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

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.

• PS—mucus 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

• Stool continues to be produced; not evacuated.

• Suppository and rectal clearing.

• Monitor results.

• Consider contrast materials used.

• Skin at risk.

ANS Dysfunction

BLADDER

• Neurogenic Bladder management

• Prevent overdistention, ureterovisical reflux.

• Skin at risk.

ANS Dysfunction

SKIN

• Turns, no less than every 2 hours.

• Visualize new areas with every turn.

• Head-to-toe assessments.

Other Issues to Address

• Impaired physical mobility

• Altered nutrition

• Sexual dysfunction

• Risk or injury r/t sensory deficits

• Altered family processes

• Risk for ineffective individual coping

• Body image disturbance

• Grief, guilt, depression

Family Involvement

Directly related to degree of successful discharge and life planning.

Teach family & caregivers all aspects of care.

Help me be ready for rehab• Prevent skin issues

• Prevent respiratory complications

• Reduce secondary complications

• Anticipate discharge

• Involve the family

• Educate & Explain

• Establish B & B regime

Questions?