http://www.rexdonald.com/facts.

html
http://www.cureparalysis.org/statistics/

Spinal Cord Injuries

Life

expectancy greatly increased since

WW II.
Intermittent

catheterization
Medications, equipment, etc
Cause

of premature death in QUADS is

usually related to COMPROMISED
RESPIRATORY FUNCTION

Spinal Cord Injuries

Whos

at risk?

ADULT

MEN BETWEEN 15 AND 30

YEARS
Anyone in a risk-taking occupation or
lifestyle
SCI

in older clients increasing largely

due to MVAs

Spinal Cord Injuries

Causes

(in order of frequency)

MVA
Gunshot

wounds/acts of violence

Falls
Sports

injuries

Spinal and Neurogenic Shock

Below
Total

site of injury:

lack of function
Decreased or absent reflexes and flaccid
paralysis
Lasts from a week to several months after
onset.
End of spinal shock signaled by muscular
spasticity, reflex bladder emptying,
hyperreflexia

Classification of SCI
Mechanism
Flexion

of injury

(bending forward)
Hyperextension (backward)
Rotation (either flexion- or extensionrotation)
Compression (downward motion)

Pathophysiology of SCI
Insert

stuff here
Insert picture here

Classification of SCI

Level or Injury

Cervical (C-1 through ??)

Thoracic (T-1through ??)
Lumbar (L-1through ??)

Degree of Injury

Complete

Total paralysis and loss of sensory and motor function

although arms or rarely completely paralyzed

Incomplete or partial

http://www.sci-recovery.org/sci.ht
m

Degree of Injury
Complete

transection

Total paralysis and loss of sensory and motor

function although arms or rarely completely
paralyzed

Incomplete

(partial transection)

Mixed loss of voluntary motor activity and

sensation
Four patterns or syndromes

Incomplete cord patterns

Insert

picture of cord here

Central cord syndrome More common in
older clients
Frequently from hyperextension of spine
Weakness in upper and lower ext, but greater
in upper.

Anterior

cord syndrome
Posterior cord syndrome
Brown-Sequard syndrome

Anterior cord syndrome

Compression

of the ant. Cord, usually

a flexion injury
Sudden, complete motor paralysis at
lesion and below; decreased
sensation (including pain) and loss of
temperature sensation below site.
Touch, position, vibration and motion
remain intact.

Posterior cord syndrome

Assoc

with cervical hyperextension

injuries
Dorsal area of cord is damaged
resulting in loss of proprioception
Pain, temperature sensation and motor
function remain intact.

Brown-Sequard syndrome
Damage to one half of the cord on either side.
Caused by penetrating trauma or ruptured disk.
ischemia (obstruction of a blood vessel), or
infectious or inflammatory diseases such as
tuberculosis, or multiple sclerosisBSS may be
caused by a spinal cord tumor, trauma (such as a
puncture wound to the neck or back),.
a rare SCI syndrome which results in

weakness or paralysis (hemiparaplegia) on one side of

the body and
a loss of sensation (hemianesthesia) on the opposite side.

Clinical manifestations of SCI

Depend

on the LEVEL and DEGREE of

the injury!
Quadriplegia occurs with C-1 through
C-8 injuries.
Paraplegia occurs with T-1 thru L-4.
SEE TABLE 57-3 ON PAGE 1725!

Clinical Manifestations of SCI

Respiratory
C1

C3: Absence of ability to breathe

independently.
C4 poor cough, diaphragmatic breathing,
hypoventilation
C5 T6: decreased respiratory reserve
T6 or T7 L4: functional respiratory
system with adequate reserve.

What is the phrenic nerve?

