vessels (vasomotor control)- dec venous return,
    orthostatic hypotension dec CO poikilothermic
    (takes on temp of room)
  • GU upper/lower motor bladder impotence sexual
    dysfunction
  • GI stress ulcers paralytic ileus bowel-
    impaction incontinence

34
Clinical Manifestations Complications
Spinal Cord Injury continued
  • Skin pressure ulcers can lead to
    infection/sepsis
  • Thermoregulation poikilothermic (take on temp of
    environment) Unable to sweat or shiver below
    level of SCI. Occurs due to SNS interruption
    Degree depends level inj
  • Metabolic needs Nasogastric suctioning may lead
    to metabolic alkalosis (Paralytic ileus).
    Nutritional needs to deep body wt and prevent
    complications- need positive nitrogen,
    high-protein diet
  • Peripheral vascular DVT pulmonary embolism

35
Clinical Manifestations Complications
Spinal Cord Injury continued
  • Neuro pain at the level of injury sensory loss
    upper/lower motor deficits autonomic
    dysreflexia spinal shock
  • Musculoskeletal joint contractures bone
    demineralization osteoporosis muscle spasms
    muscle atrophy pathologic fractures
    para/tetra/Quad plegia/paresis

36
Spinal shock result of inflammatory process in
cord after injury, causing depression of cord
ANS function below level of injury. Approx 50
develop
  • Motor loss- flaccid paralysis below level injury
  • Sensory loss- loss touch, pressure, temperature
    pain and proprioception perception below injury
  • Sympathetic NS loss results in parasympathic
    dominance with vasomotor failure-
  • Neurogenic shock, bradycardia, orthostatic
    hypotension and poor temperature control
    (poikilothermic- takes on temp of environment)
  • Parasympathetic NS loss of the S 2,3,4 reflex
    arks results in flaccid bladder
  • Distributive shock symptoms

37
Spinal shock lasts from few minutes to wks How
do you know spinal shock is over?
  • Clonus is one of the first signs
  • Hyperreflexia of foot
  • Test by flexing leg at knee quickly dorsiflex
    the foot
  • Rhythmic oscillations of foot against hand

38
Common manifestationscomplications Functional
Goals for Spinal Cord Injury
  • C1-3 usually fatal- loss phrenic inervation
    ventilator dependent no B/B control spastic
    paralysis electric w/c with chin/mouth control
  • C6- weak grasp has shoulder/biceps to transfer
    push w/c can use assistive devices dec resp
    reserve loss vasomotor no bowel /bladder
    control.
  • T1-6- full use of upper extremity transfer
    drive car with hand controls and do ADLs dec
    trunk stability no bowel/bladder control

39
C6 SCI using a transfer board
40
Collaborative Care for SCI
Diagnostic tests
  • Comprehensive neuro exam
  • X-ray of spinal column
  • CT/MRI
  • Blood gases

41
Collaborative Care Emergency care at scene,
ER ICU
  • Initial goals- sustain life and prevent further
    cord damage
  • Transport with cervical collar
  • Assess ABCs O2 tracheotomy/vent
  • IV for life line- to give meds
  • NG to suction
  • Foley- flaccid bladder

42
Collaborative Care Stabilization
immobilization with traction
43
Collaborative Care
Gardner-Wells tongs
44
Collaborative Care
External traction
  • Halo device
  • For patients who have few motor deficits
  • Experience less immobility complications

45
Collaborative Care Casts
splints collars braces
46
Collaborative Care
Special Beds for SCI
  • To decrease immobility complications
  • Rotorest bed provides for lateral rotation
  • 23 hrs a day

47
Collaborative Care Surgery for SCI
  • Manipulation to correct dislocation or to unlock
    vertebrae
  • Decompression laminectomy
  • Spinal fusion
  • Wiring or rods to hold vertebrae together

48
Collaborative Care
Drug Therapy
  • IV metylprednisone (Solu-Medrol) within 8 hrs to
    decrease cord edema/inflammation
  • Medications to control or to prevent
    complications SCI and immobility
  • Vasopressors treat bradycardia or hypotension
  • Histamine H2 blockers to prevent stress ulcers
  • Anticoagulants- immobility
  • Stool softeners
  • Antispastomotics
  • BP meds (Procardia) if sym persists with
    autonomic dysreflexia

49
Nursing Assessment Specific to SCI
Lewis 1553 Table 61-6
  • Subjective data
  • Important health info- health history cause of
    SCI
  • Function health patterns-activity
    perceptualcoping
  • Objective data
  • By systems
  • LOC/pupils- R/O head injury
  • VS- bradycardia
  • Motor Sensory
  • Clonus spontaneous movement

50
Nursing assessment
Motor assessment
  • Movement, strength and symmetry
  • Hand grips
  • Flex and extend arm at elbow- with and without
    resistance

51
Nursing assessment Motor assessment
lower extremity
  • Flex and extend leg at knee with and without
    resistance
  • Planter and dorsi flexion of foot

52
Nursing assessment Motor
assessment- Clonus
  • Clonus- hyperreflexia
  • Flex knee and quickly dorsiflex the foot with
    your hand
  • If has return of reflex function the foot will
    have repetitive movements against you hand
  • Spinal shock is over

53
Nursing assessment
Sensory assessment
  • With the sharp and dull ends of a Q-tip or
    paperclip have the individual, with their eyes
    closed identify
  • Use the dermatome as reference to identify level
  • C6 thumb T4 nipple T10 naval

