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Shepherd Center: A Catastrophic Care · PDF fileand the cauda equina, from any ... INCOMPLETE SYNDROMES ... •Anterior Cord •Posterior Cord •Conus Medullaris •Cauda Equina •Mixed

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Text of Shepherd Center: A Catastrophic Care · PDF fileand the cauda equina, from any ... INCOMPLETE...

  • Shepherd Center:A Catastrophic Care Hospital

    The Jane Woodruff Pavilion

  • Acute Management of SCI&

    Prevention of Secondary Complications

    Joycelyn Craig, BSN, RN, CRRN

    SCI Nurse Education Manager

  • FACTS & STATISTICSModel SCI Care System Data, Archives of Physical and Medical Rehabilitation, January 2008

    PREVALENCE in US

    227,080 - 300,938 living with SCI

    12,000 annually

    AGE

    24% are between the ages of 16-30

    55% are between the ages of 31-45

    11.5% are older than 60

    GENDER

    77.8% are males

  • Model Systems National SCI database

    NSCI Statistical Center

    www.spinalcord.uab.edu

    Independent and collaborative research

    Resources to individuals with SCI, family and caregivers, health care professionals and the general public www.shepherd.org

    www.pva.org

    http://www.shepherd.org/

  • SPINAL CORD INJURY

    An injury to the

    spinal cord at any

    level between the

    foramen magnum

    and the cauda

    equina, from any

    cause.

  • CERVICAL: 7 Bones-8 Nerves

  • Cervical NervesC1

    C2

    C3

    C4

    C5

    C6

    C7

    C8

    Neck

    Shoulder Shrug,

    Neck, Diaphragm

    Shoulder Muscles

    Front Arm Muscles

    Wrist Muscles,

    Shoulder Muscles

    Lower Arms, Fingers

  • THORACIC: 12 Bones-12 Nerves

  • Thoracic Nerves

    T1

    T2 thru T6

    T7 thru T12

    Hand

    Middle part of the

    body (trunk), chest

    and stomach area

    Coughing and

    laughing muscles

  • LUMBAR: 5 Bones-5 Nerves

  • Lumbar

    L1

    L2

    L3

    L4

    L5

    Hips

    Knees

    Top of Foot and

    Ankle

  • SACRAL: 1 Bone-5 Nerves

  • SacralS1

    S2

    S3

    S4

    S5

    Legs

    Feet

    Bowel & Bladder

    Sex Organs

  • CLASSIFICATION of SCI

    ASIA A E

    most widely accepted

    neurologic basis

  • ASIA CLASSIFICATIONS

    ASIA A = no motor or sensory function is preserved in the sacral segments S4-S5.

    ASIA B = sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-S5

    ASIA C = motor is preserved below the neurological level, and most of the key muscles below the neuro level have a muscle grade < 3.

    ASIA D = motor function is preserved below the neurological level, and at least half of key muscles below the neurological level have a muscle grade =or > 3.

    ASIA E = NORMAL motor and sensory testing.

  • CLASSIFICATION of SCI

    Complete SCI = no motor or sensory

    function below the LOI.

    Incomplete SCI = any sensation present

    and/or any motor function below the LOI.

  • INCOMPLETE SYNDROMES Brown-Sequard

    Central Cord

    Anterior Cord

    Posterior Cord

    Conus Medullaris

    Cauda Equina

    Mixed (combination of 2 of above)

  • INCOMPLETE SYNDROMES

    Brown Sequard: damage to one side of cord ipsilateral

    paralysis, loss proprioception

    contralateral loss of pain and temperature

  • INCOMPLETE SYNDROMES

    Central cord:

    damage to central

    part of cord

    greater weakness

    in arms verses legs

    sacral sensation

  • INCOMPLETE SYNDROMES

    POSTERIOR

    CORDLesion within

    posterior 1/3 of cord

    Sensory and motor function intact

    Loss of proprioception

    ANTERIOR

    CORDLesion within

    anterior 2/3 of cord

    Paralysis with loss of pain and temperature

    Proprioception intact

  • MECHANISM OF INJURY

    The CNS, of which the spinal cord is a part, is

    extremely fragile.

    Even slight pressure on the spinal cord from

    the primary injury or from the secondary

    injury in the form of swelling or infection or

    bruising, can result in permanent and severe

    neurologic injury.

  • Spinal Cord

  • Nursing

    Prevention of Secondary Injury

    Spinal stabilization

    Proactive Prevention of Medical Complications

  • FIRST ---Immobilize

    THEN-Assess & Test

  • Within 3 hours of the injury:

    Solumedrol 30 mg/kg IV as a bolus dose

    over 15-60 minutes, then 5.4 mg/kg/hr for 23-24 hours.

    Within 8 hours of the injury:

    Solumedrol 30 mg/kg IV as a bolus dose over 15-60 minutes, then 5.4 mg/kg/hr for 47-48 hours.

