Exam 2 - Spinal Cord Injury

CAN’T TELL PATIENTS OUTCOME UNTIL SPINAL SHOCK RESOLVES

• AREA CONTROLLED BY EACH SPINAL NERVE AT THE SKIN LEVEL
• LOWER (L5-6) ARE DISTAL TO THE DERMATOMES (I.E. FEET)
• LIDOCANE PATCH IS A GOOD EXAMPLE OF TREATING DERMATOMES

the brain (above T12)

the spinal cord

• WORSENING SYMPTOM
• PROGRESSIVE (SECONDARY INJURY) – MAKING INITIAL INJURY

• SPINAL SHOCK – ONCE THIS RESOLVES THEN THE OTHERS START
• SPASTICITY – PARALYSIS – FAMILY THINKS THEY’RE MOVING (WILL EVENTUALLY CAUSE CONTRACTURES – MUST TRY TO PREVENT)
• HYPERTONIC MUSCLE
• HYPER REFLEXIC
• +BABINSKI
• LOST VOLUNTARY CONTROL OF DEFECATION BUT LEAVE STOOL IN THE VAULT (HARD STOOL WITH SMEARING) – REGULARLY TIMED BOWEL PROGRAM, MOM, STOOL SOFTENERS, FLUIDS, FIBER – MAY NEED STIMULATION
• UNCONTROLLED VOIDING OF URINE (HIGH RESIDUALS LEFT BECAUSE OF SPASMING) CONDOM CATH, PUREWICK, ANTICHOLINERGICSREFLEX ERECTION AND EJACULATION (ANTISPASMOTICS – BACLOFEN)

• FLACCID PARALYSIS
• HYPOTONIC MUSCLES
• HYPO REFLEXIC
• EARLIER ATROPHY
• S2-S4 REFLEX ARC
• FLACCID RECTUM – HARD FORMED STOOL – REQUIRES DISIMPACTION (SUPPOSITORY, DIGITAL STIMULATION) – MUST HAVE AN ORDER. MAY CONSIDER OSTOMY, ABDOMINAL BINDER OR MASSAGE
• RETAINS URINE, OVERFLOW URINATION, MANUALLY PUSH ON THE BLADDER TO FACILITATE EMPTYING

A complete absence of all reflexes

• ►Hyperflexion injury (C5-C6) – HEAD SUDDENLY AND FORCEFULLY MOVES FORWARD
• ►Hyperextension injury – REAR END
• ►Axial loading – LANDING ON FEET/BUTTOCKS, BLOW TO HEAD
• ►Rotation injuries
• ►Penetrating injuries

Hyperflexion injury

axial loading injury

hyperextension injury

• ►Compression
• ►Contusion - BRUISING
• ►Shear injury - FRICTION
• ►Transection –TOTALLY TRANSECTS THE AREA

• INCREASED METABOLIC NEEDS = INCREASED HYPOXIA AND TISSUES NOT GETTING PROFUSED - this occurs with edema, fever, electrolyte imbalances...
• SWELLING LEADS TO SECONDARY INJURY
• ABSOLUTELY WORSENS THE PRIMARY INJURY

COMPLETE – TOTAL PARALYSIS BELOW THE LEVEL OF INJURY (transection of cord)

• INCOMPLETE  – PARTIAL OR SOME FUNCTIONING BELOW THE LEVEL OF INJURY
• Tetraplegia (Quadriplegia)
• Quadriparesis
• Paraplegia
• Paraparesis

Able to feel POSITION, VIBRATION, TOUCH

Loss of movemement, pain, temperature

• Anterior cord syndrome
• Central cord syndrome
• Brown-Séquard syndrome
• cauda equina or conus medullaris

• Can sing and dance but cannot play the piano
• MUD
• MOTOR: AFFECTS MOTOR MORE THAN SENSORY
• UPPER VS LOWER
• DISTAL IS GREATER THAN PROXIMAL

• IPSILATERAL (SAME SIDE) LOSS OF PROPRIOCEPTION, LIGHT TOUCH, MOTOR FUNCTION
• CONTRALATERAL (OPPOSITE SIDE) LOSS OF PAIN, TEMP AND SENSATION

• END OF SPINAL CORD AND CONTINUING ON OF NERVE ROOTS - CAN HAPPEN WITH A LUMBAR DISC HERNIATION
• BOWEL
• BLADDER
• SEX
• SEE FOOT DROP

• TEMPORARY SUPPRESSION OF REFLEXES BELOW THE LEVEL OF INJURY
• Flaccid paralysis
• Absent reflexes
• Absence of bowel & bladder control
• Males (with cervical injury)- may have priapism – UNCONTROLLED BLOOD FLOW (PARASYMPATHETIC)

• LOW BP: Profound vasodilation drops blood pressure
• Skin: is warm and dry
• BRADYCARDIA: Parasympathetic is opposed which causes bradycardia

1.Plain x-rays 

2.Computed tomography

3. Magnetic resonance Imaging

• CBC
• Coags
• Chemistry (electrolytes)

