week 11- SCI

Question 1

SCI in canada

Answer 1

• classified as traumatic or non traumatic (disease, infection, cancer)
• 4500 SCI anually (>1700 traumatic)
• prevalence inc w age, injuries more common in cervical spine
• most common cause of death post SCI is tetraplegia (paralysis of limbs and trunk), leads to changes in resp/renal fn and inc risk of pressure injuries (risk of aspiration, resp distress, pneumonia)
• SCI is a significant life event impacting family dynamic, ability to work, economic changes and reliance on care from others

Question 2

SCI etiology

Answer 2

• most often caused by motor vehicle/motorcyle collisions (50%), and falls/work-related incidents (30-40%)
• etiology considered biphasic (initial and secondary injury)
• initial SC injury is often a mechanical injury that places force onto SC and disrupts axons, BV and cell membranes

Question 3

secondary injury

Answer 3

• vascular dysfn, edema, ischemia, electrolyte shifts, free radicals and apoptotic cell death occur
• petechial hemorrhage results w/in SC, alters blood flow
• ischemia results above and below level of injury, permanent SC damage can occur w/in 24h
• leads to hypoxia, inc lactate and vasoactive metabolites
• inc vasospasm and hypoxia, leading to tissue necrosis
• prognosis is best made at 72h post-injury bc of slow progression

Question 4

spinal shock

Answer 4

• approx 50% of people w SCI have transient spinal shock
• dec reflexes, loss of sensation, flaccid paralysis below the level of injury
• can last for days to months
• can mask post-injury function
• appropriate to start rehab during this period

Question 5

neurogenic shock

Answer 5

• SCI at the 5th veterbra or above
• massive vasodilation and no compensation from the loss of SNSs ability to vasoconstrict
• causes significant hypotension, bradycardia and peripheral vasodilation/venous pooling
• leads to dec CO and inc risk of DVT

Question 6

classifying SCI

Answer 6

mechanism of injury, level of injury and degree of injury

Question 7

mechanism of injury

Answer 7

• flexion, hyperextension, flexion-rotation, extension-rotation and compression
• flexion-rotation is a very unstable injury
• ligaments that support the spine are torn

Question 8

level of injury

Answer 8

-** skeletal level:** vertebral level where damage to the bones and ligaments is most extensive
- neurological level: lowest level of SC, where sensory and motor fn is intact bilaterally
- cervical and lumbar levels are more common as there’s more movement in these areas

Question 9

degree of injury

Answer 9

• classified as complete or incomplete
• complete: total loss of motor and sensory function below the level of injury
• incomplete: mixed loss of sensory and motor function below the level of injury
• symptoms varied based on the level of injury and what nerve tracts are implicated
• six spinal syndromes associated w incomplete injuries

Question 10

ASIA scale

Answer 10

• gold standard assessment scale that classifies the severity of SC injury
• uses both motor and sensory fn
• degree of injury is decided based on ASIA grading
• useful to see if there are changes in neurologic status
• used to indentify goals for rehab

Question 11

testing dermatomes

Answer 11

• test both sides of the body for sensory touch, light touch and pin prick (all 28 dermatomes on each side)
• scored as 0-absent, 1-impaired, 2-normal

Question 12

central cord syndrome

Answer 12

• most often from cervical cord and hyperextension injuries
• motor weakness and sensory loss in UE & LE
• most common syndrome

Question 13

anterior cord syndrome

Answer 13

• compression of the anterior portion of SC causes damage to the anterior spinal artery
• often from flexion injuries
• motor paralysis, loss of pain and temp sensation below the level of injury
• touch, position, vibration and motion senses remain intact

Question 14

brown-sequard syndrome

Answer 14

• injury to half of the spinal cord
• loss of motor fn (spastic paralysis), sense of position (proprioception) and sense of vibration on same side as injury
• opposite side has loss of paina and temp sensation

Question 15

posterior cord syndrome

Answer 15

• compression to posterior spinal artery (rare)
• loss of proprioception below the level of injury
• pain, temp, sensation and motor fn intact below the level of injury

Question 16

conus medullaris and cauda equina

Answer 16

• damage to lowest part of SC (conus) and the lumbar and sacral nerve roots (cauda equina)
• often cause motor and sensory impairment (especially conus), and impaired bladder and bowel function (both)

Question 17

SCI- clinical manifestations

Answer 17

• higher the injury = more serious consequences
• immediate care is always to support ABCs and to minimize extent of secondary injury

Question 18

interprofessional care for SCI

Answer 18

a) assess for concurrent TBI: loss of consciousness?
b) assess for concurrent internal organ trauma: bp, hgb (bleeding?), urine output, hematuria
c) assume spine is not clear: use logroll, need at least 3 people

Question 19

diagnostic imaging for SCI

Answer 19

• canadian c-spine rules for alert and stable trauma pts, used by most EDs and by EMS
  a) x-ray: assess for fracture
  b) MRI: better view of neuro tissue and soft tissue injury
  c) CT: degree of bony injury and spinal canal
  d) vertebral angiography: if concerned about arterial injury

Question 20

non-operative spinal stabilization

Answer 20

• minimize movement, stabilize and realign spine, prev secondary injury
• c-spine traction used in pts who can clearly and accurately communicate, reduce and realign injury
• halo traction for c-spine
• thoracic and lumbar spine uses a braces which controls flexion, extension and rotation

Question 21

halo traction

Answer 21

• uses 4 pins in skull w weights to support realignment
• initially traction w rope and pulley from centre of crown
• once realignment occurs, a vest is applied to dec c-spine movement and allow pt to ambulate

