Fill in: average time in ICU following injury has declined by 50%. Days in rehab unit have gone from 98 days to __a__ days.
37 days
List top 4 causes of SCI in order
1. Vehicular (36%)
2. Falls (28%)
3. Violence (14%)
4. Sports (9%)
List the 4 mechanisms of SCI classifications
Which one is the most unstable and why?
1. Flexion
2. Hyperextension
3. flexion-rotation
4. compression
*Flexion-rotation injury is the most unstable because the ligamentous structures that stabilize the spine are torn.
- It is most often implicated in severe neurologic deficits.
Fill in: The level of injury may be cervical, thoracic, lumbar, or sacral.
If the __a__ cord is involved, paralysis of all four extremities occurs.
If the __b__ spinal cords are damaged, the result is paraplegia.
a. cervical (C1-C8)
b. thoracic, lumbar, or sacral (T1-L4)
Define complete and incomplete degree of injury
Complete: total loss of sensory and motor fxn below the level of injury
Incomplete: results in a mixed loss of voluntary motor and sensation, leaving some tracts intact.
Patho Map of Hemorrhage: Starting with RBC and platelet aggregation, state what occurs that leads to tissue ischemia or secondary injury
1. There will be a release of norepinephrine, serotonin, and dopamine
2. Vasocontriction occurs and thrombosis formation
3. Lower SCBF
4. Either tissue hypoxia or secondary injury
Patho map of hemo: Starting with breakdown of RBCs, state what occurs that leads to tissue ischemia or secondary injury
1. Hemoglobin and iron dz
2. Increased free radical formation
3. secondary injury
4. Tissue hypoxia
Patho map of Hemo: Starting with neutrophils, state what occurs that leads to tissue ischemia or secondary injury
1. Production of Leukotrienes, activation of kallikrein-kinin system (blood proteins that play a role in inflammation, BP, coagulation, and pain)
2. Vasospasm and edema
3. SCBF
4. secondary or ischemia
Describe spinal shock
What is the onset and how long can it last?
Other characteristics
Spinal shock: temporary loss of spinal reflex activity, nervous system is unable to transmit signals
Onset begins within a few mins of injury and takes several hours before FULL effects occur.
- Lasts approx. 4-6 weeks (rare cases = months)
Accurate prediction of any recovery cannot be made during spinal shock
Match: Sensory and motor neurons travel by different tracts within the spinal cord
1. Ascending tracts are __a__ and deliver information to the __b__.
2. Descending tracts are __c__ and deliver information to the __d__.
Brain
Periphery
Motor
Sensory
1. Ascending tracts are sensory and deliver information to the brain.
2. Descending tracts are motor and deliver information to the periphery.
List the three major sensory tracts and their function
1. Posterior column (dorsal) tract: proprioception (sense of position), light touch, and vibration
2. Spinothalamic tract: pain and temp
3. Spinocerebellar tract: prioprioception
Is the UMN or LMN the main source of voluntary movement?
Which one resides in the spinal cord, as well as outside of it?
UMN is the main source of voluntary movement: neurons that reside in the brain
LMN resides in the spinal cord and outside the spinal cord
What are the 2 major descending motor tracts and their function?
1. Corticospinal tract: for skeletal muscle movement
2. Subconscious motor tract: for balance, muscle tone, eye, hand and upper limb position
Select all that apply for UMN injury characteristics:
A. Flaccid paralysis
b. Spastic paralysis
c. Exaggerated stretch reflexes
d. Abnormal Babinski reflex
e. Loss of stretch reflex
f. Atrophy not prominent
g. Considerable atrophy
Select all that apply for LMN injury characteristics:
a. Flaccid paralysis
b. Spastic paralysis
c. Exaggerated stretch reflexes
d. Abnormal Babinski reflex
e. Loss of stretch reflex
f. Atrophy not prominent
g. Considerable atrophy
a. Flaccid paralysis
b. Spastic paralysis
c. Exaggerated stretch reflexes
d. Abnormal Babinski reflex
e. Loss of stretch reflex
f. Atrophy not prominent
g. Considerable atrophy
Describe the difference between UMN and LMN bowel and bladder issues
UMN: paralysis will have a spastic bowel and bladder
LMN: will have a flaccid bowel and bladder
State what occurs to these in the sympathetic nerves:
Vasocontriction or Vasodilation
Cardiac return to heart
BP
Mental status
Vasoconstriction occurs
Increased blood return to heart
Increased BP
Increased sweating, irritability or anxiety
Put these parts of the spine in order from top to bottom, with their corresponding numbers
Sacral
Thoracic
Cervical
Lumbar
Cervical: C1-C8
Thoracic: T1-T12
Lumbar: L1-L5
Sacral: S1-S5
Neurogenic Shock:
