Complete Spinal Cord Injury

and

Complete Deficit Levels

Total loss of motor and sensory function and pathways below level of injury (permanent)

Levels are: Paraplegia (T2-L1) - affects lower extremities

Tetraplegia (C1-T1) - affect all four extremities

Incomplete Spinal Cord Injury and Syndromes

Partial interruption of spinal cord messages transmission to and from brain - sacral sparing (anal sensation) and rectal tone may indicate incomplete SCI

Syndromes: Anterior, Posterior, Central, Lateral Cord Brown Sequard

Anterior Cord Syndrome

Function Lost:  motor function, pain, temp, touch, with paralysis below level of injury

Function Present: proprioreception, vibration, light touch, pressure sense

Posterior Cord Syndrome

Function Lost: motor function, loss of pain and sensation below level of injury

Function present: sense of position, pressure, vibration

Central Cord Syndrome

Function Lost: Motor, sensory deficit in upper extremities (often spastic), variable bowel/bladder dysfunction and paralysis of lower extremities

Function Present:  Motor, sensory pathways in lower extremities; varied bowel and bladder function

(respiratory is a big concern)

Lateral Cord Brown Sequard

Function Lost: Loss of voluntary motor movement proprioreception, vibration and deep touch on same side as injury, loss of pain, temp, sensation on contralateral side below level of injury.

Function Present: Side of body with best motor control has little or no sensation.

(ipslateral motor control loss/contralateral sensory loss)

Time frame that edema peaks and subsides in secondary ischemia of spinal cord injury (SCI)

Edema starts immediately, peaks in 2-3 days and subsides in 7 days

(Important because extent of SCI cannot be determined until the edema subsides; usually one week after injury)

Dextran

Plasma expander to increase cord flow and treat hypotension

Electolyte shifts in SCI

Calcium accumulates in injured cells causing demylinization and destruction of cell membrane = neuron death

Extracellular potassium and sodium concentrations increase (K+ released from damaged tissue and Na increases edema)

(Cardiac monitoring important)

Methylprednisone (Solumedrol)

Used in SCI to decrease edema (improve perfusion and decrease secondary damage)

Need to know weights and baseline and give within 8 hrs of injury and continue 24-48 hours

Goals for Acute SCI

1) Sustain life with ABC's: maintain high PaO2 as hypoxia worsens neuro deficits, prevent hypotension (fluids, vasopressors); may require diaphragmatic pacing (stimulation of phrenic nerve to breath); with CPR use the jaw thrust instead of head tilt

2) Stabilize and immobilize - transfer board, C collar, log roll, bed rest, traction

3) Obtain event history, assessment and care

X-ray with SCI

Shows bones and fractures

Positions:  C1-C2 - mouth open to see through teeth

C7-T1 - swimmers position

Diagnostic test to see soft tissues in SCI

MRI

Acute Care for SCI

Tests: X-ray, MRI or myelography

Labs: UA, ABG

ECG: bradycardia and asytole common in SCI

Hourly neuro x 24 hrs, scales comparison

Motor with and without gravity (head to toe)

Sensory (dematomes) (head to toe)

Education with SCI

Life with change - hospitalization (acute, rehab, home)

- ADL's (safety), work, financial expenses

- S/S to report (spinal shock, dysreflexia, bladder disfunction, infection)

Full extent of injury not determined for 1 week due to edema

Spasms (intense, painful) - lower extremites in those with complete lesion = not voluntary movement back

Spasms peak 2 years then gradually goes away (tx: Baclofen, do PROM, warm baths, environmental temp)

Spinal Shock

Complete, temporary loss of function (areflexia) below injury level, reflexes absent

More severe in higher injury

30-60 min after injury

Lasts 7-20 days after onset, gradual recovery ends slowly up to months

(When this ends, watch for dysreflexia)

S/S of Spinal Shock

Loss of autonomic function (decreased CO, hypotension from loss of vasomotor tone, bradycardia)

Peripheral vasodilation (loss of perspiration)

Bowel/bladder dysfunction (ileus, distention)

Flaccid paralysis, decreased reflexes

Venous pooling

Loss of sensory, reflexes, and motor below injury

Priaprism (recovery is less when present)

Spinal Shock Care

Fluid resuscitation with isotonic (LR)

Vasopressors to increase blood flow to spinal cord/organs

Symptomatic treatment

S/S of spontaneous resolution of

Spinal Shock

Spasticity

Reflex bladder emptying (bladder tone)

Hyperreflexia (increased muscle tone, DTR)

Bulbocavernous reflex (contraction of anus)

Neurogenic Shock

In injuries about T6 - loss of sympathetic control below injury allows parasympathetic output unchecked

Decreased vascular resistance and dilation - blood pools in lower extremities

Tx: fluids and vasopressor meds

S/S of Neurogenic Shock

Hypotension (vasodilation with decreased venous return)

Bradycardia

Decreased cardiac output

Hypothermia

Inability to sweat below lesion (warm, dry)