The phrenic nerve stimulates the diaphragm
to contract.
Two phrenic nerves (right and left) - injury to
one or the other paralyzes contraction of only
one half of the diaphragm but even hemi(half) paralysis can significantly interfere with
breathing for patients with lung disease.
The nerve arises from branches of the C3,4,
and 5 nerve roots.
The phrenic nerve can be damaged by
procedures exploring the neck & upper back

Loss of the phrenic nerve on either side

results in paralysis of the diaphragm on that
side.
Paralysis of the diaphragm on one side
results in less inflation of the lung on that
side.
Whether this is physiologically significant
(producing respiratory distress,
hypoventilation/hypercapnia) depends on
other aspects of a patient's pulmonary
physiology (namely underlying chronic
obstructive pulmonary disease [emphysema,
bronchitis], pneumonia, etc.).

Cardiovascular system
C1

T5 shows decreased or absent SNS

influence.
BRADYCARDIA AND HYPOTENSION
(due to vasodilation)

What is the VAGUS nerve?

The

longest of the cranial nerves- exits

out of the medulla and ends in the
abdomen
It supplies sensory and motor function
to the pharyngx
Supplies motor function to the muscles
of the abdominal organs
Provides parasympathetic activity to the
heart, lungs, and most of the digestive
system

Urinary System
Atonic

bladder with RETENTION in

spinal shock.
Post acute phase irritability causing
dribbling or frequent urination.
Urinary infection and calculi from
retention and distention.
INTERMITTENT CATHETERIZATION!

GI system
Decreased motility
Paralytic ileus
Gastric distention intermittent NG suctioning
Increased H2 administer H2 inhibitors such
as Zantac or Pepcid in initial stages
Carafate and antacids later as prophyaxis
Intraabdominal bleeding! Remember, no pain
or tenderness to warn you.
Watch for H/H decrease and impactions

Integumentary System
Pressure

ulcers!
Muscle atrophy in flaccid paralysis
Contractures in spastic paralysis
Poikilothermism the adjustment of
body temp to room temperature
Decreased ability to sweat below lesion

Peripheral vascular system

DVT

common but not detected easily

Pulmonary embolism a significant
cause of death.
Doppler studies, measurement of
extremity girth, impedance
plethysmography (what the heck is
this?)

Post Injury Assessment

Goals are to

Sustain life
Prevent further cord damage

Assessment of muscle groups; motor status

Against gravity
Against resistance
Both sides of the body
Ask to move legs, hands, fingers, wrists, then
shrug shoulders

Post injury assessment (p.1726)

Thorough

motor examination including

position sense and vibration.
Sensory examination
Pinprick

starting at toes and working

upward
ALWAYS HAVE CLIENT CLOSE EYES OR
LOOK AWAY! If he can see what youre
doing, he will answer accordingly.
Assess

for head injury and ICP

X-ray, CT scan, EMG

Surgical Therapy
Reduces
Done

injury and stabilizes the SC

for

Compression
Bony

fragments in the cord

Compound fracture
Penetrating trauma

Drug Therapy
Vasopressors

(Dopamine) to keep
mean arterial pressure greater than
80mm to 900mm/Hg so that
PERFUSION TO CORD is improved.

Methylprednisolone (Solu-medrol)
Increases

the recovery of function and

is the SOC! IV bolus then continuous
IV over a 23 hour period.

Improves

blood flow and reduces

edema in the SC

Other drug therapy

Symptom-reducing
GI

drugs for

problems - zantac, tagamet, pepcid

Bradycardia - atropine
Hypotension - vasopressors
bladder spasticity - anticholinergics
autonomic dysreflexia blood pressure
reduction

Function of Motor Neurons

Upper

motor neurons

Function of Motor Neurons

Lower

motor neurons

Diagnoses and Interventions

Impaired

Gas Exchange r/t muscle

fatigue and weakness
Decreased

Pao2, increased PaCO2

Fatigue
Diminished

breath sounds

Impaired gas exchange

Maintain

patent airway
Assess respiratory status q 2 hours
Monitor ABGs
Provide aggressive pulmonary toilet;
chest PT and quad-assist coughing
Assess strength of cough
Suction secretions

