1. SPINAL CORD INJURY

2. Spinal Cord Injury Approx 12 thousand new injuries per year
81% of SCI are males
60% of SCI between yrs old
4,800 SCI die prior to reaching the hospital
6,000 die in MVA d/t cervical fractures
1/3 are due to no seatbelt use and ejection from car

3. Annual cost $2.4 billion per year
1st Year $417,067
After $74,707
Usually die within first year
After that about a normal life expectancy
MVA- 48%
Falls- 27%
Violence - 15%
Sports- 7%
Other 8%

4. Spinal Cord Injury
Trauma to the spinal cord of sufficient force to dislocate or fracture the vertebrae and produce damage to the spinal cord resulting in loss of sensory and motor function

5. Types of injuries Compression fracture- Squashed Burst fracture
Vertebral dislocation
Fracture

6. Cord Lesions
Total Transection- complete severing of the cord with loss of movement and sensation below the level of the injury
Incomplete lesion-partial severing of the cord with loss of either motor or sensory function below the level of the injury. This varies but usually both are not loss

7. INCOMPLETE LESIONS
Anterior Cord- Due to hyperflexion injuries associated with fracture-dislocation of a vertebrae. Loss of pain, temperature and motor function. Light touch, position and vibration sensations intact.
Central Cord- Injury or edema of the central cord in the cervical area. Hyperextension injury. More motor loss in the upper extremities than the lower. Sensory varies. Variable bowel and bladder

8. Posterior cord- Hyperextension (not common) Injury to the posterior spine therefore loss of proprioception but no loss of pain, sensation, temperature or motor function.
Brown-Se’quard Syndrome- transection of a portion of the spinal cord but not complete (GSW, Stab, fracture). Ipsilateral paralysis along with loss of touch, pressure, vibration.

9. Assessment At or above C4=Loss of respiratory control
At or above C5=Quadriplegia
Between T1-T11=Paraplegia/Loss of bowel and bladder control

11. Spinal Shock
Results in the portion of the cord that is severed, resulting in complete loss of motor, sensory, reflex and autonomic function below the level of the injury.
Flaccid paralysis
Loss of all spinal reflexes
Loss of all sensations
Loss of ability to perspire
Bowel and bladder dysfunction

12. Usually lasts for 1-6 weeks after injury but may last longer
The earliest indication of end of spinal shock is the anal reflex
After Spinal shock, amount of functional recovery can be determined

13. Neurogenic Shock
Results from damage to the neurons that control the blood vessels in the lower abdomen and legs. Temporary disruption of the autonomic nervous system resulting in cardiovascular changes ?

14. Management of clients with SCI
Every Trauma client has a spinal Cord injury until proven otherwise
Immobilize
Collar, Manual, Spinal Board
Move as a unit
Cervical Tongs- Immobilization via weights and pulley
Halo Traction-skull screws, vest and supporting rods
Thoracic and Lumbar stabilization
Fiberglass/plastic body jacket
Canvass corset

15. Nursing Care Maintain alignment Pin Care
Prevent complications of immobility
Kinetic Bed
Stryker Frame
Halo Traction
Allows for the immobilization of the cervical spine with correct alignment on a long term basis
Able to mobilize earlier to prevent complications

16. Halo Traction Care Move client as a unit-NEVER pull by bars Pin Care
No Pillow
Check edged of vest for roughness
Check skin around vest for breakdown
Wash skin under jacket daily
Allow inner lining to dry completely
Do not use powder under jacket

17. Steroid Therapy Used if injury is less than 8 hours old
Lesion is above L2
Possible contraindicated
Pregnancy
< 13 years
Penetrating wounds
TB/Infections
HIV
Diabetes

18. High Dose methylprednisolone
Has resulted in recovery of neurological function. Decreases/prevents edema
Bolus 30 mg/kg of body weight administered over 15 min. Wait 45 minutes then begin drip of 5.4 mg/kg/hr over the next 23 hours

19. Multisystem effects of SCI
Respiratory System
Respiratory dysfunction related to the level of injury
Compromising the diaphragm major factor in respiratory involvement
Above C5, Diaphragm involvement
C5-T6, diaphragm spared but intercostals are involved
Immobilization

20. Cardiovascular System
Vasodilation below the level of injury results in lowered BP
Orthostatic Hypotension
Bradycardia
Vagal stimulation sensitive
Treat with anticholinergics
Dysrhythmias ?
DVT
Immobility
Hypotension/bradycardia

21. Gastrointestinal System
Gastric Dilation and paralytic ileus
Loss of bowel function
Constipation
Suppository QOD
Stool Softeners
Hi PRO, Hi Cal, Hi Bulk, Hi CHO Diet
Gastric Ulcers
Common 6-14 days after injury
Stress/ Trauma/High Dose Steroids

22. GU System Major involvement Atonic Bladder causes urinary retention?
Dysreflexia
Foley catheter ASAP progressing to intermittent catheterizations

23. Integumentary system Pressure ulcers and breakdown
Once developed difficult to heal
Special beds and appliances

24. Autonomic Dysreflexia
A generalized body reflex response to a local stimuli. There is an intact reflex arch that doesn’t communicate with the brain.
Caused by a local stimulation
Distended bladder
Fecal impaction
Decubitus Ulcer
Skin irritation
Pain

25. Clinical Manifestations
Hypertensive Crisis
Bradycardia
Severe headache
Piloerection below the level of injury
Sweating above the level of injury
Blurred vision
nasal stuffiness
Convulsions

26. Life Threatening Medical Emergency
Sit the Client up 45 degrees (decrease BP)
Notify MD
Remove stimulant
Catheterize
Check for impaction
Remove shoes, covers etc
Administer Antihypertensives

28. Spasticity State of excessive muscular tonus
Increases gradually over 1-2 years then begins to decrease
Arms are flexed and pronated, legs are extended and adducted
Not a return of function

29. Management Control of aggravating factors Physical Therapy
Cold
Anxiety
Fatigue
Emotional Distress
Infections
Impactions
Physical Therapy
ROM
Antispasmodics
Baclofen
Dantrolene
Possible Cordotomy

30. Sexual Dysfunction
LMN Incomplete lesions- 83% Psychogenic erections and 90% able to have coitus. No ejaculation or orgasm.
Females- Lack sensation during intercourse. Can become pregnant. Early C section to prevent dysreflexia
Males with UMN Lesions (Rectal Sphincter) 70-80% can consummate coitus. Most cannot ejaculate or have orgasm
LMN complete Lesions 25% can have psychogenic erections. No coitus, ejaculation or orgasm

31. Emotional Support Goes through the grief process
Allow them to express feelings
Encourage a positive attitude by recognizing
Use crisis interventions to mobilize coping mechanisms
Assist with families emotional needs
Treat Family and client as a unit
Counseling and spiritual support
Include client in decision making
Do not avoid the sexual counseling

32. Rehabilitation Begin as soon as stable in the hospital
Encourage independence for self care needs
Use of braces, wheelchairs and other assistance devices
Long Term Physical Therapy, Vocational rehab
Continued Counseling
Community Resources
Social Services
Home Care
Support Groups