http://www.rexdonald.com/facts.html

http://www.cureparalysis.org/statistics/

Spinal Cord InjuriesLife expectancy greatly increased since

WW II. Intermittent catheterization Medications, equipment, etc

Cause of premature death in QUADS is usually related to COMPROMISED RESPIRATORY FUNCTION

Spinal Cord InjuriesWho’s at risk?

ADULT MEN BETWEEN 15 AND 30 YEARS

Anyone in a risk-taking occupation or lifestyle

SCI in older clients increasing largely due to MVAs

Spinal Cord InjuriesCauses (in order of frequency)

MVA Gunshot wounds/acts of violence Falls Sports injuries

Spinal and Neurogenic ShockBelow site of injury:

Total lack of function Decreased or absent reflexes and flaccid

paralysis Lasts from a week to several months after

onset. End of spinal shock signaled by muscular

spasticity, reflex bladder emptying, hyperreflexia

Classification of SCIMechanism of injury

Flexion (bending forward) Hyperextension (backward) Rotation (either flexion- or extension-

rotation) Compression (downward motion)

Pathophysiology of SCI Insert stuff here Insert picture here

Classification of SCI Level or Injury

Cervical (C-1 through ??) Thoracic (T-1through ??) Lumbar (L-1through ??)

Degree of Injury Complete

Total paralysis and loss of sensory and motor function although arms or rarely completely paralyzed

Incomplete or partial

http://www.sci-recovery.org/sci.htm

Degree of Injury Complete transection

Total paralysis and loss of sensory and motor function although arms or rarely completely paralyzed

Incomplete (partial transection) Mixed loss of voluntary motor activity and

sensation Four patterns or syndromes

Incomplete cord patterns Insert picture of cord here Central cord syndrome More common in

older clients Frequently from hyperextension of spine Weakness in upper and lower ext, but greater

in upper. Anterior cord syndrome Posterior cord syndrome Brown-Sequard syndrome

Anterior cord syndromeCompression of the ant. Cord, usually

a flexion injurySudden, complete motor paralysis at

lesion and below; decreased sensation (including pain) and loss of temperature sensation below site.

Touch, position, vibration and motion remain intact.

Posterior cord syndromeAssoc with cervical hyperextension

injuriesDorsal area of cord is damaged

resulting in loss of proprioceptionPain, temperature sensation and motor

function remain intact.

Brown-Sequard syndrome Damage to one half of the cord on either side. Caused by penetrating trauma or ruptured disk.

ischemia (obstruction of a blood vessel), or infectious or inflammatory diseases such as tuberculosis, or multiple sclerosisBSS may be caused by a spinal cord tumor, trauma (such as a puncture wound to the neck or back),.

a rare SCI syndrome which results in weakness or paralysis (hemiparaplegia) on one side of

the body and a loss of sensation (hemianesthesia) on the opposite

side.

Clinical manifestations of SCIDepend on the LEVEL and DEGREE of

the injury!Quadriplegia occurs with C-1 through

C-8 injuries.Paraplegia occurs with T-1 thru L-4.SEE TABLE 57-3 ON PAGE 1725!

Clinical Manifestations of SCIRespiratory

C1 – C3: Absence of ability to breathe independently.

C4 – poor cough, diaphragmatic breathing, hypoventilation

C5 – T6: decreased respiratory reserve T6 or T7 – L4: functional respiratory

system with adequate reserve.

What is the phrenic nerve? The phrenic nerve stimulates the diaphragm

to contract. Two phrenic nerves (right and left) - injury to

one or the other paralyzes contraction of only one half of the diaphragm but even hemi- (half) paralysis can significantly interfere with breathing for patients with lung disease.

The nerve arises from branches of the C3,4, and 5 nerve roots.

The phrenic nerve can be damaged by procedures exploring the neck & upper back

Loss of the phrenic nerve on either side results in paralysis of the diaphragm on that side. 

Paralysis of the diaphragm on one side results in less inflation of the lung on that side. 

Whether this is physiologically significant (producing respiratory distress, hypoventilation/hypercapnia) depends on other aspects of a patient's pulmonary physiology (namely underlying chronic obstructive pulmonary disease [emphysema, bronchitis], pneumonia, etc.). 

Cardiovascular system C1 – T5 shows decreased or absent SNS

influence. BRADYCARDIA AND HYPOTENSION

(due to vasodilation)

What is the VAGUS nerve?The longest of the cranial nerves- exits

out of the medulla and ends in the abdomen

It supplies sensory and motor function to the pharyngx

Supplies motor function to the muscles of the abdominal organs

Provides parasympathetic activity to the heart, lungs, and most of the digestive system

Urinary SystemAtonic bladder with RETENTION in

spinal shock.Post acute phase – irritability causing

dribbling or frequent urination.Urinary infection and calculi from

retention and distention. INTERMITTENT CATHETERIZATION!

GI system Decreased motility Paralytic ileus Gastric distention – intermittent NG suctioning Increased H2 – administer H2 inhibitors such

as Zantac or Pepcid in initial stages Carafate and antacids later as prophyaxis Intraabdominal bleeding! Remember, no pain

or tenderness to warn you. Watch for H/H decrease and impactions

Integumentary SystemPressure ulcers!Muscle atrophy in flaccid paralysisContractures in spastic paralysisPoikilothermism – the adjustment of

body temp to room temperatureDecreased ability to sweat below lesion

Peripheral vascular systemDVT common but not detected easilyPulmonary embolism a significant cause

of death.Doppler studies, measurement of

extremity girth, impedance plethysmography (what the heck is this?)

