NPCC RN 4S T3 Spinal Trauma
Spinal Shock Treatment
-Monitor patient for respiratory difficulty -Bladder and bowel management -Environmental control (control room temp) -*When spinal shock ends, flaccid* *muscles become spastic*
Spinal Cord Injury
*Always* assume there is a spinal cord injury until it is ruled out! -Immobilize -Prevent flexion, rotation or extension of neck. -Avoid twisting patients If conscious, patients will usually mention acute pain in back or neck which may radiate along the involved nerve.
Nursing
*Assessment!* Immobilization Continuous EKG monitoring -- look for signs of bradycardia Diagnostics: -X-rays (lateral cervical spine) -CT scan -MRI --Myelogram if MRI is contraindicated
Spinal Cord Injury
*Secondary injury is the primary* *concern for ED and Critical Care* *nurses*. *Secondary injury is reversible during* *the first 4-6 hours after injury*. Management is *aimed at preventing* further injury and observing for progression of neuro deficits
Autonomic Dysreflexia - Causes
-Anything that can cause discomfort to a neurologically intact person -The most common stimulus is a distended bladder or rectum -Other causes include: Stimulation of the skin from pressure, pain, heat or cold. -Treatment: identify and *remove the* *cause/stimulus* --Elevate HOB 90 degrees or sit patient with feet down to promote orthostatic reduction in BP.
Incomplete Injuries-- Anterior cord syndrome
-Damage to the motor and sensory pathways in the anterior areas of the cord. -Loss of movement and overall sensation, although some sensations that travel by way of the still intact pathways can be felt.
Spinal Cord
-Dorsal roots: *Sensory* nerve cells -Ventral roots: *Motor* nerve cell bodies When the spinal cord is injured, the communication system is interrupted, leaving parts of the body disconnected from the brain.
Spinal Cord
-Extends from the skull -Vertebra surround the spinal cord -Vertebra stack like drums, fitting at structures called "facets"
Medical Management of Spinal Cord Injuries
-High dose (~ a gram+/lbs) corticosteroids (solu medrol) improves the prognosis and decreases disability if initiated within 8 hours of injury. -->Glucose & <immune system Patient receives a loading dose and then a continuous drip -High dose steroids, Mannitol, Dextram -Nalaxone has shown some promise and may promote neurological improvement Also look for GI bleeds from PU --The mechanistic rationale for their use initially centered on the expectation that they would reduce post-traumatic spinal cord edema. Medications. Methylprednisolone (Medrol) is a treatment option for an acute spinal cord injury. If methylprednisolone is given within eight hours of injury, some people experience mild improvement. It appears to work by reducing damage to nerve cells and decreasing inflammation near the site of injury documented the ability of naloxone to maintain spinal cord blood flow40 and to improve neurological recovery after contusion SCI.
Gardner-Well Tongs
-Immobilizes the head and neck and reduce cervical facet dislocation -Is secured by screws into the skull -Traction is usually initiated at 10 to 15 lbs Do NOT let weights drag the floor!
Pathophysiology
-Injury to spinal cord vasculature *causes nerve fibers to swell &* *disintegrate*. -Blood circulation to the gray matter of the spine is impaired. -*Secondary chain of events occur*: *Ischemia, hypoxia, edema, and* *hemorrhagic lesions*. -These secondary events result in *destruction of myelin and axons*.
Nursing Interventions: Improving Mobility
-Maintain proper body alignment at ALL times. -Reposition frequently using log rolling technique -Use splints to prevent foot drop Trochanter rolls should be used at crest of ilium and midthigh to both legs to prevent external rotation of the hip joints. -Passive ROM to help prevent contractures. --Patients with lesions above midthoracic region have loss of sympathetic control of peripheral vasoconstrictor activity and may not tolerate changes in position. Monitor blood pressure.
Complication - Orthostatic Hypotension
-May develop in acute or transitional phase -Caused by venous pooling in the legs and abdomen and loss of skeletal muscle pump and impaired sympathetic nervous system control of BP -May occur with position changes and can result in syncope, bradycardia, or asystole.
Spinal Shock
-Occurs with injuries above T6 -Swelling occurs result of injury -Increase in blood pressure due to *release of catecholamines*, followed by hypotension. -Is *transient*, can lasts days to months. Priapism can occur -Absence of all voluntary and reflex neurologic activity below the injury --Decreased reflexes --Loss of sensation --Flaccid paralysis below injury -Spinal shock and neurogenic shock can occur in the same patient, but they are NOT the same disorder.