    Monitor blood glucose

    High Dose Solumedrol Protocol

  • Spinal Stabilization

    Goals:

    Prevent further damage to the spinal cord.

    Provide means for early mobilization.

  • Cervical Traction: Gardner-Wells Tongs Proper alignment until surgery.

    Constant traction force at all times. Ensure that weights hang freely.

    Pin-site care with soap and water every shift.

    Log rolls

  • Halo Vest

    A device that is used for unstable cervical injuries that are in alignment.

    Skin care.

    Patient safety.

  • Cervical Fusion and Wiring Anterior and/or Posterior Fusion

    Hard collar to be worn at all times

    post-op, for 6 weeks.

    Skin.

  • Harrington Rods For thoracic-lumbar injuries.

    Embedded in the neural arch to provide a distraction force.

    TLSO post operatively for 4-6 weeks.

    Skin.

  • Rehab Priorities 1st 72 Hours

    Spinal Shock

    Respiratory Intervention

    Skin Protection

    Bowel Function

    Bladder Health

    Early Mobilization

  • Spinal Shock

    Occurs 30-60 minutes post traumatic SCI

    Can last a few hours to several weeks

    Flaccid paralysis

    Absence of all spinal reflexes below the level of injury.

    Loss of pain, touch, temperature, and pressure.

    Loss of bowel & bladder function.

  • Spinal Shock

    Bowel- Initiate suppository and manual evacuation within

    24-48 hours.

    Daily bowel program.

    Skin care.

    Bladder- Foley.

    Perineal skin care.

  • SKIN Bed

    Padding & Positioning

    Shearing

    Spasms

    Bony prominences

    Visualize new areas

    Head-to-toe assessments

    Pressure relief

    Turns

    Weight Shifts

  • EVERY PatientDeserves Their Turn!

    Evaluate to increase 30 min/week

    Skin checks at least twice per shift

    Keep pressure off affected areas

  • Padding and Positioning

    Protect the skin

    Prevent contractures

    Prevent painful shoulders

    Decrease respiratory complications

  • Autonomic Nervous System

    ANS Dysfunction

    ANS disruption makes the parasympathetic system dominant.

  • ANS Dysfunction

    Bradycardia

    Hypotension

    Pneumonia/ Atelactasis

    DVT

    Stress Ulcers/ GI Bleed

    Poikilothermism

    Autonomic Dysreflexia

    Bowel

    Bladder

    Skin

  • ANS Dysfunction

    Bradycardia

    Already decreased due to parasympathetic dominance--the absence of the inhibiting effects of the sympathetic system

    Often due to vagus nerve stimulation

    Can be extreme: Pre-medicate prior to suctioning

    Pacemaker

  • ANS Dysfunction

    Hypotension

    Parasympathetic dominance resulting in vasodilation.

    Vasoconstrictive therapy: Dopamine

    Neosynephrine

    Florinef

    Midodrine

  • ANS DysfunctionPneumonia/Atelectasis

    Leading cause of death in SCI population.

    PSmucus production increases; bronchial constriction

    Result of immobilization, artificial ventilation, and general anesthesia.

    Interventions:

    Aggressive pulmonary toiletry

    Bronchodilator therapy

  • ANS DysfunctionDVT/PE

    Result of increased platelet aggregation and common post-op complication

    Intervention:

    Continuous Assessment

    Early Detection

    Prophylactic anticoagulants

  • ANS DysfunctionGI PS-increased gastric secretions, motility,

    digestion Gastroduodenal ulcers; GI bleeding Disruption of CNS, stress response, abdominal

    trauma Interventions:

    Initiate proper delivery of nutrition Prophylactic meds

  • ANS DysfunctionPoikilothermism

    Interruption of sympathetic pathways to hypothalamus.

    Loss of sympathetic response below level of injury resulting in the inability to shiver or perspire.

    Warming or cooling blankets.

  • Temperature control

    NO vasoconstriction, piloerection or heat loss through sweating below level of injury

    Do not over cool or over heat.

  • ANS Dysfunction

    Autonomic Dysreflexia

    Life-threatening.

    Inappropriate reflex action, occurring with injury levels T6 and above.

    Noxious stimuli: distended bladder, full rectal vault, skin issue, infection, ingrown toenail.

  • ANS Dysfunction

    Autonomic Dysreflexia

    S & Sx

    Pounding headache

    BP > 15mm Hg over baseline

    Sweating

    Blotchy/skin redness above LOI

    Nasal congestion

  • ANS Dysfunction

    Autonomic Dysreflexia

    Interventions: Elevate HOB to 90 degrees

    Remove constrictions: binder, TED hose, etc.

    Assess foley for drainage problems

    Bowel program with nupercaine

    Skin issues

  • ANS Dysfunction

    Autonomic Dysreflexia

    Monitor time

    Monitor BP

    Treat BP-procardia

    Notify MD

    Continue to search for cause

    Monitor BP

  • ANS DysfunctionBOWEL

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