Spinal Cord Injury and Traumatic Brain Injury - Quiz 4

SCI patho

primary cord injury (damage at time of impact) associated with damage to the vertebral column

• blunt or penetrating trauma

• spinal cord compression

• spinal cord laceration

Secondary injury

• hemorrhage, edema, metabolites → ischemia

• hypoperfusion, release of catecholamines, increase neurotransmitters → oxidative damage

• eventual necrosis & dissolution

extent of injury cannot be determined at the time of the accident

what determines SCI outcomes

mechanism of injury

degree of injury

level of injury

mechanism of injury

severity of primary injury is the strongest prognostic indicator of morbidity and mortality

degree of injury

complete SCI- irreversible loss of all sensation and motor function below the site (tetraplegia or paraplegia)

incomplete SCI - partial loss of sensation or motor function; pressure, vibration, proprioception

SCI level of injury

spinal level strongly influences patient deficits

areas of greatest mobility are more likely to be injured- C5-6, T11-12, L1

cervical spine:

• C1-C4: 50-75% likelihood of quadriplegia (aka tetraplegia)

  • C4 breath no more - vent may be needed

  • full paralysis of the upper and lower limbs, torso, trunk, and diaphragm

SCI emergency management

in traumatic injury (MVC, diving, sport injury, fall, or head injury) , ALWAYS assume a neck injury

• immobilize the spine

• ABCs, chin thrust for neck injured victims

• transport to trauma center ASAP

• document baseline neuro & measures taken to immobilize spine

• prepare for diagnostics, surgery

• may see use of high dose corticosteroids IV within 8 hours

drug therapy for SCI

methylprednisone is no longer universally recommended, no clinical benefits in acute SCI, and harmful side effects are reported with large doses

• may still see it used to reduce edema within first 8 hours

low molecular weight heparin to prevent VTE unless contraindicated (internal bleeding, surgery)

vasopressors are used to maintain MAP >90 to perfuse the spinal cord

SCI management

protect from further injury

• immobilize

• reduction of dislocations, spinal fusion

• traction: crutchfield tongs, halo brace

• log rolling technique

surgical goal: stabilize & support the spine, fusions

• debridement

• evaluation of hematomas

• decompression of cord

spinal cord edema may be present for 1 week

SCI: assessment

findings depend on level and extent of injury

SCI specific: assess QH for first 24 hours

• motor function

• sensory: pain, temp, pressure, proprioception

• spinal, DTR, superficial reflexes

if traumatic injury, assess for increase ICP, hemorrhage, other injuries

complications: pulmonary, shock syndromes, infections, & autonomic dysreflexia

complication: spinal shock

follows SCI, temporary flaccid paralysis, loss of sensory & motor function (can last days to months)

assessment:

• flaccid paralysis at and below the level of SCI is hallmark sign

• sensory loss below level of injury

  • pain, temp, touch, pressure, proprioception, somatic, visceral sensation

spinal shock is resolved when spinal cord reflexes return and muscles become spastic

complication: neurogenic shock

loss of SNS innervation & autoregulation

assessment:

• BRADYCARDIA

• hypotension

• poikilothermic: loss of core temp control

interventions:

• flat position

• fluids

• BP & HR support - may need atropine to increase HR

complication: autonomic dysreflexia

potentially life threatening disorder; occurs with SCI above T6; rate of occurrence 48-90%

any strong sensory input below level of SCI → message not received in brain → reflex increase symp stimulation

possible stroke, seizure, or death

assessment:

• extreme HTN, pounding HA, bradycardia, anxiety, jittery, chills, red blotchy skin with diaphoresis above level of SCI

interventions:

• vitals (especially BP)

• increase HOB

• remove noxious stimuli

• monitor VS

• administer antihypertensives

• loosen clothes

• prevent skin pressure

• decrease environmental stimulation

SCI nursing management: respiratory

injuries C1-4 need mechanical ventilation

problems:

• altered ventilatory mechanics & ineffective cough

• limited diaphragmatic excursion

• atelectasis and pneumonia

interventions

• assess airway, lung fields, breathing patterns

• TCDB, assisted cough, suction, check TV, VC

• ABGs, O2 sat

• breathing exercises, chest PT

SCI nursing management: cardiovascular

problems:

