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Concept Map: Selected Topics in Neurological NursingPATHOPHYSIOLOGY

Traumatic Brain InjurySpinal Cord Injury

Specific Disease Entities: Amyotropic Lateral Sclerosis Multiple Sclerosis Huntingtons Disease Alzheimers Disease Huntingtons Disease Myasthenia Gravis Guillian-Barre Syndrome Meningitis Parkinsons DiseasePHARMACOLOGY

--Decrease ICP--Disease / Condition Specific MedsASSESSMENTPhysical Assessment Inspection Palpation Percussion Auscultation ICP MonitoringNeuro Checks Lab MonitoringCare PlanningPlan for client adls, Monitoring, med admin.,Patient education, Discharge Planning, morebasedOn Nursing Process: A_D_P_I_ENursing Interventions & EvaluationExecute the care plan, evaluate for Efficacy, revise as necessary

Objectives

Explain pathophysiology of various SCIs and related conditions

Detail signs & symptoms and functionality of different level SCIs

Differentiate between Neurogenic Shock and Spinal Shock

Explain Autonomic Dysreflexia / Hyperreflexia and list appropriate nursing interventions

Discuss overall medical & nursing management of SCIs *

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SCI Involves loss of:

Motor functionSensory functionReflexesControl of elimination*

Common Causes SCI

Motor vehicle accidents (MVA) - Auto and motorcycle accidents the leading cause of spinal cord injuries

Acts of Violence mostly gunshot wounds

Falls SPI after age 65 is often caused by a fall

Sports and recreation injuries - Impact sports and diving in shallow water * ATV *

Diseases - Cancer, infections, arthritis and inflammation

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*Breakdown of Fall Statistics Breakdown of Sports Statistics Breakdown of Road Traffic Accident Statistics

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SCI Type

Incomplete / Partial spinal cord injury- Spinal cord is able to convey some messages to or from the brain. Therefore, retain some sensation and possibly some motor function below the affected areaComplete injury- Complete loss of motor function and sensation below the area of injury

**** Even in a complete injury, the spinal cord is almost never completely cut in half. Doctors use the term "complete" to describe a large amount of damage to the spinal cord.

It's a key distinction because many people with partial spinal cord injuries are able to experience significant recovery, while those with complete injuries are not *

Complete or Partial ?*

Compressison / Wedge Fracture

As the forces push forwards and backwards, pressure is applied to the front and/or back of the spinal bones causing damage in these areas as indicated by the arrowIn these injuries, direct compression forces downwards literally squash the bones, resulting in a loss of height seen on x-ray. This x-ray also shows a chip fracture at the front of the lumbar vertebrae (green arrow) (See how much bigger and stronger this bone is compared to the cervical bone in the picture on the left)*

Spinal Cord InjuryMost trauma to the spinal cord causes permanent disability or loss of movement (paralysis) and sensation below the site of the injury

Paralysis can involve all four extremities, a condition called quadriplegia or tetraplegia, or only the lower body, a condition called paraplegia*

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*C4C6T6L1

SCI Causal Categories

Traumatic spinal cord injury may stem from:- Sudden, traumatic blow that fractures, dislocates, crushes or compresses one or more of vertebrae- Gunshot or knife wound that penetrates and cuts your spinal cord- Additional (secondary) damage usually occurs over days or weeks because of bleeding, swelling, inflammation and fluid accumulation in and around spinal cord

Non-traumatic spinal cord injury may be caused by arthritis, cancer, blood vessel problems or bleeding, inflammation or infections, or disk degeneration of the spine*

Risk factors

Gender - Spinal cord injury affects a disproportionate amount of men

Age (Young adults and seniors)- Between ages 16 and 35 / MVA leading cause - Another peak in people older than 60 / falls leading cause

People active in sports High risk athletic activities include football, rugby, wrestling, gymnastics, diving, surfing, ice hockey and downhill skiing

Predisposing conditions - A relatively minor injury can cause spinal cord injury in people with conditions that affect their bones or joints, such as arthritis or osteoporosis *

At the ScenePriorities1. Maintaining ability to breathe2. Preventing shock3. Immobilization to prevent further spinal cord damage (Backboard & C-Collar)*

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Vertebrae Commonly Involved*C5 T12

Baseline Assessment At Scene & Upon Arrival to ERABCs / ATLS assessment includes Vital Signs & Glasgow Coma Score

Neck / Spine stabilization

Maintaining BP

Multisystem support

May be sedated*

Diagnosis

X-Ray

C-Spine FIRST !!

