SCI

Spinal Cord Injury (SCI) Overview

Objectives

  • Describe the mechanism of injury, clinical signs and symptoms, diagnostic testing, and treatment options for spinal cord injuries (SCI).

  • Assess for and manage common complications of SCI.

  • Recognize nursing priorities and interventions for SCI complications.

Definition of Spinal Cord Injury

What is a Spinal Cord Injury (SCI)?

  • Causes:
      - Primary Trauma: Vehicle accidents, falls, violence.
      - Non-traumatic: Tumors, infections, vascular diseases.

  • SCI blocks communication from brain and body

Pathophysiology of SCI

Types of Spinal Cord Injuries

  1. Transient Concussion:
       - Patient fully recovers; symptoms come and go with no permanent damage.

  2. Contusion:
       - Bleeding within the spinal cord.

  3. Laceration:
       - Torn or cut tissue resulting in damage.

  4. Compression:
       - Pressure on the cord which may occur alone or in combination with other injuries.

  5. Complete Transection:
       - Severing of the spinal cord leading to paralysis below the level of injury.

Categories of SCI

Primary and Secondary Injuries

  • Primary Injuries:
      - Result from the immediate insult or trauma; usually permanent and often irreversible.

  • Secondary Injuries:
      - Result from contusion or tearing, leading to nerve fiber swelling and disintegration due to factors like hypoxia, edema, and infection.
      - If treatment is applied within 4-6 hours, symptoms can be significantly mitigated.

  • Nursing Focus: Prevent further damage and manage the secondary injury cascade.

Level of Spinal Cord Injury

  • The level of injury directly affects functional loss:
      - Tetraplegia: Involves all four limbs, usually results from cervical injury (C1-C8). Injury above C4 may require mechanical ventilation.
      - Paraplegia: Affects lower body;
        - Cervical Injuries (C1-C8): Tetraplegia.
        - Thoracic Injuries (T1-T12): Paraplegia; full arm and hand function maintained.
        - Lumbar Injuries (L1-L5): Paraplegia; varying levels of leg muscle control.
        - Sacral Injuries (S1-S5): Variable weakness in legs and loss of bowel/bladder function.

Clinical Manifestations

  • The American Spinal Injury Association (ASIA) assessment tool classifies SCIs based on sensory and motor function after injury. Main nursing roles include recognizing deficits, treatment plans, and communication with doctors.

Acute Management & Priorities

Immediate Goals

  1. Preserve life and prevent neurological damage:
       - Airway & Breathing: Administer oxygen, ensuring airway is clear especially in patients with C3-C5 injuries who may require intubation.
       - Immobilization: Stabilize the spinal column to prevent further injury.
       - Cardiovascular Stability: Assess heart rate (HR) and blood pressure (BP); be alert for possible asystole requiring compressions.

Assessment and Diagnostic Findings

  • Conduct a detailed neurologic exam:
      - Assess pupils and grip strength.

  • Use imaging for diagnosis:
      - X-rays (lateral cervical spine), CT scans, and MRI.

  • Continuous cardiac monitoring is essential due to the risk of bradycardia and asystole.
       

Key Complications

  • Awareness and management of life-threatening changes:
      1. Spinal and Neurogenic Shock
      2. Deep Vein Thrombosis (DVT)
      3. Orthostatic Hypotension
      4. Autonomic Dysreflexia

Medications for Treatment

  • Methylprednisolone:
       - Administer and taper down; do not abruptly stop.

Nonsurgical Management

  • Focus on decompression, stabilization, and realignment of the spinal cord while preserving neurologic function.

  • Halo Device:
       - Used in specific cases; patients with thoracic and lumbar injuries are generally not placed in traction due to stability in these regions. Surgical intervention is often immediate for more severe injuries.

Surgical Management

  • Surgery is indicated for severe injuries; Laminectomy is the most common procedure for decompression or stabilization of the spinal column.

Managing Acute Complications

Types of Shock in SCI

  1. Spinal Shock:
       - A temporary loss of all reflex activity and sensation below the injury level; not a true shock but can appear as areflexia.
       - Symptoms:
         - Sudden reduction in reflex activity.
         - Muscles become paralyzed and flaccid.
         - Affects bladder and bowel function leading to distention or paralytic ileus; treated with intestinal decompression via NG tube.
       - Duration: Hours to weeks.

  2. Neurogenic Shock:
       - A life-threatening state of circulatory shock, primarily below T6 injuries; results from loss of autonomic function.
       - Symptoms:
         - Low BP and HR, warm skin, loss of sweating in paralyzed areas, risk of fever.
       

