Module 7 SCI

How are spinal cord injuries described by?

• Level of the injury- the cord segment or dermatome level

• Such as C6; L4 cord injury

Para

meaning two extremities

tetra or quadra

all four extremities

Paresis

weakness

Plegia

paralysis

Manifestations are related to?

The level and degree of injury

The higher the injury

The more severe the symptoms

C1-C7

Tetraplegia

T1-L4

Paraplegia

Primary Spinal Cord Injury- Initial mecahnism of injury

• Compression

• Interruption of the blood supply

• Traction

• Penetrating Trauma

Secondary Spinal Cord Injury

• Ongoing progressiv damage

• Ischemia

• Hypoxia

• Micrhemorrhage

• Edema

What occurs in the cord post inury causing more damage?

Hemorrhage and edema

Apoptosis

• Programmed cell death

• can continue for weeks

What occurs over the first few days of the SCI? What happens at 72 hours?

a.) Extension of the cord injury from cord edema

b.) Prognosis

Which nerve should be watched? Why?

Phrenic nerve- because it is the nerve that controls the diaphragm, which is responsible of for breathing

What is initially experienced?

• Initially SCI experience spinal shock

• Depression of all cord & ANS function below injury. Lasts from few minutes to weeks

Spinal Shock

• Decreased reflexes and loss of sensation below the level of injury

• Motor loss- flaccid paralysis below the level of injury

• Sensory loss- loss of touch, pressure, temperature, pain, and proprioception perception below the injury

• Last days to weeks Maks post-injury function

• Sign of the return of function

• Clonus

Neurogenic Shock

• Cervical or High thoracic injury (T6 or higher)

• Loss of SNS innervation results in parasympathetic dominance with vasomotor failure

• Causes peripheral vasodilation, pooling, and decreased cardiac output

• Hypotension and Bradycardia

• Orthostatic hypotension and poor temperature control (poikilothermic)

• Poor perfusion can worsen spinal cord ischemia

How is Neurogenic Shock Treated?

• With vasopressors to maintain MAP and help perfuse spinal cord and IV fluids to maintain BP

Classifications of SCI

Mechanism of Injury

Skeletal and Neurologic Level

Completeness (degree) of Injury

Skeletal Level of Injury

• The vertebral level where the most damage to the bones

Neurological Level of Injury

The lowest segment of the spinal cord with normal sensory and motor function on both sides of the body

Spinal Cord Level of Injury

• When referring to spinal cord injury, it is the reflex arc level (neurologic), not the vertebral or bone level

• The thoracic, lumbar, & sacral reflex arcs are higher than where the spinal nerves actually leave through the opening of the vertebral bone

Complete Injury

Total loss of sensory & motor function below the level of injury

Incomplete Degree of Injury

• Mixed loss of voluntary motor activity and sensation; leaves some tracts intact

Incomplete Spinal Cord syndromes

• Central cord syndrome

• Anterior Cord syndrome

• Brown Sequard Syndrome

• Posterior Cord Syndrom

• Causa Equine and Conus Medullaris

Complete Deficitis After Spinal Shock

• Motor deficits: spasitc paralysis below the level of injury

• Sensory- Loss of all sensory perception

• Autonomic deficits- vasomotor failure and spastic bladder

Central Cord Syndrome

• Injury to the center of the cord by edema and hemorrhage

• Motor weakness and sensory loss in all extremities

• Upper extremities affected more

Brown Sequard Syndrome

• Incomplete

• Hemi section of cord

• Ipsilateral paralysis

• Ipsilateral superficial sensation, vibration, and proprioception loss

• Contralateral loss of pain and temperature perception

Anterior Cord Syndrome

• Incomplete

• Injury to the anterior cord

• Loss of voluntary motor, pain, and temperature perception below the injury

• Retains posterior column function (sensations of touch, position, vibration, motion)

