1. Spinal cord injury mild flexion-extension whiplash ~ complete transection with permanent quadriplegia

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Bridget Lee
5 years ago
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1 Wk 5. Management of Clients with Neurologic Trauma 1. Spinal cord injury mild flexion-extension whiplash ~ complete transection with permanent quadriplegia most common in cervical, lower thoracic-upper lumbar vertebrae 1) Etiology and Risk Factors Trauma : most common cause Males, 16~30 yrs (1) Flexion-Rotation, Dislocation, Fracture-Dislocation Injuries Common in C5-6 level, T12-L1 level (2) Hyperextension Injuries after a fall in which the chin hits an object and the head is thrown back (3) Compression Injuries often caused by falls or jumps 2) Pathophysiology most common sites: C1-2, C4-6, T11-L2 most mobile segment, therefore most easily injured acceleration, deceleration, another force (compressing, pulling, or tearing the tissues) flexor responses with extensor predominantly extensor activity limbs spasm into extension with movement 3) Clinical Manifestations (1) Level of Injury Function lost below the level of injury or lesion Voluntary movement Sensation of pain, temperature, pressure, and proprioception Bowel and bladder function Spinal and autonomic reflexes lowest segment with bilateral intact sensory and motor function specific patterns of motor loss C7 injury: able to lift the shoulders, elbows, wrists, hand function below C7: no motor function or sensation remains Thoracic or lumbar spinal segment injury: paraplegia upper extremities be mobile in W/C, crutches, braces

2 L5 injury: extend great toe, dorsiflex ankle no sensation in perianal area, calf, heel, or small toe (2) Changes in Reflexes Reflexes absent in early SCI d/t spinal shock Blood pressure and temperature fall markedly, respond poorly to reflex stimuli After spinal shock, some functions may return by reflex (3) Muscle Spasms after traumatic complete transverse spinal cord lesion involuntary, not mean return of voluntary movement (4) Autonomic Dysreflexia known as autonomic hyperreflexia, life-threatening syndrome Above T6 level after spinal shock (5) Clinical Syndromes Causing Partial Paralysis Five spinal cord syndromes cause partial paralysis Central Cord Syndrome Anterior Cord Syndrome Brown-Se quard Syndrome Conus Medullaris Syndrome Cauda Equina Syndrome (6) Spinal Shock Immediate response to cord transection complete loss of skeletal muscle function, bowel and bladder tone, sexual function, autonomic reflexes last for 1~6 wks return of reflexes and emptying of the bladder 4) Diagnostic Findings X-rays, CT scans, MRI 5) Management (1) Initial Care neck should be stabilized in neutral position without flexion or extension fixed immobilizing device apply logrolling maneuver in supine position on firm surface immobilized with a firm, padded cervical collar halter traction may be considered, SCI-trained personnel should remain

3 6) Medical Management (1) Maintaining Vital Functions Vasoactive agents to support BP Short-term highdose methylprednisolone therapy within 8 hrs Bolus dose of 30 mg/kg infused over 1 hour 5.4 mg/kg infused over 23 hrs (2) Assessment of Other Injuries, monitoring for Complications Several associated injuries: orthopedic, head, chest, abdominal, genitourinary injury ongoing assessments 7) Nursing Management (1) Assessment hemodynamic monitoring: V/S, fluid balance, peripheral oxygen saturation Assess pain, sensation of touch and pinprick Levels of sensation according to dermatomes Reflexes: achilles, patellar, biceps, triceps (2) Risk for Hypotension related to vasodilation and inability to vasoconstrict initially treated with IV fluid (3) Impaired Spontaneous Ventilation, Ineffective Airway Clearance, Impaired Gas Exchange Chest physical therapy, suctioning, assisted coughing to prevent pneumonia (4) Risk for Aspiration Suctioning Asses breath sounds every 1 or 2 hrs ABGA, pulse oximetry monitor (5) Ineffective Thermoregulation loss of hypothalamic control of SNS with above T6 level 7) Surgical Management Decompressive laminectomy Stabilization by surgical fusion insertion of metal plates and screws use of bone grafts alone 8) Spinal Cord Injury Rehabilitation Key to rehabilitation: multidisciplinary team of physicians, nurses, and allied health care providers (physical therapists, occupational therapists, speech, language pathologists) to reduce morbidity, maximize functional recovery, and promote independence