Swimmers View

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Be Vigilant !Spinal cord injury isn't always obvious

Numbness or paralysis may result immediately after a spinal cord injury or gradually as bleeding or swelling occurs in or around the spinal cord

In either case, time between injury and treatment is a critical factor that can determine the extent of complications and the level of recovery

It's safest to assume that trauma victims have a spinal cord injury until proved otherwise

If you suspect that someone has a back or neck injury Spinal Immobilization STAT !

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History of InjuryLoss of Consciousness?

Other victims seriously hurt?

Mechanism of injury?

Driver / passenger / seatbelt ?Fall height / what caused fall?Hit where and with what?Gunshot / impaled object ?*

Mechanism of Injury

*Different mechanism of injury

CT Scan*

MRI*

ContinuedMRI For identifying herniated disks, blood clots or other masses that may be compressing the spinal cord. But MRI can't be used on people with pacemakers or on trauma victims who need certain life-support machines or cervical traction devices

Myelography - Dye injected into spinal canal then X-rays or CT scan can suggest a herniated disk or other lesions. Used when MRI isn't possible *

Primary Spinal InjuryResult of initial trauma

Injury usually permanent*2000 Brian Smith Greg Louganis's Diving Accident, 1988 Sports Illustrated

Secondary Spinal InjuryOccurs after Spinal cord trauma

Damage at cellular level

Necrosis (Cells swell, burst and leak toxic substances to other cells)

Apoptosis (Programmed cell death / cell suicide to prevent bursting)

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Secondary SCI*

Secondary SCI*

SCI Disability

1. Depends on Location

Injuries (lesion) higher in the spinal cord produce more paralysis

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SCI Disability

*2. Depends on type of injury

Spinal Cord - Horizontal View*

American Spinal Injury Association (ASIA) Classification*

Incomplete / Partial SCICentral

Lateral / Brown-Sequard Syndrome

Anterior

Posterior

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Anterior Cord SyndromeDamage o front 2/3 of spinal cord, loss of pain and temperature sensation, and motor function below level of injury

Light touch (pressure) and position and vibration sensation preserved

Possible for some people with this injury to later recover some movement

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Central Cord Syndrome

Usually with unbelted MVA and falls of elderly

Typically results greater weakness in arms vs lower extremities

Sensory loss varies but more severe in upper extremities

Control over the bowel and bladder varies and may be preserved

Possible for some recovery from this type of injury, usually starting in the legs, gradually progressing upwards

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Brown-Sequard SyndromeUsually stab or GSW

Damage is towards one side of the spinal cord

Ipsilateral (same side as the cord injury) Impaired or loss of movement, touch, pressure and vibration ** (Hemiparaplegia)

Contralateral (opposite side of cord injury) loss of pain and temperature sensation ** (Hemianesthesia)*

Posterior Cord SyndromeDamage is towards the back of the spinal cord

May leave the person with good muscle power, pain and temperature sensation

However they may experience difficulty coordinating movement of their limbs

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Motor (blue) and Sensory (red) axons in the spinal cord and peripheral nerves.

Sensory neurons reside in the dorsal root ganglia (DRG) while Motoneurons reside in the spinal cord and innervate muscle (yellow). *

SCI Goals of CareThere's no way to reverse damage

Treatment focuses on:

1. Preventing further injury

2. Enabling people to return to an active and productive life within the limits of their disability*

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