Inability to sustain spontaneous

ventilation
Related

to diaphragmatic fatigue or
paralysis evidenced by
Dyspnea
Use

of accessory muscles
Abnormal ABGS
Provide

chest PT
Assist with mechanical ventilation
Provide emotional support

Decreased cardiac output

Related

to venous pooling of blood and

immobility as evidenced by
Hypotension
Tachycardia
Restlessness
Oliguria
Decreased

pulmonary artery pressures

Decreased cardiac output

Monitor

blood pressure, pulse and

cardiac rhythm
Administer vasopressors to maintain
MAP at 800mm/Hg or above
Apply pneumatic compression boots or
stockings
Perform ROM at least q8h to aid in
muscle contraction and venous return

Impaired skin integrity

Related

to immobility and poor tissue

perfusion
Inspect skin and areas around pins or
tongs
Turn at least q2h and use kinetic table
or other specialty care devices.
Insure adequate nutritional intake
INFORM family and client about risk of
pressure ulcers

Constipation
to location of injury, fluid
intake, diet, immobility AEB

Related
Lack

of BM in over 2 days
bowel sounds
Palpable impaction
Hard stool or incontinence

Constipation
Auscultate

bowel sounds and monitor

abdominal distention
Note and report any nausea and vomiting
Begin bowel program when BS return and
teach to client and family
Administer suppositories and stool
softeners
Ensure appropriate fluid and fiber intake

Bowel program for SCI

Needs

to be consistent
Give suppository after meal and place
on toilet approx 30 minutes after.
Do this at same time each day!
Fiber, fluids and activity are important
Constipation leads to AUTONOMIC
DYSREFLEXIA!!!

Urinary Retention
Related

to injury and limited fluid intake

as evidenced by
Decreased

output
Bladder distention
Involuntary emptying of bladder

Urinary Retention
Palpate

bladder every shift

During acute phase, insert indwelling
catheter
Begin intermittent cath program when
appropriate
Keep I and O and end fluids
Monitor BUN and creatinine
Crude (pronounced croo-DAY)
manuever when voiding/cathing

Risk for AUTONOMIC

DYSREFLEXIA
Assess

for HTN, bradycardia,

headache, sweating, blurred vision,
flushing, nasal stuffiness/congestion
Reduce or eliminate noxious stimuli
such as impaction, urine retention,
tactile stimulation and skin lesions or
pain!

Autonomic dysreflexia
Elevate

HOB 43 degrees
Identify cause and eliminate
Take BP and pulse
Administer antihypertensives as
ordered if hypertensive.
Call physician if interventions not
effective
TEACH CLIENT AND CARGIVERS
HOW TO PREVENT THIS!

Other diagnoses
Impaired

physical mobility
Altered nutrition: < body requirements
Sexual dysfunction
Risk or injury r/t sensory deficits
Altered family processes
Risk for ineffective individual coping
Body image disturbance

Acute intervention
Immobilization
Crutchfield

tongs

Halo

vest
Stryker bed
Roto-rest bed (side to side)

Motion sickness a problem with these.

Respiratory dysfunction
Intubation

if injury is high
Decreased tidal volume and shallow
breathing lead to pneumonia and
atelectasis
CPT and pain management
Prone position may be risky
Count to 10 test
QUAD COUGH technique to assist with
ineffective abdominal muscles

Fluids and nutrition

Paralytic

ileus common in 48-72 hours

When bowel sounds return:
High

calorie, high protein, high fiber diet

Evaluate SWALLOWING before feeding!
EATING

CAN BECOME A POWER

STRUGGLE!

Bowel and Bladder mgmt.

Indwelling

catheter initially
Intermittent catheterization when able
Monitor pH of urine (should be acetic!)
Ascorbid acid and Mandelamine (an
antiseptic) given to keep down bacteria

Temperature control
NO

vasoconstriction, piloerection or
heat loss through sweating below level
of injury
Do not over cool or over heat client.
They only have the remaining upper
portion of their bodies, generally, for
temperature adjustment