Post Injury Assessment Goals are to

Sustain life Prevent further cord damage

Assessment of muscle groups; motor status Against gravity Against resistance Both sides of the body Ask to move legs, hands, fingers, wrists, then

shrug shoulders

Post injury assessment (p.1726)Thorough motor examination including

position sense and vibration.Sensory examination

Pinprick starting at toes and working upward

ALWAYS HAVE CLIENT CLOSE EYES OR LOOK AWAY! If he can see what you’re doing, he will answer accordingly.

Assess for head injury and ICPX-ray, CT scan, EMG

Surgical TherapyReduces injury and stabilizes the SCDone for

Compression Bony fragments in the cord Compound fracture Penetrating trauma

Drug TherapyVasopressors (Dopamine) to keep

mean arterial pressure greater than 80mm to 900mm/Hg so that PERFUSION TO CORD is improved.

Methylprednisolone (Solu-medrol)

Increases the recovery of function and is the SOC! IV bolus then continuous IV over a 23 hour period.

Improves blood flow and reduces edema in the SC

Other drug therapySymptom-reducing drugs for

GI problems - zantac, tagamet, pepcid Bradycardia - atropine Hypotension - vasopressors bladder spasticity - anticholinergics autonomic dysreflexia – blood pressure

reduction

Function of Motor NeuronsUpper motor neurons

Function of Motor NeuronsLower motor neurons

Diagnoses and Interventions Impaired Gas Exchange r/t muscle

fatigue and weakness Decreased Pao2, increased PaCO2 Fatigue Diminished breath sounds

Impaired gas exchangeMaintain patent airwayAssess respiratory status q 2 hoursMonitor ABGsProvide aggressive pulmonary toilet;

chest PT and quad-assist coughingAssess strength of coughSuction secretions

Inability to sustain spontaneous ventilation

Related to diaphragmatic fatigue or paralysis evidenced by Dyspnea Use of accessory muscles Abnormal ABGS

Provide chest PTAssist with mechanical ventilationProvide emotional support

Decreased cardiac outputRelated to venous pooling of blood and

immobility as evidenced by Hypotension Tachycardia Restlessness Oliguria Decreased pulmonary artery pressures

Decreased cardiac outputMonitor blood pressure, pulse and

cardiac rhythmAdminister vasopressors to maintain

MAP at 800mm/Hg or aboveApply pneumatic compression boots or

stockings Perform ROM at least q8h to aid in

muscle contraction and venous return

Impaired skin integrityRelated to immobility and poor tissue

perfusion Inspect skin and areas around pins or

tongsTurn at least q2h and use kinetic table

or other specialty care devices. Insure adequate nutritional intake INFORM family and client about risk of

pressure ulcers

ConstipationRelated to location of injury, fluid

intake, diet, immobility AEB Lack of BM in over 2 days bowel sounds Palpable impaction Hard stool or incontinence

ConstipationAuscultate bowel sounds and monitor

abdominal distentionNote and report any nausea and vomitingBegin bowel program when BS return and

teach to client and familyAdminister suppositories and stool

softenersEnsure appropriate fluid and fiber intake

Bowel program for SCINeeds to be consistentGive suppository after meal and place

on toilet approx 30 minutes after.Do this at same time each day!Fiber, fluids and activity are importantConstipation leads to AUTONOMIC

DYSREFLEXIA!!!

Urinary RetentionRelated to injury and limited fluid intake

as evidenced by Decreased output Bladder distention Involuntary emptying of bladder

Urinary RetentionPalpate bladder every shiftDuring acute phase, insert indwelling

catheterBegin intermittent cath program when

appropriateKeep I and O and end fluidsMonitor BUN and creatinineCrude (pronounced croo-DAY)

manuever when voiding/cathing

Risk for AUTONOMIC DYSREFLEXIA

Assess for HTN, bradycardia, headache, sweating, blurred vision, flushing, nasal stuffiness/congestion

Reduce or eliminate noxious stimuli such as impaction, urine retention, tactile stimulation and skin lesions or pain!

Autonomic dysreflexiaElevate HOB 43 degrees Identify cause and eliminateTake BP and pulseAdminister antihypertensives as ordered

if hypertensive.Call physician if interventions not

effectiveTEACH CLIENT AND CARGIVERS

HOW TO PREVENT THIS!

Other diagnoses Impaired physical mobilityAltered nutrition: < body requirementsSexual dysfunctionRisk or injury r/t sensory deficitsAltered family processesRisk for ineffective individual copingBody image disturbance

Acute intervention

ImmobilizationCrutchfield tongsHalo vestStryker bedRoto-rest bed (side to side)

Motion sickness a problem with these.

Respiratory dysfunction Intubation if injury is high Decreased tidal volume and shallow

breathing lead to pneumonia and atelectasis

CPT and pain management Prone position may be risky Count to 10 test QUAD COUGH technique to assist with

ineffective abdominal muscles

Fluids and nutritionParalytic ileus common in 48-72 hoursWhen bowel sounds return:

High calorie, high protein, high fiber diet Evaluate SWALLOWING before feeding!

EATING CAN BECOME A POWER STRUGGLE!

Bowel and Bladder mgmt. Indwelling catheter initially Intermittent catheterization when ableMonitor pH of urine (should be acetic!)Ascorbid acid and Mandelamine (an

antiseptic) given to keep down bacteria

Temperature controlNO vasoconstriction, piloerection or

heat loss through sweating below level of injury

Do not over cool or over heat client. They only have the remaining upper portion of their bodies, generally, for temperature adjustment