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
