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
24% are between the ages of 16-30
55% are between the ages of 31-45
11.5% are older than 60
77.8% are males
Model Systems National SCI database
NSCI Statistical Center
Independent and collaborative research
Resources to individuals with SCI, family and caregivers, health care professionals and the general public www.shepherd.org
SPINAL CORD INJURY
An injury to the
spinal cord at any
level between the
and the cauda
equina, from any
CERVICAL: 7 Bones-8 Nerves
Front Arm Muscles
Lower Arms, Fingers
THORACIC: 12 Bones-12 Nerves
T2 thru T6
T7 thru T12
Middle part of the
body (trunk), chest
and stomach area
LUMBAR: 5 Bones-5 Nerves
Top of Foot and
SACRAL: 1 Bone-5 Nerves
Bowel & Bladder
CLASSIFICATION of SCI
ASIA A E
most widely accepted
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
Mixed (combination of 2 of above)
Brown Sequard: damage to one side of cord ipsilateral
paralysis, loss proprioception
contralateral loss of pain and temperature
damage to central
part of cord
in arms verses legs
posterior 1/3 of cord
Sensory and motor function intact
Loss of proprioception
anterior 2/3 of cord
Paralysis with loss of pain and temperature
MECHANISM OF INJURY
The CNS, of which the spinal cord is a part, is
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
Prevention of Secondary Injury
Proactive Prevention of Medical Complications
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
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.
A device that is used for unstable cervical injuries that are in alignment.
Cervical Fusion and Wiring Anterior and/or Posterior Fusion
Hard collar to be worn at all times
post-op, for 6 weeks.
Harrington Rods For thoracic-lumbar injuries.
Embedded in the neural arch to provide a distraction force.
TLSO post operatively for 4-6 weeks.
Rehab Priorities 1st 72 Hours
Occurs 30-60 minutes post traumatic SCI
Can last a few hours to several weeks
Absence of all spinal reflexes below the level of injury.
Loss of pain, touch, temperature, and pressure.
Loss of bowel & bladder function.
Bowel- Initiate suppository and manual evacuation within
Daily bowel program.
Perineal skin care.
Padding & Positioning
Visualize new areas
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 painful shoulders
Decrease respiratory complications
Autonomic Nervous System
ANS disruption makes the parasympathetic system dominant.
Stress Ulcers/ GI Bleed
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
Parasympathetic dominance resulting in vasodilation.
Vasoconstrictive therapy: Dopamine
Leading cause of death in SCI population.
PSmucus production increases; bronchial constriction
Result of immobilization, artificial ventilation, and general anesthesia.
Aggressive pulmonary toiletry
Result of increased platelet aggregation and common post-op complication
ANS DysfunctionGI PS-increased gastric secretions, motility,
digestion Gastroduodenal ulcers; GI bleeding Disruption of CNS, stress response, abdominal
Initiate proper delivery of nutrition Prophylactic meds
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.
NO vasoconstriction, piloerection or heat loss through sweating below level of injury
Do not over cool or over heat.
Inappropriate reflex action, occurring with injury levels T6 and above.
Noxious stimuli: distended bladder, full rectal vault, skin issue, infection, ingrown toenail.
S & Sx
BP > 15mm Hg over baseline
Blotchy/skin redness above LOI
Interventions: Elevate HOB to 90 degrees
Remove constrictions: binder, TED hose, etc.
Assess foley for drainage problems
Bowel program with nupercaine
Continue to search for cause