Summary of Spinal vs. Neurogenic Shock

Category

Spinal Shock

Neurogenic Shock

Definition

Immediate temporary loss of power, sensation, reflexes below injury

Sudden loss of sympathetic nervous system signals

Blood Pressure

Hypotension

Hypotension

Pulse

Variable

Bradycardia

Bulbocavernosus reflex

Absent

Variable

Motor Function

Flaccid paralysis

Variable

Time Frame

48-72 hours post-SCI

Immediate following injury

Mechanism

Peripheral neurons unresponsive to stimulation

Disruption of autonomic pathways affecting vasodilation

Roto-Bed

  • An apparatus that maintains patient alignment, assisting in turning the patient to reduce pressure.

Autonomic Dysreflexia

  • A medical emergency primarily in patients with T6 or higher injuries; caused by a massive sympathetic response to stimuli below the injury level.

  • Common Triggers:
      - Bladder: Distention, usually the most frequent cause.
      - Bowel: Issues like constipation or fecal impaction.
      - Skin: Irritation from tactile, pain, or thermal stimuli.

Symptoms of Autonomic Dysreflexia

  1. Severe, pounding headache with sudden hypertension.

  2. Profuse sweating, particularly on the forehead.

  3. Nausea.

  4. Nasal congestion.

  5. Bradycardia.

  6. Pale skin below the lesion; red skin above.

Interventions for Autonomic Dysreflexia

  1. Sit the patient up or raise the head of the bed to lower BP.

  2. Find and Fix the Cause:
       - Bladder: Use a bladder scan, catheter as needed (checking for kinks).
       - Bowel: Administer stool softeners, and address fecal impaction.
       - Skin: Inspect for pressure areas or irritations; remove any stimuli causing distress.

Deep Vein Thrombosis (DVT)

  • Monitor for signs and symptoms of DVT or pulmonary embolism (PE).

  • Preventive measures include:
      - Assessment and DVT prophylaxis.
      - Nonpharmacologic strategies: Sequential Compression Devices (SCDs).
      - Range of motion machines and exercises, possibly implement a filter in the vena cava to minimize embolism risks.

Additional Nursing Considerations

  • Preventing secondary complications is a core nursing function and priority.

  • Skin integrity, ensured by moving patients every 2 hours, alongside proper nutrition/hydration including vitamins.

  • Neurogenic Bladder: May require daily straight catheterization.

  • Neurogenic Bowel: Establish a bowel regimen utilizing stool softeners.

Long-Term Goals & Rehabilitation

  • Transition care focus from acute survival to promoting independence and enhancing quality of life.

  • Functional Goals:
      - Improve mobility.
      - Provide psychosocial support addressing grief/loss as patients adjust to changes in their lives.
      - Patient & family education to support understanding and management of their conditions.

Must-Know Priorities in Spinal Cord Injury (SCI)
Safety Priorities (ABCs)

  1. Airway Management:    - Administer oxygen carefully, ensuring the airway is clear, especially in patients with C3-C5 injuries who may need intubation.

  2. Breathing:    - Monitor ventilatory status and provide support as necessary.

  3. Circulation:    - Assess heart rate (HR) and blood pressure (BP); be alert for bradycardia or asystole requiring immediate intervention.

Life-Threatening Conditions

  1. Spinal and Neurogenic Shock:    - Characterized by loss of reflexes, flaccid paralysis, and associated autonomic instability.    - Symptoms may lead to profound hypotension and bradycardia.

  2. Deep Vein Thrombosis (DVT):    - Risk of embolism must be monitored due to immobility; provide prophylaxis as indicated.

  3. Autonomic Dysreflexia:    - A medical emergency occurring in patients with T6 or higher injuries characterized by extreme hypertension and bradycardia. Immediate intervention is required.    - Identify triggers such as bladder distention or bowel impaction.

Hallmark Signs of SCI

  • Complete Paraplegia/Tetraplegia:    - Depend on the level of injury; paralysis may affect breathing in high cervical injuries (C1-C4).

  • Spinal Shock Symptoms:    - Sudden loss of reflex activity, paralysis, bowel/bladder dysfunction.

  • Neurogenic Shock Symptoms:    - Warm skin, low blood pressure, and severe autonomic instability; may require IV fluids and medications.

  • Autonomic Dysreflexia Symptoms:    - Severe headache, profuse sweating above injury site, paleness, nasal congestion, and bradycardia.

Summary

Stay vigilant in monitoring respiratory and cardiac function, identify signs of shock, and manage immediate complications efficiently. Understanding the hallmark signs of SCI is crucial for timely and effective management.