Conus Medullaris

• Incomplete

• Injury to the sacral cord (conus) and lumbar nerve roots

• Result- areflexic (flaccid) bladder and bowel, flaccid lower limbs

Cauda Equina

• Incomplete

• Injury to the lumbosacral nerve roots

• Result- areflexic (flaccid) bladder and bowel, flaccid lower limbs

Acute Care Diagnostics

• Immobilization

• Hx & PE

• ABGs, O2, intubation, Serial bedside PFT

• Cardiac Output- MAP, BP, HR

• Electrolytes, glucose, H&H, coagulation studies

• Urinlaysis

• CT, MRI, EMG

• X rays

• NGT/ Foley

• Nutrition

Health History

• Description of how and when the injury occurred, e.g., falls, gunshot or stabbings, sports injuries- description

• Other Illnesses or disease processes

Physical Exam

Ability to move, breathe, and associated injury such as a head injury,fractures

• LOC and pupils- may have indirect SCI from head injury

• Respiratory status- phrenic nerve (diaphragm) and intercostals; lung sounds

• Vitals

• Motor Sensory

• B/B function

Motor Assessment

• Upper Extremity

• Movement, strength, and symmetry, hand grips, flex and extend the arm at the elbow with and without resistance

• Lower extremity

• Flex and extend leg at the knee with and without resistance, plantar and dorsi flexion of foot, and assess for clonus

Sensory assessment

• With the sharp and dull ends of a paperclip have the individual, with their eyes closed identify, use the dermatome as reference to identify level

• C6 thumb

• T4 nipple

• T10 naval

How much respiratory loss is associated with cervical injury above C3?

total loss

What controls the diaphragm bilaterally?

• The phrenic nerve (C3-5) in a cervical injury C3-5

• If the nerve is nonfunctioning then the individual is ventilator dependent

How is the respiratory system affected with a cervical injury below C6?

• Patient cannot cough effectively

• Decreased chest expansion

• Cough reflex & vital capacity

What can cause hypoventilation, atelectasis, & pneumonia in Cervical & Thoracic injuries?

Paralysis or weakening of the abdominal and intercostal muscles

Respiratory System Interventions

1. Assess RR, rhythm, depth, breath sounds, respiratory effet, ABGs, O2 sat

2. Assess signs of impending extension of SCI up cord to phrenic nerve level (C305)

3. Need for ventilatory assistance, tracheotomy, ventilator

4. O2, suctioning

5. Tilt bed (spine immobilized)

6. Quad cough (assistive cough, chest PT, BiPAP

Cardiovascular System Manifestations of SCI

Bradycardia

Peripheral vasodilation

Decreased CO

Relative hypovolemia

What causes Bradycardia? Interventions?

• Decreased SNS

• Cardiac monitoring necessary

• Atropine may be needed

What does Peripheral vasodilation cause? Interventions?

• causes hypotension decreased CO

• IV fluids or vasopressors (norepinephrine) may be needed

• Maintain MAP at 85-90

What is the main cause of relative hypovolemia?

venous dilation

What are some ways to prevent/ treat orthostatic hypotension?

• Assess BP, especially when rising

• Abdominal binder, calf compressors, TED hose

• Assist PT with tilt table as individual gradually gets used to being in an upright position

• Midrodine, salt

VTE prophylaxis

• ROM, fluids, SCD’s Assess for VTE

• Heparin

• Assess skin breakdown thrombophlebitis; remove TED hose at least every shift

Urinary System Manifestations

• Urinary retention

• Flaccid Bladder

• Spastic Bladder

Urinary retention

• Common with spinal shock and acute phase of SCI

• Post acute phase- hyperirritable bladder causing reflex emptying

What is the bladder function dependent on? What are urinary carre goals? Risks?

• dependent on the level of injury

• goal is to prevent infections, minimize/ contain incontinence

• Risk for renal calculi, UTI, and reflux.

