Why is it useful to think of spinal shock like a concussion?
CAN’T TELL PATIENTS OUTCOME UNTIL SPINAL SHOCK RESOLVES
What are dermatomes?
- 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
Where do Upper motor neurons (UMN) originate?
the brain (above T12)
Where do lower motor neurons (LMN) originate?
the spinal cord
A DECREASE IN SENSATION of dermatomes, FROM BASELINE ESPECIALLY IN A UPPER DERMATOMES IS REASON TO CALL MD, why?
- WORSENING SYMPTOM
- PROGRESSIVE (SECONDARY INJURY) – MAKING INITIAL INJURY
When UMN (above T12) are involved what are the S/S?
- 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
- 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)
When LMN (below T12) are involved what are the S/S?
- 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
What is spinal shock?
A complete absence of all reflexes
Name the 5 different mechanisms of injury for SCI
- ►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
This type of SCI happens when the head suddenly and forcefully moves foreward:
This type of injury happens when a person falls and lands on feet or buttocks or takes a blow to the head
axial loading injury
This type of SCI happens when a person is rear ended
What are the four types of damage that occur with primary spinal cord injury?
- ►Contusion - BRUISING
- ►Shear injury - FRICTION
- ►Transection –TOTALLY TRANSECTS THE AREA
With a secondary spinal cord injury, how does damage occur?
- 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
What are the different functional classifications of SCI?
COMPLETE – TOTAL PARALYSIS BELOW THE LEVEL OF INJURY (transection of cord)
- INCOMPLETE – PARTIAL OR SOME FUNCTIONING BELOW THE LEVEL OF INJURY
- Tetraplegia (Quadriplegia)
With anterior cord syndrome what is the level of function?
Able to feel POSITION, VIBRATION, TOUCH
Loss of movemement, pain, temperature
Name the incomplete cervical SCI injuries
- Anterior cord syndrome
- Central cord syndrome
- Brown-Séquard syndrome
- cauda equina or conus medullaris
With Central cord syndrome what is the level of function?
- Can sing and dance but cannot play the piano
- MOTOR: AFFECTS MOTOR MORE THAN SENSORY
- UPPER VS LOWER
- DISTAL IS GREATER THAN PROXIMAL
With Brown-Sequard syndrome what is the level of function?
- IPSILATERAL (SAME SIDE) LOSS OF PROPRIOCEPTION, LIGHT TOUCH, MOTOR FUNCTION
- CONTRALATERAL (OPPOSITE SIDE) LOSS OF PAIN, TEMP AND SENSATION
With lumbar/sacral injuries what is the level of function?
- END OF SPINAL CORD AND CONTINUING ON OF NERVE ROOTS - CAN HAPPEN WITH A LUMBAR DISC HERNIATION
- SEE FOOT DROP
What is spinal shock?
- 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)
What are the S/S of spinal shock?
- LOW BP: Profound vasodilation drops blood pressure
- Skin: is warm and dry
- BRADYCARDIA: Parasympathetic is opposed which causes bradycardia
Which diagnostic test should be ordered to R/O SCI?
3. Magnetic resonance Imaging
What additional diagnostic tests should be performed for SCI?
- Chemistry (electrolytes)
What type of med do we use to increase BP?
Vasopressors (constrict vessels)
What are the PRIMARY assessment priorities?
- Circulation – give fluids, assess bleeding
- Environment, exposure, infection control
What are the SECONDARY assessment priorities?
- Full set of V/S
- Give comfort measures
- Head to toe
- Inspect posterior surfaces
How do we test for spinal shock?
How is the bulbocavernosus reflex tested?
- 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
What drugs should be given for the initial management of a SCI?
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
What is neurogenic shock?
What are the S/S of Neurogenic Shock?
PERIPHERAL VASODILATION: WARM DRY SKIN
Name some respiratory complications related to SCI's
- respiratory failure (ventilatory muscles damaged)
- pulmonary edema
- pulmonary embolism
- impaired clearance of secretions
- ineffective cough
SCI's at C3 and above will need what?
ventilator to breath
What are nursing safety priorities with a Halo device?
- 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
Patient and family teaching for Halo device
- 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
How is the log-roll done?
- three people required
- person at the head ALWAYS makes the call (on the count of three...
- the side rollers cross over the middle hands
What chronic complications result from SCI?
- Autonomic hyperreflexia
- VS changes- hypotension, bradycardia, orthostatic hypotension
- 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
What is autonomic hyperreflexia? (formerly Autonomic Dysreflexia)
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
What are S/S of autonomic hyperreflexia?
- Severe hypertension
- Severe headache
- Blurred vision
Nursing priorities with autonomic hyperreflexia?
- 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
How is the micturition center affected?
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)
How is the spinal defecation center impaired?
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.
Where is the reflex arc located?
How is the sexual reflex center affected?
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
What chronic complications result from SCI?
- ►Bone metabolism- osteoporosis & heterotrophic ossification
- ►Musculoskeletal- contractures
- ►Pressure ulcers
- ►Pain syndromes
- ►Neurologic deterioration
- ►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
What interventions will the nurse perform for pain?
- ANTIEPILEPTICS (gabapentin)
- ANTISPASMODICS (baclofen)
What nursing diagnoses are applicable to a client with an SCI?
- Risk for respiratory distress/failure
- Ineffective tissue perfusion
- Impaired physical mobility
- Self-care deficit
- Impaired urinary elimination and/or constipation
- Impaired adjustment
- Imbalanced nutrition
What interventions will the nurse perform for Respiratory Distress/Failure?
- Cough assist (quad cough)
- incentive spirometry
- Respiratory therapy
- monitor breathing and lung sounds