54
Pertinent Nsg problems/intervention SCI
Lewis p.1554-5 NCP 61-1
  • Impaired gas exchange
  • Decrease CO
  • Impaired skin integrity
  • Constipation
  • Impaired urinary elimination
  • Risk for autonomic dysreflexia
  • Ineffective coping
  • Interrupted family process

55
Pertinent nursing problems/interventions
Acute intervention Immobilization
  • Log roll as a single unit provide assistance as
    needed to keep alignment teach patient
  • Care traction, special beds, collars, splints,
    braces, assistive devices for ADLs
  • Flaccid paralysis- use high top tennis shoes or
    splints to prevent contractures. Remove at least
    every 2 hrs for ROM (active ROM best)

56
  • Spastic paralysis- assess for clonus
  • Prevent spasms by avoiding sudden movements or
    jarring of the bed internal stimulus (full
    bladder/skin breakdown use of footboard staying
    in one position too long fatigue
  • Treat spasms by decreasing causes hot or cold
    packs passive stretching antispasmotic
    medications
  • Assess skin break down thrombophlebitis remove
    TED hose at least every shift

57
Pertinent nursing problems/interventions
Respiratory
  • Phrenic nerve thoracic and intercstal nerves
    abdominal muscles
  • Monitor vital capacity, respiratory effort,
    ABGs, O2 saturation, need for ventilator
    assistance
  • Assess for signs of impending extension of SCI up
    cord to phrenic nerve level (C3-5)
  • Quad cough (assistive cough) as needed

58
Pertinent nursing problems/interventions
Acute intervention Cardio/nutrition
  • Cardiovascular instablity
  • Prevent/treat orthostatic hypotension
  • Abdominal binder, calf compressors, TED hose when
    individual gets up
  • Assess BP, especially when rising
  • Assist Physical Therapy with tilt table as
    individual gradually gets use to being in an
    upright position
  • Fluid and nutritional maintenance
  • NG to suction in acute monitor FE
  • High protein/high calorie diet

59
Pertinent nursing problems/interventions
Acute intervention Bladder
  • Bladder reflex ark- sacral 2,3,4
  • Flaccid bladder (lower motor neuron lesion) has
    no reflex from S2,3,4. Have automatic empting of
    bladder. Urine fills the bladder and dribbles
    out. Need foley or freq intermittent self
    catherization
  • Spastic bladder (upper motor neuron lesion) has
    reflex ark, but no connection to or from brain.
    Reflex fires at will. Bladder training- trigger
    points to stimulate empting self catherization

60
Upper/lower motor bladder-Website
http//www.rnceus.com/course_frame.asp?exam_id56
directoryuro
61
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62
4. Autonomic Dysreflexia
  • SCI above T6
  • Results in loss of normal compensatory mechanisms
    when sympathetic nervous system is stimulated
  • Life threatening- if goes unchecked BP can result
    in cerebral hemorrhage

63
Autonomic Dysreflexia- assess
  • Vasodilatation symptoms above SCI
  • Vasoconstriction symptoms below SCI
  • The cause of SNS stimulation

64
Autonomic Dysreflexia- treatment
  • Elevate head of bed- causes orthostatic
    hypotension
  • Identify cause/alleviate- if full bladder- cath
    if skin- remove pressure, if full bowel- empty,
    etc
  • Remove support hose/abdominal binder
  • Monitor blood pressure- can get gt 300 S
  • Give PRN medication to lower BP
  • If above not effective call physician

65
  • Use bladder scan to see amount of urine in
    bladder
  • Goal- residual lt100ml/20 bladder capacity
  • Some individuals may need suprapubic catheter
  • Assess effectiveness of medication
  • Urecholine to stimulate the parasympathic S 2,3,4
    reflex to fire and cause bladder contraction
  • Urinary antiseptic

66
Pertinent nursing problems/interventions

other
  • Bowels
  • Temperature control
  • Stress ulcer
  • Sensory deprivation
  • Reflexes- may see hyperreflexia as return of
    motor function
  • Rehabilitation and home care Resp neurogenic
    bladder/bowel skin care sexuality
    grief/depression

67
Bowel
  • Bowel rely more on bulk than on nerves
  • Stimulate bowels at the same time each day. Best
    after a meal when normal peristalsis occurs
  • Individual may progress from ducolax suppository
    to glycerin then to gloved finger for digital
    stimulation
  • Assess bowel sounds prior to giving food for the
    first time paralytic illus!

68
Sexual dysfunction
  • Assess readiness/knowledge/your ability
  • Male sexual function- reflexogenic (S2,3,4)
    erections psychogenic erections (psychological
    stimulation) Ejaculation/fertility may be
    affected
  • Female- hormones more than nerves regarding
    fertility. C-section because of chance for
    autonomic dysreflexia during labor. Lack of
    sensation/movement affects sexual performance

69
  • Suggestions empty bladder before sex withhold
    fluids and antispasmodics certain positions may
    increase spasms explore new erogenous zones
    penile implants

70
Low self-esteem
  • Assess thoughts on quality of life body image
    role changes
  • Physical and psychological support
  • Most common SCI is 15-30 yeas old and generally a
    risk taker this greatly affects their perception
    of life and rehabilitation progress

71
Home care
  • Assess psychological, physical resources, need
    for rehabilitation (in-house or outpatient) need
    for community resources
  • Home evaluation
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