Neurogenic Shock
-Occurs within 30 minutes to patients with cord injury T6 or above. -Develops as a result of the loss of autonomic nervous system function below the level of the lesion. --Hypotension (due to massive vasodilation) --Bradycardia (due to unopposed parasympathetic simulation) --Poikilothermia (unable to regulate temperature) Skin stays warm and dry and will have a flushed appearance --The difference between hemorrhagic shock and neurogenic shock is in neurogenic shock the sympathetic nervous system is not working and the heart rate is low normal and the patient cannot move. Where as in hemorrhagic shock the pulse is rapid Patients are generally hypotensive with warm, dry skin. The loss of sympathetic tone may impair the ability to redirect blood flow from the periphery to the core circulation leading to excessive heat loss and hypothermia. Bradycardia is a characteristic finding of neurogenic shock; however, it is not universally present. These symptoms can be expected to last from one to three weeks. The anatomic level of the injury to the spinal cord impacts the likelihood and severity of neurogenic shock. Neurogenic shock may occur with incomplete or complete spinal cord injuries
Incomplete Injuries-- Central Cord Syndrome
-Results from injury to the center of the cervical area of the cord. -Patients experience weakness or paralysis in the arms and some loss of sensory reception. -The loss of strength and sensation is less in the legs than in the arms. Moves legs but not arms! --The damage affects the corticospinal tract, which is responsible for carrying signals between the brain and spinal cord to control movement
Incomplete Injuries-- Brown-Sequard Syndrome
-Results from injury to the right or left side of the cord. -On the side of the body where the injury occurred, movement and sensation are lost below the level of the injury. -On the side opposite of the injury, temperature and pain sensation are lost due to the crossing of these pathways in the spinal cord May have to wait for 24-48h or until swelling & busing is under control to really know extent of injury
Halo Vest/Traction Care
-Wash under vest daily by passing a WATER ONLY -dampened towel. Pull towel back and forth under the vest. -Do not use soaps, creams, lotions or oil-based powders. These might irritate skin -Do not shower, may use bathtub with 2-3 inches of water, make sure vest does not become wet.
ASIA Impairment Scale
A = Complete: No motor or sensory function preserved in sacral segments S4-S5 B = Incomplete: Sensory but not motor function is preserved below level, and includes sacral segments S4-S6 C = Incomplete: Motor function is preserved below neurologic level, and more than half of key muscles below the neurologic level. Muscle have a muscle grade of 3. D = Incomplete: Motor function is preserved below neurologic level; and at least half of the key of key muscles below the neurologic level have a muscle grade of 3 or greater E = Normal: Motor and sensory functions are normal.
Nursing
Airway Management -First priority -Open airway with jaw-thrust maneuver -Use bag-valve mask devise initially for airway compromise and if necessary to prepare for intubation. Detection of possible respiratory failure is detected by: -Observing patient -Measuring vital capacity -Monitoring oxygen saturation -Monitoring arterial blood gases
Neurogenic Shock Management
Airway support (#1) Fluids as needed -- dopamine( >BP & >HR) & Neo-Synephrine (>BP, not HR) Atropine for bradycardia Vasopressors (neo-synephrine) for BP support Control of environmental temperature
Autonomic Dysreflexia
An acute emergency! Is an exaggerated response to stimuli Occurs only after spinal shock has resolved The increase in ICP and blood pressure can lead to cerebral hemorrhage
Pin Care
Areas around pins should be cleansed at least 2X daily with cotton tip applicator. -Make sure you use new applicators for each pin
Nursing Interventions - GI Complications
Assess for bowel distention -May require NG tube Medications -Anti-ulcer medications --Proton-pump inhibitors, carafate, mylanta -Stool softeners -Reglan (increases muscle contractions in the upper digestive tract and speeds up the rate the stomach empties into the intestines) Bowel regimen (rehabilitory)
Type of ASIA Scale
Assess for: Sensory *and* motor assessment (move & feel) Spinal shock (priaprism) Change in neurological condition Temperature Gastric distention
Vertebral Column
Cervical: C1-C8 Thoracic: T1-T12 Lumbar: L1-L5 Sacrum: 5 vertebrae fused together Coccyx
DVT & PE Interventions
DVT prophylaxis -Compression hose -Low dose Heparin or Lovenox -ROM -Vena Cava filters Measure thighs and calves daily Coumadin for long term treatment
Respiratory Complications
Detection of possible respiratory failure is detected by: -Observing patient -Measuring vital capacity -Monitoring oxygen saturation -Monitoring arterial blood gases In spinal cord injury of C4 and higher, all the muscles which control breathing will be paralyzed, these are the intercostal muscles, the diaphragm and the abdominal muscles. -These patients will require ventilators to breathe.
