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

2. 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

3. 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).

4. Mechanisms of Injury

5. 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.

6. 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

8. 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

12. Clinical Manifestations: SCI

13. 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

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

16. 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

17. 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

18. Emergency Management: SCI

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

20. 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

21. 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

22. 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.

23. 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

24. 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

25. 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.

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

27. 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.

28. 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

29. 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

30. 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

31. 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

32. 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.

33. 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

34. 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

35. 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

37. 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