Chapter 63 Management of Patients With Neurologic Trauma Spinal Cord Injury Dr. Maha Subih

Spinal Cord Injury (SCI) A major health problem Persons live with disability from SCI Risk factors: Young Caucasian adult, ages 16–30 account for more than half of all new SCIs male gender alcohol and drug use. Motor vehicle crashes falls violence (gun shot wounds) recreational sporting activities

A victim with a spinal injury has an increased risk of permanent neurologic damage, Paraplegia (paralysis of the lower body) and tetraplegia (formerly quadriplegia—paralysis of all four extremities).

Mechanisms of Injury

Pathophysiology Damage in SCI ranges from transient concussion (from which the patient fully recovers), to contusion, laceration, and compression of the SC substance, to complete transection of the spinal cord. The vertebrae most frequently involved are (C5 to C7), (T12), and (L1), because there is a greater range of mobility in the vertebral column in these areas . SCIs two categories: primary injuries and secondary injuries.

Pathophysiology Primary injuries are the result of the initial trauma and are permanent. Secondary injuries are the result of a contusion or tear injury, in which the it damage nerve. produces ischemia, hypoxia, edema, and hemorrhagic lesions. it is reversible during the first 4 to 6 hours after injury. Early treatment to prevent partial damage from becoming total and permanent

Clinical Manifestations: SCI depend on the type and level of injury (Chart 63-7) Incomplete spinal cord lesions (sensory or motor fibers, or both, are preserved below the lesion) are classified according to the area of SC damage: Central, lateral, anterior, or peripheral. (Chart 63-8). “Neurologic level” :the lowest level at which sensory and motor functions are normal. Below it, total sensory and motor paralysis, loss of bladder and bowel control, loss of sweating and vasomotor tone, and reduction of BP

Clinical Manifestations: SCI

Clinical Manifestations: SCI A complete spinal cord lesion (total loss of sensation and voluntary muscle control below the lesion) paraplegia or tetraplegia. If conscious, the patient may complains of acute pain in back or neck, radiate along the involved nerve. Respiratory dysfunction injury: T1 - T11 and C4. Above C4: acute respiratory failure may cause death. Table 63-3

Dx tests neurologic examination is performed. x-rays (lateral cervical spine x-rays) CT scan MRI Myelogram

Emergency Management: SCI Initial care must include a rapid assessment, immobilization, and stabilization or control of life-threatening injuries, and transportation to the most appropriate medical facility. the patient immobilized on aback board, with the head and neck maintained in a neutral position, to prevent an incomplete injury from becoming complete. One of the team must control patient’s head by placing hands on both sides of the patient’s head at about ear level while a spinal board or cervical immobilizing device is applied

Emergency Management: SCI Once the extent of the injury has been determined, the patient may be placed on a rotating specialty bed or in a cervical collar. If a specialty bed is not available, the patient should be placed in a cervical collar and on a firm mattress. if SCI have been ruled out, the patient may be moved to a conventional bed or the collar may be removed

Emergency Management: SCI

Medical Management (Acute Phase): SCI The goals: to prevent secondary injury to observe symptoms of progressive neurologic deficits to prevent complications.

Medical Management (Acute Phase): SCI Resuscitation and oxygenation and maintain cardiovascular stability Pharmacologic Therapy high-dose IV corticosteroids in the first 24 or 48 hours Respiratory Therapy Oxygen to maintain a high PaO2, because hypoxemia worsen neurologic deficit If ETT is necessary, extreme care to avoid flexing or extending the neck In high cervical spine injuries, diaphragmatic pacing to stimulate the diaphragm to help the patient breathe

Medical Management (Acute Phase): SCI Skeletal Fracture Reduction and Traction immobilization and reduction of dislocations and stabilization of the vertebral column. The cervical spine is aligned with skeletal traction (tongs or calipers, or halo device

Skeletal Fracture Reduction and Traction Traction is applied to the skeletal traction device by weights, the amount depending on the size of the patient and the degree of fracture displacement. The traction is then gradually increased by adding more weights. As the amount of traction is increased, vertebrae are given a chance to slip back into position. The weights should hang freely so as not to interfere with the traction.