Types of Spinal Cord Injury
Divided into: -*Complete*: *Total loss of sensation* and motor ability below the site of the injury -*Incomplete*: Does not result in complete *loss of movement and* *sensation below injury site* *It is possible that the classification of* *the injury may change during* *recovery* -- must consider swelling above injury
Nursing Interventions -Genitourinary Complications
During acute injury phase, the bladder is atonic so the patient is unable to void voluntarily: *Foley catheter* In and Out Catheter *Strict input and output* Assess for UTI Monitor BUN/Cr *Administer anticholinergic for* *bladder spasticity: Detrol, Ditropan*
Gastrointestinal Complications
Gastric ulcer (solu-medrol) -GI Bleeding (carafate, mylanta -- alternate bc can't be giving together) -Gastric hemorrhage Paralytic ileus Constipation Abdominal distention Fecal Impaction
Genitourinary Complications
Genitourinary problems: Atonic or spastic bladder *Loss of bladder sensation and control* *Bladder dysfunction* (retention) *UTI!!!* (septicemia) Kidney disease Sexual dysfunction
Long Term Complications: Teaching NUTRITION
High protein, vitamins, and calories Monitoring emotional well-being
Surgical Management
Indicated: -Compression of the cord -The injury results in fragmented or unstable vertebral body -The injury involves a penetration of the cord -Bony fragments are in the spinal cord -Neurological status is deteriorating Early stabilization provides better outcomes
Nursing Diagnosis
Ineffective breathing patterns Ineffective airway clearness Disturbed sensory perception Risk for impaired skin integrity Impaired urinary elimination Constipation Acute pain
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Injuries between C4 and T6 will leave the person able to breath on their own, however, the intercostal muscles may be weakened or paralyzed depending on the level of the injury. -Coughing may be a problem. (airway clearance problems)
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Injuries between T6 and T12 do not normally affect breathing, however the ability to cough will be impaired. Injuries below T12 will have normal breathing and coughing reflexes.
Other Complications
Integumentary Problems -Potential for breakdown which can result in pressure ulcers and sepsis Thermoregulation Problems -Lack of temperature regulation due to interruption of sympathetic nervous system prevents temperature sensation from reaching hypothalamus. -Inability to sweat or shiver below level of injury Sensory and perceptual alterations -Provide prism glasses to enable the patient to see from the supine position. -Encourage use of hearing aids -Provide emotional support
Nursing Interventions - Respiratory Complications
Management of pulmonary complications: Assess lung sounds Suctioning Incentive spirometer (if not ventilated) Postural drainage (pneumonia) Monitor ABG's Chest x-rays Quad cough technique Tracheostomy care if appropriate --Suctioning should be done with caution to avoid stimulating the vagus nerve and producing bradycardia and cardiac arrest
Halo/Gardner Tongs
Notify physician for: -Pins that move or shift -Any open areas around pin sites -Odorous discharge from pin sites -Redness, drainage, or pain If pin becomes dislodged keep head stabilized in neutral position and call neurosurgeon
Autonomic Dysreflexia Pathophysiology
Occurs with spinal cord lesions above the thoracic sympathetic outflow (T6 or T7). The feedback system between the sympathetic and parasympathetic branches of the ANS is disrupted. The parasympathetic response is partially disabled and the sympathetic response is dominant. Normally, baroceptors in the cerebral vessels, carotid sinus, and aorta detect the rising blood pressure and attempt to trigger visceral and peripheral vasodilatation, but these impulse are blocked by a damaged cord. The parasympathetic response is limited to vagal slowing of the heart rate and vasodilatation, flushing, and diaphoresis above the level of spinal cord injury.
Quad Cough Technique
Place hands on either side of the body, just below the ribcage. Caution: No pressure should be placed on ribs and sternum. -Ask the patient to take 3 deep breaths -On the third exhalation, the patient should attempt to cough. -When the patient attempts to cough, you do a quick, thorough and upward push at the same time. Do NOT use if: Pain Internal problems Chest injury such as broken ribs Flail Chest
Autonomic Dysreflexia -- S/S
Pounding headache Marked hypertension Diaphoresis (particularly of the forehead) Bradycardia Flushing Piloerection (bristling of hair on arms) Nausea Nasal Congestion --involuntary erection Remove stimulus -- usually bladder, sheets, hoses, etc.; should return to normal within ~10 min
Spinal Cord Injury
Primarily males (50%) ages 16-30 years of age. Causes: -Motor vehicle accidents (48%) -Falls (23%) -Violence (14%) -Sports (9%)
Orthostatic Hypotension Interventions
Quickly return the patient to a supine position. Administer oxygen Atropine to increase heart rate TED stockings to promote venous return from the extremities.