1. What is the onset right after an injury and how long can it last?
2. Which parts of the spine are usually involved?
3. Will it effect the sympathetic or parasympathetic system?
4. How will #3 affect the body system?
1. Occurs within 30 mins after an injury and lasts about 6 weeks
2. Injuries usually above T5
3. Loss of sympathetic nervous system, as well as vasomotor tone (essential determinant of BP)
- Hypothermia d/t loss of sympathetic tone, impairing ability to redirect blood from periphery to core circulation (s/s: warm, dry skin)
Select the characteristics that match Spinal shock:
a. Flaccid paralysis
b. Loss of reflex response
c. Loss of sympathetic nervous system
d. Loss of sensation
e. Effects are generally from dmg to cervical or high thoracic injury (T6 or higher)
f. Loss of vasomotor tone
g. Loss of sensation
h. Hypotension and bradycardia
i. Cord edema, resulting in loss of sensory and motor fxn
j. Hypothermia
a. Flaccid paralysis
b. Loss of reflex response
c. Loss of sympathetic nervous system
d. Loss of sensation
e. Effects are generally from dmg to cervical or high thoracic injury (T6 or higher)
f. Loss of vasomotor tone
g. Loss of sensation
h. Hypotension and bradycardia
i. Cord edema, resulting in loss of sensory and motor fxn
j. Hypothermia
Select the characteristics that match Neurogenic Shock:
a. Flaccid paralysis
b. Loss of reflex response
c. Loss of sympathetic nervous system
d. Loss of sensation
e. Effects are generally from dmg to cervical or high thoracic injury (T6 or higher)
f. Loss of vasomotor tone
g. Loss of sensation
h. Hypotension and bradycardia
i. Cord edema, resulting in loss of sensory and motor fxn
j. Hypothermia
a. Flaccid paralysis
b. Loss of reflex response
c. Loss of sympathetic nervous system
d. Loss of sensation
e. Effects are generally from dmg to cervical or high thoracic injury (T6 or higher)
f. Loss of vasomotor tone (affects BP)
g. Loss of sensation
h. Hypotension and bradycardia
i. Cord edema, resulting in loss of sensory and motor fxn
j. Hypothermia
List interventions for ED
Rapid ID and stabilizing life-threatening injuries
ABCs and immobilization
Differential diagnosis (look for hypotension, bradycardia, hypothermia, warm and dry skin)
IV fluids
Inotropic agents (dopamine)
Atropine (antiarrythmic, tx for bradycardia) or pacemaker
Methylprednisolone (corticosteroid for acute SCI, suppresses inflammation)
Thermoregulation support
Surgery if needed
This C-3 injury results in pulmonary and cardiac arrest.
List interventions
Bulbar-cervical dissociation
- Immediate CPR
- If tetraplegia occurs, pt. will be ventilator dependent.
Describe the differences between above the waist and below the waist SCI (complete)
Which body systems do both supply with nerves?
Above the waist: nerve fibers supply organs of the abdomen in the thoracic cavity (heart, lungs, and skin, brain, etc.)
- After SCI, parasympathetic nerves beginning at the brain continue to work during the phase of spinal shock.
Below the waist: nerves beginning at sacral level, supply the reproductive organs, bladder, pelvis, and legs
If either the sympathetic or parasympathetic system becomes affected during a spinal injury, how will they react during a spinal shock event?