Flaccid bladder

• lower motor neuron lesion

• No reflex from S2,3, 4

• Automatic emptying of bladder

• Urine fills the bladder and dribbles out

• Need Foley or frequent intermittent self-catheterization

Spastic bladder

• upper motor neuron lesion

• Reflex arc but no connection to or from brain

• relfex firres at will

• Bladder training- trigger points to stimulate emptying; self-catheterization

What stages will require an indwelling? What happens once stable?

a. early stages require an indwelling cath

b. clean intermittent catheterization (CIC) q 4-6h/ 24 hours

• Urinary antiseptic

• Lidocaine

• Use bladder scan to see amount of urine in bladder

• Goal- residual <100mL/ 20% bladder capacity

• hydration

Other urinary interventions?

• Condom catheter, bladder tapping, supra pubic cath, stoma

• assess effectiveness of meds:

• Urecholin- stimulates bladder contraction

• Oxybutynin- to relax bladder

GI Manifestation of SCI

• Decreased GI motility- Injury at T6 and ^, decreased GI motility, NG tube for intermittent suction

• Stress ulcer prophylaxis- 6-14 day ^ risk, test stool and NGT drainage for blood, Monitor labs for decreased HCT, H2 blockers/ PPIs

• Neurogenic bowel- reflex emptying occurs, bowel program

GI Interventions

• Bowels rely more on bulk than on nerves

• Fiber, fluids, bulk laxatives, stool softeners

• Stiimulate bowels at the same time each day

• Best after a meal when normal peristalsis occurs

• Below T-12 may have Valsalva ability

• Individual may progress from Dulcolax suppository to glycerin then to gloved finger for digital stimulation

• Assess bowel sounds before giving food for the first time- paralytic ileus

What is a significant risk for the integumentary system?

Pressure ulcer and long term complication is pressure injury

Prevention is the goal

What are the contributing factors of pressure ulcers?

• lack of movement

• loss of sensation

• compromised circulation

• weight loss/ weight gain

• incontinence

Integumentary systemt interventions

• change position frequently- Q2h

• Keep skin clean and dry

• protection from extremes in temperature

• inspect skin at least 2x/day especially over boney prominences

• care for traction, collars, splints, braces

• Avoid shearing and friction to soft tissue with transfers

• removal of TED hose Q8h

• Assess nutritional status/hydration

• pressure mattress

Management of Temperature Control

thermoregulation

• Poikilothermism- adjustment of body temp to room temp

• Interruption of the sympathetic nervous system prevents temperature sensation from reaching the hypothalamus

• Decreased ability to sweat of shiver below level of lesion

• Hypothermia is common

• Monitor temperature Q4h during acute phase

• Adequate clothing in cool environment

Management of Nutrition

• 48-72 hours- GI tract may stop- paralytic ileus

• NGT to suction

• Weight loss (> than 10%)

• Nutritional support wi/i 72 hours

• parenteral nutrition

• bowel sounds/ flatus/ swallow test before eating

• refer to a dietitian

Musculoskeletal manifestations

• joint contractures

• bone demineralization

• osteoporosis

• muscle spasms

• muscle atrophy

• pathologic fractures

• para/tetraplegia

Musculoskeletal Interventions

• Log roll as a single unit; assist as needed to keep alignment; teach patient

• care for traction, collars, splints, braces, assistive devices for ADLs

Flaccid paralysis interventions

• use high top tennis shoes or splints to prevent contractures.

• remove at least Q2h for ROM- active is best

Spastic Paralysis interventions and prevention

• 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; fatigues)

• Treat spasms by decreasing causes; hot of cold pack; passive stretching; antispasmodic meds

Male sexuality Manifestations

• UMN lesion

• reflexogenic (S2,3,4) erections

• LMN lesion

• psychogenic erections

• ejaculation/fertility may be effected

Female Sexuality Manifestations

• Hormones more than nerves regarding fertility

• C-section b/c of chance for autonomic dysreflexia during labor

• Lack of sensation/ movement affects sexual performance