Manual Stabilization with Acute SCI

Gardner Wells or Vinke - to reduce C fracture (holes drilled with local anesthesia)

Weights (10# - injury w/o fracture; 5# added per level;

2-4 weeks)

Treat with muscle relaxants and emotional support

Halo - head ring with 4 pins attached to vest

- immobilization of cervical spine w/early ambulation (5 days after injury)

Tongs, Traction and Halo Care w/ SCI

Pin care with assessment - call Dr. if pins loose, check and clean to prevent infection

Safety and Comfort - neutral neck, weights hang freely, muscle relaxants, t-shirt under halo, keep dry, assess skin, halo wrench on vest, mobility with halo

(No showers, remember top heavy and easy hypotension, raise HOB to help them get up)

Acute SCI - Surgery Care

Goal: preserve neuro function

Assess thoracic and lumbar areas for cord compression, frag/unstable vertebral body, penetrating wound with bone frags, deteriorating neuro status

Don't forget baselines and approach route

(anterior approach for cervical - monitor swallowing to prevent aspiration; anterior approach for lumbar - monitor bowel function)

Acute Care SCI - Impaired Gas Exchange

 ABC assessment

Vent dependence at C4 and above

Risk for resp. failure - atelectasis, PE, Infection

(assess VS, vital capacity, labs (WBC, ABG, sats)

Temp is not always a good indicator - look at labs

Use bronchodilators, mucolytics to mobilize secretions

AB as prescribed (watch for thrush - Diflucan)

Early mobility/TCDB & quad cough/IS q 2/increase fluids 2-3 L/day but watch for CHF/suction PRN carefully - vasovagal stimulation, abd binders, avoid smoking

Acute SCI care - decreased cardiac output (CO)

Hemodynamic monitoring

BP alterations

Watch for fluid overload

Abdominal Binders (enc venous return and diaphragm support)

Risk for DVT and PE - Lovenox, Vena cava filter, SDC, mobility, PROM TID, elevate legs 20 min/shift (do not massage)

BP in Acute Care of SCI

Check BP in all positions - use tilt table (watch for N/V and passing out)

Give Atropine for brady or hypotension

Dopamine for hypotension (keep systolic > 90, MAP 85-90 x 7 days)

Give Dextran to increase flow to cord and hypotension

Urinary Function in Acute SCI

Dysfunction depends on level of injury after spinal shock

Reflex (spastic) bladder - above T12 - spontaneous voiding (contracts and empties invol. in response to filling pressure (500 mL and not patient controlled)

Nonreflexive (areflexive) bladder - flaccid - injury to sacral plexis - retention and overflow voiding

Acute Care - GU for SCI

Foley to measure strict I/O

Prevent and assess for UTI (give fluids and Vit C)

Meds for UTI - urecholine, baclofen, ditropan

Acute Care SCI - GI

Immed. after injury - paralytic ileus risk - NG tube

NPO - start intake with bowel sounds

Meds: Zantac, Tagamet, Pepcid - ulcer prevention

stool softeners, antidiarrheal for SE of AB therapy, supplements like protein

Bowel training

Bladder/Bowel Stimulation

tap bladder

pull pubic hair

stroke inner thigh

Crede for bowel

Why is protecting a SCI patient from constipation important?

Constipation/full bowel or bladder can cause autonomic dysreflexia which can kill them.

Acute Care of SCI - Immobility

Neutral position at all times (keep fluids out of lungs, blood flow)

Specialty beds (kinetic for constant movement, stryker frame for side to side and lateral movement)

Skin assessment using Braden Scale

Care: early mobilization, turn q 2, lubrication, wheelcare repositioning/move selves q hr, adequate nutrition, hygiene, no IM below level of injury, PROM 4-5 x/day to prevent contractures, meds for spasticity, NSAID's for aches, DVT prophylaxis, safety - orthostatic hypotension

Autonomic Dysreflexia - Hyperreflexia

Life threatening - PREVENT

Massive vasoconstriction (BP up to 200)

When multiple cord responses fire at once and stimuli unable to ascend cord

After spinal shock resolved but may be lifelong

Common in T6 and above

*Exaggerated ANS response to noxious stimuli below level of lesion from:  full bladder, fecal impaction, funning skin feeling, UTI, stones, pain, decuiti, ingrown nail (onychocryptosis), chilling

S/S of Dysreflexia

Pounding HA, blurred vision, anxiety, bradycardia (30-40), hypertension (systolic > 200), warm, diaphoresis and flushing above injury, pale cold dry below injury, venous pooling in extremities, nasal stuffiness, dilated pupils, nausea, maybe even LOC changes seizures, apnea

Nursing for Autonomic Dysreflexia

Promoting venous pooling - Elevate HOB 45, notify Dr, remove TED hoses and tight clothing

Rapidly identify and treat cause - empty bladder, examine rectum and skin

BP and pulse q 2-3 min while locating cause

Give meds - procardia, apresoline, nitro

Watch for IICP for venous rupture