Vasopressors (constrict vessels)

Fluids

• Airway
• Breathing
• Circulation – give fluids, assess bleeding
• Disability
• Environment, exposure, infection control

• Full set of V/S
• Give comfort measures
• Head to toe
• Inspect posterior surfaces

bulbocavernosus reflex

• squeezing of the clitoris or penis
• causes anal sphincter to contract

if the anal sphincter DOES NOT contract then the patient is in spinal shock

DEXTRAN HAS HIGH OSMOTIC PRESSURE - TO KEEP PLASMA IN THE CELLS – FILLS UP AND HOLDS IT IN THE SPACE

ATROPINE FOR BRADYCARDIA – BECAUSE THEY HAVE LOST FIGHT OR FLIGHT – UNIQUE TO NEUROGENIC SHOCK – WILL END UP WITH PACEMAKER

DOPAMINE - for severe hypotension

Hemodynamic instability

SEVERE BRADYCARDIA

PERIPHERAL VASODILATION: WARM DRY SKIN

SEVERE HYPOTENSION

• respiratory failure (ventilatory muscles damaged)
• pulmonary edema
• pneumonia
• pulmonary embolism
• impaired clearance of secretions
• ineffective cough
• atelectasis
• hypoventilation

ventilator to breath

• never move or turn by holding device
• do not adjust screws
• check skin frequently
• make sure one finger fits between skin and jacket
• assess neuro status
• tape wrench to vest for emergencies

• fall risk: weight of device alters balance
• wear loose clothing
• wash under lambs wool to prevent rashes
• sponge bath or bathtub
• support the head when sleeping
• keep as active as possible
• do not drive
• small pieces of food to avoid choking, use straws
• wrap pins with cloth in cold weather
• observe pin sites daily for infection or loosening
• increase fluids/fiber
• use a position of comfort during sexual activity

• three people required
• person at the head ALWAYS makes the call (on the count of three...
• the side rollers cross over the middle hands

• Cardiovascular:
• Autonomic hyperreflexia
• CAD
• VS changes- hypotension, bradycardia, orthostatic hypotension

• Pulmonary:
• Pneumonia
• VTE / PE – NEED PROPHYLAXIS

URINARY: CAN’T FEEL FOR BACK PAIN, ETC. NEED TO WATCH FOR FEVER, FOUL SMELLING URINE

SEXUAL DYSFUNCTION: DEPENDS ON THE LEVEL OF INJURY

Exaggerated sympathetic response that occurs in patients with cord injuries at T6 or above, occurs after spinal shock is resolved


THIS IS A PROBLEM OF HYPERTENSION - SOMETHING TRIGGERS THEIR SYMPATHETIC (UNCONTROLLED OVER STIMULATION) – MEDICAL EMERGENCY

• Severe hypertension
• Bradycardia
• Severe headache
• Sweating
• Flushing
• Blurred vision

• Sit them up
• Search immediately for the cause: impacted stool, kinked foley cath, retention, remove tight fitting clothes
• Notify the provider
• Can give nitro, nifedipine, captopril, hydralazine

UMN injury: results in spastic bladder - frequent and uncontrolled voiding. intermittent catheterization or condom cath, stroke or pull hair to stimulate voiding

LMN injury: results in autonomous, flaccid bladder - manually push on bladder (Crede)

UMN = hard stool with smearing - add irritant cathartics (MOM, lactulose...), bowel program, digital stimulation

LMN = hard stool requiring disimpaction by suppository or digital manipulation, abd binder or massage. Ostomy last resort.

S2-S4

UMN – NEED STIMULATION

LMN – PSYCHOGENIC ERECTION POSSIBLE

• No matter upper or lower – will have sexual dysfunction
• 90% of males with SCI do not ejaculate
• Female sexual responses are impaired, ovulation and menstruation are intact
• REMEMBER THAT SEXUAL RESPONSE IS FOREVER ALTERED

• ►Bone metabolism- osteoporosis & heterotrophic ossification
• ►Musculoskeletal- contractures
• ►Pressure ulcers
• ►Spasticity
• ►Pain syndromes
• ►Neurologic deterioration
• ►Syringomyelia
• ►Psychiatric - HIGHER RATES OF SUICIDE, ESPECIALLY IN THE FIRST YEAR, DEPRESSION, DRUG ADDICTION
• ►Thermoregulatory - SPECIFICALLY AT T6, NEUROPATHWAYS AND HYPOTHALAMUS, CAN’T SELF REGULATE
• ►Functional deficits

• ALIGNMENT
• STABILITY
• ANTIEPILEPTICS (gabapentin)
• ANTISPASMODICS (baclofen)

• Risk for respiratory distress/failure
• Ineffective tissue perfusion
• Pain
• Impaired physical mobility
• Self-care deficit
• Impaired urinary elimination and/or constipation
• Impaired adjustment
• Imbalanced nutrition

• Cough assist (quad cough)
• incentive spirometry
• Respiratory therapy
• monitor breathing and lung sounds