Question 22

operative spinal stabilization

Answer 22

• based on availability of experts
• includes internal fixation and/or fusion of vertebrae
• used w evidence of cord compression, progressive neurologic deficits, compound fractures of the vertebra, bony fragments, penetrating wounds to SC or stabilization cannot be done non-operatively

Question 23

SCI- resp signs and symptoms

Answer 23

• symptoms correlate w level of injury
• above C4 results in diaphragm paralysis, mech ventilation is needed (inc risk of pneumonia, body image changes)
• cervical and thoracic injuries cause paralysis of abd and intercostal muscles
• shallow/rapid breathing, dec cough reflex, inad lung expansion
• can result in neurogenic pulmonary edema (inc alveolar fluid from changes in SNS leading to pulm congestion/dec gas exchange)

Question 24

SCI- resp interventions

Answer 24

• w/in 48h of injury, SC edema can result and worsen SC function (inc resp distress)
• intubation indicated if patient tired, injury above or at C4 or ABG worsens
• pts at risk for pneumonia and atelectasis, pooling secretions and poor cough
• worsens w age, previous or co-morbid resp conditions, tachypnea at admission

Question 25

SCI- resp nursing assessment

Answer 25

- assess rate, depth, effort, symmetry, perfusion, cough reflex - pt can participate in chest physio (ie. cough assist machine, cupping of hand and banging on chest)

Question 26

SCI- cardio signs and symptoms

Answer 26

- any injury abve T6 will dec influence of SNS - results in neurogenic shock (brady, peripheral vasodilation, hypotension/relative hypovolemia, inc risk of VTE) - vagus nerve is unopposed leading to bradycardia and inc vagal tone (cardiac arrest)

Question 27

SCI- cardio interventions

Answer 27

- hypotension is treated w pressors (NE/dopamine) to support MAP <85 - compression socks to help w venous return and prevent DVT, SCDs - LMWH (heparin, enoxaparin) for VTE prophylaxis - ROM and stretching useful for circulation, spine clearance essential

Question 28

SCI- urinary signs and symptoms

Answer 28

- urinary retention, bladder becomes atonic and easily distended w spinal shock (foley) - distension causes reflux to kidneys, renal failure, bladder perf - after acute injury, bladder becomes irritable and reflex emptying can occur - once pt stabilizes, remove foley and use intermittent cath to support bladder tone and dec UTI risk - monitor I&O

Question 29

intermittent cath schedule

Answer 29

Q3h if >500mL, Q4h if 300-500 mL, Q6h if <300mL

Question 30

SCI- GI signs and symptoms

Answer 30

- if injury above T5, hypomotility and paralytic ileus can result - leads to abdo distension and rqrs NG tube for intermittent suction - stress ulcers result from inc HCl in stomach, peaks 6d post-injury and rqrs PPI or H2 receptor antagonists - neurogenic bowel can occur, areflexic bowel w no sphincter tone - common w spinal shock and always occurs w injury at or below T12 - as reflexes return, sphincter tone inc and reflexic emptying may occur - diff to assess for abdo pain, look for blood in stool/abdo girth

Question 31

SCI- integ signs and symptoms

Answer 31

- high risk for skin bd, especially in areas of low or no sensation/motor fn (ie. back, shoulder blades, heel, coccyx, elbows, hip bones, trach, behind ears) - interventions incl comprehensive visual and tactile assessment - check for blanching, temp, moisture, reposition every 2h, prophylactic dressings

Question 32

alterations in thermoregulation

Answer 32

- interruptions in SNS innervation prevent peripheral temp sensations to be transmitted to CNS - inability to alter body temp, often remains at room temp (lower than 36.5) - loss of ability to sweat or shiver below the level of injury - higher the injury, less ability to thermoregulate - if a fever develops, external cooling is needed

Question 33

fluid and nutrition needs

Answer 33

- can begin oral or parenteral feedign after BM or flatus have resumed - require high protein, high fibre, high calorie diet - calorie counting important, integrate pt as able - important to assess swallow reflex, consult SLP - anorexia often seen post-SCI, focus on goal-setting and give pt control as appropriate

Question 34

reflexes

Answer 34

- as reflexes return, they may be exaggerated - mild twitches to convulsion-like spasms below the level of injury, **not a return of fn** - useful for bladder, bowel and sexual retraining - often controlled w antispasmodics and or botox

Question 35

autonomic dysreflexia

Answer 35

- occurs when injury is T6 or higher after spinal shock subsides - massive, unopposed CV reaction that occurs from visceral stimulation - if not resolved, can lead to status epilepticus, MI, stroke or death - most comonly caused by rectal/bladder distension, pain

Question 36

autonomic dysreflexia- signs and symptoms

Answer 36

- HT (SBP >300), headache, diaphoresis and flushing above injury, bradycardia (30-40), blurry vision, anxiety, nausea and nasal congestion - caused by arteriolar vasoconstriction below injury, baroreceptors sense HT and stimulate PSNS causing brady but efferent impulses cannot go past the SCI

Question 37

autonomic dysreflexia- interventions

Answer 37

- check bp asap - elevate HOB 45 degrees - check for kinks in catheter, flush w small volume slowly - if no catheter, place one using lidocaine jelly - if stool, digital rectal exam w anesthetic ointment - remove any skin stimuli - if HT continues, give alpha antagonist or arteriolar vasodilator (nifedipine) - important pt and family teaching prior to discharge