1. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 37: Spinal Cord Injury

2. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Incidence and Causes Incidence –11,000 new cases a year –Estimated 225,000 to 296,000 patients with cord injuries today Age – 16 to 30 (82% male) Cause –Motor vehicle accidents –Violence –Falls –Sports

3. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Classifications of Spinal Cord Injuries Mechanism of injury Types of vertebral fracture/dislocation Level of injury Type of transection

4. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Mechanism of Injury Hyperflexion – chin on chest injury Hyperextension – “whiplash” (most common injury) Axial loading – lands on feet or head; compression of cord Rotational injuries – twisting of cord (Refer to Figure 37-1.)

5. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Types of Vertebral Fractures/Dislocations Simple Compressed Wedge compression Teardrop Comminuted (Refer to Box 37-1.)

6. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Level of Cord Injury High cervical (C1-C2) Lower cervical (C3-C8) C1 through T1 called tetraplegic Thoracic (T1-T12) T2 through L1 called paraplegic Lumbar (L1-L5) Sacral (S1-S5) (Refer to Figure 37-2.)

7. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question In a patient with a head injury, spinal precautions must be taken until an x-ray of the head/neck is done. A. True B. False

8. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer A. True Rationale: Many injuries of the head involve traumatic injury to the cord, and many cord injuries involve head injuries as well. Until x-rays of the cervical spine are done, the head, neck, and body must be turned as a single unit.

9. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Spinal Cord Syndromes Central cord syndrome –The cord is damaged centrally –Mechanism of injury is usually hyperextension –Damage is seen in the upper arms but the legs and bladder function are preserved Anterior cord syndrome –The cord is damaged anteriorly –Complete motor paralysis below the level of injury –Light touch, sensation, and sense in space (proprioception) are preserved

10. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Types of Transection A partial transection of the cord can become a complete transection if spinal precautions are not maintained after the injury! Complete transection –Total loss of muscle control and sensation below the level of the injury Partial transection –Retain all or some motor and sensory capacities

11. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Spinal Cord Syndromes Brown-Séquard syndrome –One side of the cord is injured –Mixed motor/sensory symptoms

12. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Autonomic Nervous System Syndromes SPINAL SHOCK Immediate - blocked impulses from brain NEUROGENIC SHOCK Distributive shock High cervical and thoracic injuries Loss of sympathetic input ORTHOSTATIC HYPOTENSION Unable to compensate for changes in position HR, SVR, preload, BP, body temp all go down Hypotension, severe bradycardia; loss of ability to sweat below the lesion Drop in BP Lasts for days/months Return of perianal reflex signals the end Transient

13. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Pathophysiology Cord is located at the level of L1 to brain Primary injury –Cervical spine is most mobile and therefore more prone to injury –The impact area Secondary injury –Continues hours after the trauma

14. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question In a patient with a traumatic axial loading injury, which of the following would NOT result from a secondary injury to the cord? A. Free radicals are released that alter the sodium- potassium pump mechanisms. B. Edema leads to a higher level of cord injury. C. Vasoactive substances increase permeability, allowing calcium to enter the spinal cord cells. D. Vertebrae compress the cord.

15. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer D. Vertebrae compress the cord. Rationale: The initial injury of axial loading compresses the cord between the bony vertebra, causing primary injury. All of the other choices are a cause of secondary injury.

16. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Initial Assessment of Spinal Cord Injuries Prehospital –Mechanism of injury –Airway, breathing, circulation (ABCs) –Spinal precautions instituted and maintained –Patient usually reports numbness, tingling, or loss of sensation –Check for other related injuries and quick transport In-hospital emergency assessment –Airway and breathing –High-dose steroids (still controversial) –Physical assessment

17. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Patient Assessment: Body Systems Review Pulmonary –Watch for respiratory function decrease (C1-C5) –Pulse oximetry (continuous) –Respiration rate and pattern –Pulmonary function tests –Other chest injuries –Pre-existing injuries (worsen the prognosis) –Pulmonary edema (too much fluid volume, too fast)

18. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Patient Assessment: Body Systems Review (cont.) Cardiovascular –Cardiac monitor –Serial BP readings –Monitor for shock syndromes –Foley catheter with hourly outputs –Intake and output Neurological –Level of responsiveness (LOR) –Glasgow Coma Scale (GCS) –Digital rectal exam (DRE) Bladder –Incontinence –Indwelling catheter

19. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question In a patient who has just been admitted with a high cervical fracture, the physician wants to perform a digital rectal examination (DRE). This test will indicate: A. Whether the patient is at risk for autonomic dysreflexia B. What sexual function will return C. If the cord has a complete or incomplete transection D. If the patient’s bowels are empty

20. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer C. If the cord has a complete or incomplete transection Rationale: If the patient can feel pressure when examined, there is a partial cord transection. Although it is important to prevent bowel impaction, autonomic dysreflexia doesn’t occur until after the initial phase of injury. The other answers are irrelevant at this time.

21. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Diagnostic Studies X-ray of the cervical spine first, then others to determine other injuries CT of bony structures MRI of soft tissue injuries Somatosensory evoked potentials

22. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Ongoing Nursing Assessment and Management Spinal stabilization –Medical management Traction (Gardner-Wells, Crutchfield tongs) Vests & braces (halo vest, Jewett brace) –Surgical management Removal of foreign objects from trauma Laminectomy Problems with postop infections

23. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Ongoing Respiratory Assessment and Management Respiratory problems are the leading cause of death, so prevention is key. Prevention of atelectasis Trends in pulmonary function tests Coughing and deep breathing (quad cough) Turning (usually at least 3 nurses to maintain spinal alignment) Suctioning Prone positioning

24. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question A patient with a spinal cord injury is being suctioned through a freshly inserted tracheostomy. During the procedure, the patient’s pulse rate falls from 98 to 52. The nurse stops the procedure and bags the patient with 100% oxygen. What is the most likely reason why the pulse rate fell? A. The patient is hypoxic. B. The patient no longer needs suctioning. C. The patient has had a vasovagal response to suctioning. D. The patient is going into hypovolemic shock.

25. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer C. The patient has had a vasovagal response to suctioning. Rationale: A bradycardia that occurs during suctioning is a result of the parasympathetic stimulation overriding the sympathetic due to high blockage of the cervical spine. Hypoxia, shock, and the need for suctioning usually are evidenced by a tachycardia.

26. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Ongoing Nursing Assessment and Management Cardiovascular stability Role of the pulmonary artery catheter Prevention of DVT, PE Cardiac enzymes/MI monitoring Vasopressors if decreased BP Atropine/pacer if HR falls Neurological management Neuro checks q1h Motor/sensory checks Medication administration Avoid SQ/IM Central line management Pain management