Sympathetic: During a neurogenic shock injury, there will be a loss of the sympathetic nervous system and vasomotor (hypotension, bradycardia, hypothermia)
Parasympathetic: nerves that begin at the brain continue to work during the phase of spinal shock.
- The pause of the sympathetic system causes the parasympathetic to become unregulated during shock.
What is autonomic dysreflexia?
Is it caused by damage to sympathetic or parasympathetic system?
What are the major concerns?
List s/s
AD: a condition in which your involuntary nervous system overreacts to external or bodily stimuli (also known as autonomic hyperreflexia)
It is caused by stimulation of the sympathetic nerves causing AD.
It can lead to life-threatening HTN, strokes, seizures, MI and death.
s/s: Severe HTN, bradycardia, throbbing HA
- others: marked diaphoresis (above level of injury), anxiety and spasticity, piloerection
List Tx of autonomic dysreflexia, beginning with immediate interventions.
What do you want to check to rule out noxious stimuli?
Immediate: raise HOB (this lowers BP and allows blood to pool in LE), then check BP q5mins.
- remove noxious stimulus
- call MD if above actions do not relieve s/s
Rule out NS:
- check bladder is empty, no foley kinks
- check bowel status, but avoid rectal exams
- check skin and toenails for ulceration and infection
- remove tight apparel
What is a Noxious stimulus?
What are somethings that can cause it?
Noxious: means a harmful, poisonous, or very unpleasant
Causes: full or irritable bladder (90% of cases)
- stimuli to the colorectum d/t fecal impaction (12%)
- decubitus ulcer or skin infection (4%)
- DVT
- Others: tight clothing, leg bag straps, or invasive procedures
List interventions to decrease incidence of autonomic dysreflexia
List 3 meds for AD
Prevention:
Maintain regular bowel function
Use local anesthetics if manual rectal stimulation is used to promote bowel fxn
Monitor urine output
Wear Medical alert bracelet indicating hx of AD
Meds:
1. Diazepam IVP to relieve spasm of skeletal and smooth muscle
2. Phenazopyridine (urinary tract analgesic)
3. Ca+ channel blocker for persistent HTN
Match: Central cord syndrome is most common in older adults with this type of injury
A.
Central Cord syndrome
What is Hematomyelia? What may it result in?
What is Cord contusion?
What is myelopathy and the common myelopathic finding with CCS
Myelopathy: any functional disturbance and/or pathological change in the spinal cord
- Sphincter dysfunction, usually urinary retention
Select the characteristics that will get affected with anterior cord syndrome:
A.
Select the characteristic(s) that will get affected with a posterior column cord tract damage: (select all that apply)
C. Pain and temp
b. sensation of touch
c. vibration
d. positioning
List tx for anterior cord syndrome
Surgical?
Prognosis?
With anterior spinal artery occlusion, no surgical intervention required
- patient will be on bed rest
List sensory deficits with Brown-Sequard syndrome
Say if these will be same side as lesion or opposite side of lesion:
a. UMN weakness
b. Loss of position and vibration
c. Loss of pain and temp
Sensory deficits: loss of pain and temp. sensations
Same side:
a and b
Opposite side:
c
Posterior cord syndrome
Which mechanism of injury is typical cause?
What loss occurs with damage to dorsal area of cord?
List sensory functions that remains intact
Typical cause: cervical hyperextension injury
Dorsal damage: loss of proprioception
Intact: pain and temp
- as well as motor function
Describe Cauda Equina syndrome
what are s/s?
Compression of nerves at end of spinal cord (lumbar/sacral nerve roots)
s/s: low back pain, siatica, bowel and bladder incontinence, lower extremity motor and sensory loss
What is the function of the phrenic nerve?
their location on spinal cord?
Fxn: stimulates diaphragm to contract
- dmg = paralysis of diaphgragm
Location: right and left sides of C3-5
What is the function of the vagus nerve?
Provides parasympathetic activity
- to heart, lungs, and GI
Supplies sensory and motor fxn to the pharynx
Supplies motor function to muscles of abdominal organs
List urinary management of both initial and post acute phase
