Management of Spinal Cord Injury outside of a specialist Spinal Injuries Centre The Derby Experience
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1 Management of Spinal Cord Injury outside of a specialist Spinal Injuries Centre The Derby Experience Sharon Budd Trauma Nurse Derby Hospitals NHS Foundation Trust
2 Learning Outcomes To understand the role of the SCI Link Worker in Derby To increase knowledge of certain aspects of the acute management of SCI To be aware of the issues relating to the development of guidelines and the implementation into practice
3 Background Initial management is key in preventing complications both in the acute and rehabilitation phases Spinal injury care was not consistent or evidence based within the trust No local guidelines / care plans available within the acute trust Working group developed
4 Spinal Link Worker Scheme - Sheffield SCIC Training provided for staff in T&O, critical care, 4 levels of competence Opportunity for theoretical and practical experience within the unit Identified group of staff with expert knowledge within the organisation
5 Spinal Link Worker key aspects Check patient referred to SCIC as per national guidelines (4hrs) Care planning Bowel management Psychological support patient and relatives
6 Spinal Link Worker key aspects Liasion with peer support worker/scic Monitor for complications Education / training across the trust
7 Management aspects Positioning / pressure area care / musculoskeletal Bowel management Psychological support
8 Positioning 5% natural increase in level of lesion (cord oedema) but 7% due to poor manual handling (SCOOP for transfers) Legs supported on pillows lengthways Passive exercises plan agreed by consultant, dependent on level of injury. Support joints to prevent hyperextension
9 Joint contractures develop quickly eg C5 injury Spasm triggers can be sudden noise, bed clothes being removed, helped by passive exercises, turning. Note relatives may confuse with return of function
10 NB - Hypersensitivity / phantom pain / proprioreception Muscle wastage up to 30% in 7 days, need dietician referral / supplements
11 Preventing pressure sores Firm mattress 2 hourly turns / change of position / helps other systems?? to sit up (surgeon request) Heels elevated, support feet to prevent foot drop (splints not used routinely)
12 DVT prevention DVT swelling may only be apparent 10 days after developed Anticoagulants (delay if surgery) AV boots remove 2 hrly to check skin Stockings full length, re measure at 72 hrs and then weekly
13 Bowel management (1) Spinal shock rectum and anus are flaccid, risk of over distension Daily PR (latex free gloves, Instillagel if sensation present) Trust guidelines for competency for DRE
14 Anal reflex stimulant enemas / digital stimulation Flaccid - continue to need daily DRE Senna only used in initial management
15 Bowel management (2) Do not use bed pans for any level of injury until stabilised and / or documented in the notes. Use pads and explain reason to patient Care prolonged turning onto left side can lead to syncope in cervical lesions (vagal stimulation) NB constipation and impaction is a common cause of Autonomic Dysreflexia
16 Autonomic dysreflexia Medical emergency, BP can reach 220 systolic Usually injury above T6, can occur at anytime after spinal shock subsided, often post discharge
17 Autonomic dysreflexia Response to presence of noxious stimuli eg blocked catheter (do not try washout, further increases problem), impacted bowel, ingrowing toenail or pressure sore Patients have an alert card to highlight to GP/ED
18 Psychological support Diagnosis may be delayed due to presence of spinal shock and cord swelling (48hrs 6 weeks). Be honest and consistent. Involve SCIC / peer support Loss of touch and positional awareness - regular turning, touch and contact, encourage to look at paralysed limbs
19 Challenges Initial development of the guidelines and updating with current evidence and best practice Communication of the guidelines throughout the trust (link staff) Infrequency of patients and staff turnover
20 Links / further reading management guidelines also photographs available of transfers / positioning for relatives guidelines
21 Any questions?
22 Further information
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