• decreased venous return, vasodilation, pooling

• DVT, thromboembolic, PE

• orthostatic hypotension

• bradycardia

interventions

• assess vital signs, s/s of thrombus

• DVT prevention - SCDs, anticoagulants, SVC filter

• passive ROM, gradually raise HOB

• aggressively prevent hypotension

SCI nursing management: temp regulation

impaired thermoregulation

• absence of piloerection

• absence of perspiration below level of injury

interventions

• monitor body temp

• maintain appropriate room temp

• avoid infection & fever

SCI nursing management: skin

impaired skin integrity: prevent breakdown

• immobility & poor tissue perfusion pressure ulcers, contractures, muscle wasting

interventions

• frequent position change

• skin care

• avoid pressure to bony prominences

• elbow & heel guards

• watch for infection at breakdown areas

SCI nursing management: nutrition

nutritional status

• acute phase: hypermetabolic

• dysphagia

• paralytic ileus, stress ulcers

• disinterest in food, depression, control

interventions

• small frequent meals after bowel sounds return

• high calorie, protein, vitamins

• enteral feedings if dysphagia persists

• identify food preferences

SCI nursing management: urinary function

urinary elimination, retention, infection

• tone & sensory problems

interventions

• assess for bladder distention

• monitor I&O

• acidify urine with acid ash foods

• avoid high calcium foods

• start bladder training, intermittent catheterization

• maintain a schedule

SCI nursing management: bowel function

bowel elimination / constipation & impaction

• no awareness of bowel fullness and movement

• no control of anal sphincter or abdominal muscles

interventions: maintain a schedule

• fluids

• roughage

• stool softener and bulk forming agents

• cathartics and suppositories

• bowel regimen for paras or tetras: 2 hours with 2x/wk with digital stimulation, must be done regularly

SCI nursing management: other issues

spasticity: upper motor neuron syndrome (UMN)

• hypertonia & spasticity with weakness, fatigue, pos babinski

• can occur a few weeks to 6 months post injury

• Rx: antispasmodics - botox to relieve hypertonia

self care deficit, body image, coping

sensory deprivation

powerlessness

sexual dysfunction

coup

site of impact

contrecoup

injury to opposite side of skull

closed head injury

blunt trauma, skull intact

open head injury

penetration into the skull by object

acceleration injury

injury caused by head in motion

deceleration injury

injury caused by sudden stop

concussion

sudden transient mechanical head injury

contusion

focal area brain bruising

laceration

torn brain tissue

TBI fracture types

linear

depressed

diastatic

comminuted

compound

basilar fracture

open head injuries

linear fractures

compound depressed

best dx: CT scan

head injury assessment findings

ABCs: airway, anoxia, increase ICP, seizures

otorrhea, rhinorrhea: check drainage for sugar

battle sign

raccoon eyes

bulging of tympanic membrane

conjugate deviation of gaze

vertigo, tinnitus

s/s ICP and seizures

pneumocephalus

dx: x ray and CT

nursing care: otorrhea and rhinorrhea

notify doctor

check nasal drainage for sugar

position: decrease HOB *unless increase ICP

no dressing in nose or ears

no NG tube

no nasotracheal suctioning

high risk of meningitis: stat antibiotics

TBI nursing care

ABCs, airway patency

avoid hypotension and hypoxia

same nursing care as increase ICP

pain management

seizure precautions

prevention of complications (the basics)

• DVTs

• pulmonary

• skin breakdown

• infection

• malnutrition

concussion

brief disruption in LOC

amnesia regarding the event

HA

post concussion syndrome: recurrent HA, lethargy

contusion

potential for infarction, hemorrhage and edema

seizures are common

focal deficits

lacerations

tear in brain tissue

patient education guide: minor head injury

awake q3-4 hours

expect HA, nausea or dizziness for 24 hours

avoid sedative, alcohol for 24 hours

no strenuous activity for 24 hours

no nose blowing or ear cleaning for 48 hours

back to ER for blurred vision, drainage, from ear or nose, slurred speech, progressive sleepiness, vomiting, worsening HA, unequal pupil size

seizures

a sudden alteration in normal brain electrical activity causing distinctive changes in behavior &/or body function

• most people who have 1 seizure will not have another

epilepsy: >2 unprovoked seizures

• most idiopathic

types of seizures

focal onset:

• aware or impaired awareness

generalized onset

• impaired awareness

unknown onset

sz inducing factors

abnormal or altered sleep wake cycle

prolonged and intense emotional stress

specific sensory stimulation

cyclic hormonal balance

alkalosis, acidosis

hypoxemia

fever

toxic states: drugs, liver, renal failure

electrolyte imbalances, hypoglycemia

other disease conditions

seizure dx & tx

accurate and comprehensive health history

EEG

differential tests

seek med for seizure (esp 1)

rx: antiseizre meds

seizure mngmt: status epilepticus

continuous seizure of >5 m or 2+ seizure w/o return of consciousness

emergency: prolonged seizures (>30 min) = irreversible brain damage/death

• acute phase: ABCs

  • IV: NS

  • protect form injury

  • drugs: dilantin, benzo, barbitates

  • goal: stop seizure

  • do not give dilantin rapid IV

• assessment: monitor V/S, neuro stat, I&O, cardiac

dx: lytes, ABGs, glucose, BUN, Ca++, toxicology, MRI, CT

documentation for sz

precital

ictal

postictal