4 (1) Establish Functional Goals degree of residual muscle function It is intended to be a guide and might not (2) Promote Mobility Having proper W/C Use their arms Back of W/C: level of scapula lower than normal to facilitate transfers Cushions reduce risk of pressure ulcers, weight shifts every 10 to 15 minutes teach how to transfer from bed to W/C, from W/C into and out of a car, from W/C onto a toilet strengthening muscles > using braces back braces may be prescribed after lumbar spinal injury (3) Reduce Spasticity Cons: interferes with positioning, functional activities Pros: maintains muscle bulk, facilitates venous return, prevents DVT, aid in transfers (4) Improve Bladder and Bowel Control neurogenic bladder: describe bladder control changes both upper and lower motor neuron disorders Intermittent urinary catheterization: U/O < 600 ml in 4 to 6 hrs reduces risk of infection and bladder stone formation C6 level and lower: self-catheterization possible - hand function, lower extremity clothing Crede maneuver emptying bladder Urinary complications: incomplete emptying, necessitating catheterization Neurogenic bowel for UMN suppositories or digital stimulation every day or every other day to reduce risk of autonomic dysreflexia Neurogenic bowel for LMN difficult to regulate, manual removal of impacted fecal material (5) Prevent Pressure Ulcers Numb skin is associated with pressure ulcers Seated in W/C: ischia ulcer (6) Reduce Respiratory Dysfunction Injury to C3: paralyzed diaphragms, need phrenic pacing Lower than C3: diaphragm the only functional muscle (7) Promote Expression of Sexuality Sexual function depend on location of lesion Reflex erection: UMN lesions

5 (8) Control Pain Dysesthetic pain: distal to site of injury, similar to phantom sensation nonopioid analgesicst transcutaneous nerve stimulators 9) Ongoing Nursing Management (1) Promoting Adequate Breathing and Airway Clearance Detect potential respiratory failure by observing pt, measuring V/C, monitoring oxygen saturation (2) Improving Mobility Maintain proper body alignment Apply neck brace or molded collar (3) Promoting Adaptation to Disturbed Sensory Perception Stimulate area above injury level through touch, aromas, flavorful food and beverages, conversation, and music (4) Maintaining Skin Integrity Change position every 2 hours Inspect the skin, particularly under cervical collar. (5) Maintaining Urinary Elimination Perform intermittent catheterization to avoid overstretching the bladder and infection. If this is not feasible, insert an indwelling catheter. (6) Improving Bowel Function Monitor reactions to gastric intubation. (7) Providing Comfort Measures Reassure patient in halo traction that he or she will adapt to steel frame (ie, feeling caged in and hearing noises). Cleanse pin sites daily, and observe for redness, drainage, and pain; observe for loosening. If one of the pins becomes detached, stabilize the patient s head in a neutral position and have someone notify the neurosurgeon; keep a torque screwdriver readily available. (8) Monitoring and Managing Potential Complications ORTHOSTATIC HYPOTENSION Reduce frequency of hypotensive episodes by administering prescribed vasopressor medications. Provide antiembolism stockings and abdominal binders; allow time for slow position changes, and use tilt tables as appropriate. Close monitoring of vital signs before and during position changes is essential. AUTONOMIC HYPERREFLEXIA Perform a rapid assessment to identify and alleviate the cause of autonomic hyperreflexia and remove the trigger. Place patient immediately in sitting position to lower BP.

6 Catheterize the patient to empty bladder immediately.

Spinal Cord Injury Transection Injury, Spinal Shock, and Hermiated Disc. Copyright 2014, 2011, 2006 by Saunders, an imprint of Elsevier, Inc.

Spinal Cord Injury Transection Injury, Spinal Shock, and Hermiated Disc 1 Spinal Cord Injury Results from fracture and/or dislocation of vertebrae // Compresses, stretches, or tears spinal cord Cervical