Surgical Management: SCI Surgery is indicated in any of the following situations: • Compression of the cord is evident. • The injury results in a fragmented or unstable vertebral body. • The injury involves a wound that penetrates the cord. • Bony fragments are in the spinal canal. • The patient’s neurologic status is deteriorating. The goal of surgical treatment are to preserve neurologic function by removing pressure from the SC and to provide stability

Complications/Spinal and Neurogenic Shock Spinal shock A sudden depression of reflex activity below the level of spinal injury(a reflexia) Muscular flaccidity, paralyzed, lack of sensation Neurogenic shock Due to loss of function of the ANS BP, heart rate, and CO decrease Venous pooling due to peripheral vasodilation

Complications With injuries to the cervical and upper thoracic spinal cord, innervation to the major accessory muscles of respiration is lost and respiratory problems develop. decreased vital capacity, retention of secretions, increased (PaCO2) levels and decreased oxygen levels, respiratory failure, and pulmonary edema.

Complication of SCI Deep Vein Thrombosis related to immobility risk for PE Low-dose anticoagulation therapy is initiated Antiembolism stockings Permanent indwelling filters

Autonomic Dysreflexia Acute emergency! Occurs after spinal shock has resolved and may occur years after the injury. Occurs in persons with a SC lesion above T6. ANS responses are exaggerated. Symptoms: severe pounding headache, sudden increase in BP, diaphoresis, nausea, nasal congestion and bradycardia.

Nursing Diagnosis Ineffective breathing pattern Ineffective airway clearance Impaired physical mobility Disturbed sensory perception Risk for impaired skin integrity Impaired urinary elimination Constipation Acute pain

Nursing Interventions Promoting Adequate Breathing and Airway Clearance Monitor carefully to detect potential respiratory failure Pulse oximetry, ABGs and Lung sounds Early and strong pulmonary care to prevent and remove secretions Suctioning with caution???? stimulating the vagus nerve and producing bradycardia and cardiac arrest Breathing and coughing exercises Humidification and hydration

Nursing Interventions Improving Mobility Maintain proper body alignment Turn only if spine is stable and as indicated by physician Monitor BP with position changes (Patients with lesions above the midthoracic level have loss of sympathetic control of peripheral vasoconstrictor activity, leading to hypotension). Passive ROM at least four times a day to prevent contractures Use neck collar, as prescribed, when patient is mobilized Move gradually to erect position

Promoting Adaptation to Sensory and perceptual alteration Nursing Interventions Promoting Adaptation to Sensory and perceptual alteration Assist to compensate for sensory and perceptual alterations Stimulate intact senses above the level of the injury by touch, aromas, flavorful food and music. Provide prism glasses to see from supine position use of hearing aids Provide emotional support and teaching

Nursing Interventions Maintaining Skin Integrity Pressure ulcers are a significant complication of SCI may begin within hours of an acute SCI patients who wear cervical collars for prolonged periods may develop breakdown from the pressure of the collar under the chin, on the shoulders, and at the occiput. Turning and position is changed at least every 2 hours. skin should be kept clean and dry.

Nursing Interventions Maintaining Urinary Elimination(neurogenic bladder) The urinary bladder becomes a tonic and cannot contract by reflex activity. Urinary retention due to loss of sensation of bladder distention and overstretching of the bladder Intermittent catheterization record fluid intake, voiding pattern, amounts of residual urine after catheterization, characteristics of urine, and any unusual sensations

Nursing Interventions Improving Bowel Function a paralytic ileus usually develops NGT to relieve distention and to prevent vomiting and aspiration. Bowel activity usually returns within the first week. After BS return give a high-calorie, high-protein, high-fiber diet, with the amount of food gradually increased. stool softeners

Nursing Interventions Providing Comfort Measures: Halo Traction + pins, tongs for cervical stabilization Appearance of these devices and being caged in noise created by the steel frame of a halo device clean areas around the pin sites and observe for redness, drainage, pain and loosening The skin under the halo vest is inspected

Nursing Interventions Monitoring and Managing Potential Complications Thrombophlebitis. Orthostatic hypotension Close monitoring of vital signs before and during position changes Vasopressor medication Anti-embolism stockings Abdominal binders Autonomic dysreflexia