Motor and Sensory Function (cont)
Sensation is evaluated by gently pinching the skin or touching it lightly with an object such as a tongue blade. -Start at shoulder level and work down both sides of the extremities. -*Have the patient close their eyes* while you do this examination so you get an accurate assessment and not what the patient hopes or wants to feel. Any decrease in function is reported immediately
Nursing Interventions
Skin integrity -Keep skin free of irritants and pressure --Pressure ulcers can occur within 6 hours -Specialty beds Environmental control for temperature
Spinal Shock vs Neurogenic Shock
Spinal Shock: -*Due to acute spinal cord injury* -Absence of all voluntary and reflex neurologic activity below level of injury -Transient -*Lasts days to months* Neurogenic Shock: -*Hemodynamic phenomenon* with spinal cord injuries -Critical features --Hypotension --Bradycardia --Lack of temperature regulation. -*Occurs within 30 min and can last* *up to 6 weeks*
Long Term Complications: Teaching
Teach care giver: -Signs & Symptoms --Autonomic Dysreflexia ---Constipation ---Urinary retention --DVT & PE --UTI -Monitoring patient for skin breakdown -ROM to decrease contractures -Bowel and bladder regimen -Should be performed at regular time intervals --Massage is contraindicated if there is spasticity of the anal sphincter. The sphinter is massaged by inserting a gloved hand 1 to 1.5 inches into the rectum and moving in a circular motion from side to side Bowel regimen should be done usually every 48 hours, after a meal and at a convient time.
DVT & PE Complication
The incidence of DVT is extremely high in SCI due to loss of the skeletal muscle pump Major cause of morbidity and mortality
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The peripheral nervous system takes up where the central nervous system leaves off. Information from the spinal tracts and the brain are transmitted though the spinal nerves to the end organs Information from the organs and tissues are transmitted through the spinal nerves to the spinal cord and brain for processing. There are thirty one pairs of spinal nerves which extend from the spinal cord, each having a sensory(dorsal root) and a motor(ventral) root. The spinal nerves again extend from the spinal foramen of each vertebra to the peripheral skin tissues and organs. Each spinal nerve supplies sensory information to a certain amount of area; these areas
Spinal Cord
The spinal cord is *very delicate*, immediate response to touch is to swell. This is why with injuries such as dislocations where the cord is stretched caused swelling despite the fact that no boney fracture has occurred. *Requires oxygen and sugar to* *function* (must have both!) -Perfusion is critical to function -Requires 90-100% saturation in the presence of injury (keep from deteriorating) -Hypoxia and hypotension are very damaging --For the cord to function, oxygen, sugar and waste removal has to be present. Adequate amounts require adequate perfusion. A systolic pressure of at leas 90mmHg in the presence of injury is required to maintain perfusion to the cord. It depends on the systolic pressure and how long it is low as to how long it takes for ischemia/hypoxia injury to the cord to occur. --However, when the cord is damaged, secondary injury such as ischemia , hypoxia, hypotension, hypoglycemia will extend or make permanent any damage that is present.
Causes of Cord Injury
Transient concussion Contusion/brussing Laceration Compression Transection (never gain function again) Concussion: Transient spinal cord dysfunction caused by mechanical injury Contusion: Bruising that includes bleeding and subsequent edema, and possible necrosis from edematous compression. The neurological involvement depends on the severity of the contusion and necrosis.
Spinal Cord Injury
Two categories: -*Primary injury* (nothing we can do about this) Result of initial insult or trauma and are usually permanent -*Secondary injury* (This is RN's concern) Usually the result of swelling and disintegration of nerve fibers producing ischemia, hypoxia, edema, hemorrhage which causes destruction of myelin and axons. --Destruction of myelin and axons occurs, believed to be reversible 4-6 hours after the injury with the use of high dose corticosteroid therapy
Motor and Sensory Function Assessment
Use of *ASIA (American Spinal Cord* *Association*) classification is commonly used to record baseline neurological status and changes. -Motor ability is tested by asking patient to spread fingers, squeeze your hand, move the toes and turn the feet.
Halo Vest/Traction
Used post surgery to immobilize the head and neck. Consists of three parts: -The vest -Ring or halo -Rods Must be worn at all times and patient can go home with halo traction in place The halo vest is usually worn next to the skin and is lined with wool or acrylic matter. -May slide a cotton t-shirt under vest Skin should be checked daily; a flashlight may be used for this. Check for: -Redness -Blistered areas -Pressure sores
Long Term Care and Complications
Usually patients are encouraged to attend a spinal clinic Patients are prone to UTI -Assessment of urinary tract at prescribed intervals -Intermittent catheterization may be indicated Heterotropic ossification: overgrowth of bones in hips, knees, shoulders and elbows Contractures