Spinal Cord Injury

LPN to RN Track

Spring 2004

Significance

Result of spinal cord compression Leading cause of death WITH GOOD CARE will be able to live within 5

years of previous life expectancy Nurses caring for spinal cord clients have to be

able to encourage independence Many spinal cord clients end up in nursing

homes, group homes

Mechanism of Injury

Flexion Extension Flexion-rotation Compression

From PathologyFor Health-relatedProfessions

From RehabilitationNursing

From RehabilitationNursing

From Lewis

Degree of Spinal Cord Involvement

Complete – Cord is severed and there is no movement below the level of injury

IncompleteCentral cord – More common in adults.

Compression of anterior horn cells. Motor weakness more in upper limbs Sensory depends on site of injury. Usually has bladder involvement. Recovery will depend on resolution of edema and how intact the spinal tracts are

From Rehabilitation Nursing

Degree of Spinal Cord Involvement

Anterior cord syndrome – Often a flexion injury Immediate motor paralysis below level of injury Decreased sensation and loss of temperature

below injury Posterior tracts are intact so sense of touch

position, vibration and motion are intact

From Rehabilitation Nursing

Degree of Spinal Cord Involvement

Brown – SequardHalf of spinal cord is transectedUsually from penetrating injuriesMotor function, vibratory, and position sense

are lost on side that is cut. Opposite side has loss of pain and temperature

These losses are below the level of injury

From Rehabilitation Nursing

Degree of Spinal Cord Involvement

Posterior Cord SyndromeFrom cervical hyperextensionHas damage to posterior part of the spinal

cord with sensory neurons and position-senseLoss proprioception Pain , temperature, sensation and motor

function remain intact

Pathophysiology

Initial injuryAutodestruction – quickly after injury there is

bleeding in the cord. Hemorrhage, edema and metabolites contribute to ischemia which leads to necrosis in the cord.

Within 4 hours there is infarction in the gray matter

Pathophysiology

Hypoxia interferes with metabolic needs of the spinal cord

There is a release of norepinephrine and vasospasms in the spinal cord

This causes necrosis, more hypoxia and necrosis of the cord

Pathophysiology

The spinal cord cannot increase its blood flow to compensate

Damage is permanent in 24 hours Because the spinal cord has nowhere to expand

to, edema from the injury will cause compression of the cord 2 vertebral spaces above and 2 spaces below. (If a client presents with an injury at C6 initial swelling will affect C4 though C8

Spinal Shock

Damage from edema lasts 72 hours to 1 week

Cannot tell extent of injury until edema subsides

During spinal shock, the cord does not function below the level of injury

Hypotension, bradycardia, and warm, dry extremities

Spinal Shock

Peripheral vasodilation, venous pooling and decreased cardiac output

Bowel, bladder and musculoskeletal systems are all affected

Lasts for 7 to 10 days Hyperreflexia, reflex emptying of the bladder

and spasticity mark the end of spinal shock

Complications

Patent airway Adequate ventilation Adequate blood volume Prevent further cord damage

Respiratory

C1-C4 loss of respiratory function Require being on ventilator Below C4 has diaphragmatic breathing if

phrenic nerve is intact. Diaphragmatic breathing causes decrease

in vital capacity and tidal volume Abdominal muscles are paralyzed so client

cannot cough effectively to clear secretions

Cardiovascular

Above T5 decreases the sympathetic system Parasympathetic has control and causes

bradycardia, peripheral dilatation that results in hypotension

May need medication to raise heart rate Watch for hypoxemia Causes decreased cardiac output

Urinary System

Retention is big problem In spinal shock bladder will overfill Post acute bladder will partly empty as

reflex and retain residual. Use intermittent cath to control this

May have kidney and bladder stones

GI System

Above T5 problems are related to hypomobility

Risk for paralytic ileus Stress ulcers are common

Skin

Big risk for skin breakdown Do pressure relief every 15 minutes when

wheelchair Will need special bed Poikilothermism – cannot control body

temperature below level of injury Assume temperature of their environment Also have decreased sweating

Metabolic Needs

Need proper nutrition for healing May need tube feeding until can take

sufficient PO

Peripheral Vascular

DVT is a BIG problem Also prone to have PE – is leading cause

of death

Drug Therapy

Dopamine is used to keep MAP at 80 -90. This helps perfuse the spinal cord

Methylprednisone (Solumedrol) is used to control edema and improve blood flow in the spinal cord

Drug Therapy

SolumedrolReduce spinal cord ischemia Improve energy balanceRestore extracellular calcium Improve nerve impulse conductionRepress release of free fatty acids from spinal

tissue

Acute Care

Keep head in alignment Protect cervical spine If traction is used must keep on at all times If has tongs, do pin care regularly If pins come loose, you will hear a clicking noise If has a halo vest be sure to do good skin care MUST HAVE WRENCH ATTACHED TO VEST

AT ALL TIMES

From Lewis

Respiratory

May need ET tube or trach Cannot effectively cough – suction or do

quad cough Use incentive spirometry every 2 hours

while awake

Cardiovascular

Prone to hypotension – move and get up slowly. If BP bottoms out when you get the client up, lean them back in their W/C until this resolves

Use TED hose to prevent DVT and help keep BP up. Also abdominal binder

May need atropine IV or temporary pacemaker to keep HR up

Fluids and Nutrition

In first couple of days is at risk for paralytic ileus

May need an NG tube Evaluate swallowing in high cervical client

before feeding them (hint: the gag reflex) Encourage roughage to help with bowels

Bowel and Bladder

May retain urine Use Foley in acute phase, then use

intermittent cathing schedule. Must done on a schedule and not PRN.

Encourage fluids – will be prone to kidney stones

Give stool softeners, laxatives and enemas to prevent impaction

Reflexes

Families see the return of reflexes as a sign that client will recover. In most cases, this is not the case.

If spasms are a problem, baclofen can be given either PO or by pump

Warm baths might help

Autonomic Dysrreflexia

Uncompensated sympathetic response to sympathetic response of autonomic nervous system

Caused by visceral stimulation in client with injuries above T7

This is an emergency Aggravated by sensory stimulation for

bladder, bowel, skin

Autonomic Dysrreflexia

Symptoms: Hypertension Blurred vision Throbbing headache Diaphoresis above the level of injury (there is an error

on your handout) Bradycardia Piloerection (gooseflesh) Nasal congestion Nausea

Nursing Interventions

ELEVATE HOB Check Foley is there is one If no cath and has not been cathed lately cath client

using Lidocaine jelly If has not had a BM lately – check for impaction using

Lidocaine jelly If you need to give BP med, be aware that the BP will

drop when the cause is found and corrected Remember Quads typically have a lower BP if their injury

is old

Pediatric Considerations

Most common spinal cord damage is from congenital causes

Child’s bones don’t fracture as easily and may not show up on x-ray

Child with function down to L3 will be able to walk

Important to have child walk and be weight bearing to prevent osteoporosis and hypercalcemia

Females

Female teen will have menses return in about 6 months.

Is possible for quad teen to get pregnant This is a high risk pregnancy with high risk

of autonomic dysreflexia during labor Quad may not be able to feel contractions

and tell when she is labor

Sexual Function

Males with upper motor neuron may have unpredictable erections that cannot be maintained. Ejaculation is not possible

Males with a complete lower motor neuron cannot have erection

Males with incomplete lower motor neuron have the best chance of erection and ejaculation. Sperm will have decreased number and motility