Management of

Spinal Cord Injury outside

of a specialist

Spinal Injuries Centre –

The Derby Experience

Sharon Budd

Trauma Nurse

Derby Hospitals NHS Foundation Trust

Learning Outcomes • To understand the role of the SCI Link

Worker in Derby

• To increase knowledge of certain aspects of the acute management of SCI

• To be aware of the issues relating to the development of guidelines and the implementation into practice

Background • Initial management is key in preventing

complications both in the acute and rehabilitation phases

• Spinal injury care was not consistent or evidence based within the trust

• No local guidelines / care plans available within the acute trust

• Working group developed

Spinal Link Worker Scheme

- Sheffield SCIC • Training provided for staff in T&O, critical

care, 4 levels of competence

• Opportunity for theoretical and practical

experience within the unit

• Identified group of staff with ‘expert’

knowledge within the organisation

Spinal Link Worker – key aspects

• Check patient referred to SCIC as per

national guidelines (4hrs)

• Care planning

• Bowel management

• Psychological support patient and relatives

Spinal Link Worker – key aspects

• Liasion with peer support worker/SCIC

• Monitor for complications

• Education / training across the trust

Management aspects

• Positioning / pressure area care /

musculoskeletal

• Bowel management

• Psychological support

Positioning

• 5% natural increase in level of lesion (cord oedema) but 7% due to poor manual handling (SCOOP for transfers)

• Legs supported on pillows lengthways

• Passive exercises – plan agreed by consultant, dependent on level of injury. Support joints to prevent hyperextension

• Joint contractures – develop quickly eg C5

injury

• Spasm – triggers can be sudden noise,

bed clothes being removed, helped by

passive exercises, turning. Note relatives

may confuse with return of function

• NB - Hypersensitivity / phantom pain / proprioreception

• Muscle wastage – up to 30% in 7 days, need dietician referral / supplements

Preventing pressure sores

• Firm mattress

• 2 hourly turns / change of position / helps

other systems

• ?? to sit up (surgeon request)

• Heels elevated, support feet to prevent

foot drop (splints not used routinely)

DVT prevention

• DVT – swelling may only be apparent 10

days after developed

• Anticoagulants (delay if surgery)

• AV boots – remove 2 hrly to check skin

Stockings – full length, re measure at 72

hrs and then weekly

Bowel management (1)

• Spinal shock – rectum and anus are flaccid, risk of over distension

• Daily PR (latex free gloves, Instillagel if sensation present)

• Trust guidelines for competency for DRE

• Anal reflex –stimulant enemas / digital

stimulation

• Flaccid - continue to need daily DRE

• Senna only used in initial management

Bowel management (2)

• Do not use bed pans for any level of injury until stabilised and / or documented in the notes. Use pads and explain reason to patient

• Care – prolonged turning onto left side can lead to syncope in cervical lesions (vagal stimulation)

• NB constipation and impaction is a common cause of Autonomic Dysreflexia

Autonomic dysreflexia

• Medical emergency, BP can reach 220 systolic

• Usually injury above T6, can occur at anytime after spinal shock subsided, often post discharge

Autonomic dysreflexia

• Response to presence of noxious stimuli eg blocked catheter (do not try washout, further increases problem), impacted bowel, ingrowing toenail or pressure sore

• Patients have an ‘alert card’ to highlight to GP/ED

Psychological support • Diagnosis may be delayed due to

presence of spinal shock and cord

swelling (48hrs – 6 weeks). Be honest and

consistent. Involve SCIC / peer support

• Loss of touch and positional awareness -

regular turning, touch and contact,

encourage to look at paralysed limbs

Challenges • Initial development of the guidelines and

updating with current evidence and best

practice

• Communication of the guidelines

throughout the trust (link staff)

• Infrequency of patients and staff turnover

Links / further reading

• www.mascip.co.uk – management

guidelines also photographs available of

transfers / positioning

• www.spinal.co.uk for relatives

• www.boa.ac.uk guidelines

Any questions

?

Further information

sharon.budd1@nhs.net