Acute to Rehab Spinal Cord Injuries Anna Brown CNC, Certificate SCI Nursing, Grad Dip Rehabilitation Studies, La Trobe Victorian Spinal Cord Service Austin Health
SCI Acute to Rehab Let the rollercoaster ride begin...
National Data Causes of SCI Land Transport 46 % MV occupants 51% Unprotected road users 49% Falls 28 % Low falls < 1 metre 64% High falls 1 metre or > 36% Diving & Water Related 9 % Struck by another person or object 9 % Miscellaneous causes 8 % Lynda Norton, 2010 Spinal cord injury, Australia 2007-08 Research Centre for Injury Studies, Flinders University
Australian Demographics Spinal Cord Injuries 237 new SCIs in Australia per year VSCS admits 85 90 annually Paediatric incidence is not clear Segment of population at greatest risk adult men b/w 16 30 years Men > Women approx 4 : 1 Paediatric incidence is > in boys than girls Most common age 19 years
7 cervical 12 thoracic 5 lumbar 5 sacral (fused) 4 coccygeal (rudimentary)
Vertebral Column Ligaments & Stability
The Spinal Cord Approx. 45 cms in length Continuous with the brain Consists of millions of neurone bundles Extends from superior border of C 1 The thickness of the little finger Consistency of toothpaste Encased & protected by the vertebrae Ends at vertebral level L 1 /2
The Spinal Nerves 31 pairs of nerves 8 cervical 12 thoracic 5 lumbar 5 sacral 1 coccygeal
A Spinal Cord Injury Results in Loss of movement Loss of sensation Interruption to ANS sympathetic pathways Resulting in low BP Inability to control body temperature Altered respiratory function Loss of bladder & bowel control Altered sexual function
Classification of SCI Quadriplegia / Tetraplegia T 1 and above Paraplegia T 2 and below Complete / Incomplete Motor and / or sensory sparing
Neurological Examination Motor power - myotome / muscle innervation 0-5 grading Sensory function - dermatome level 0-2 score Light touch / aesthesia Pin prick / analgesia Proprioception Reflex activity 0 - +++ score
http://www.asiaspinalinjury.org/publications/2006_classif_work sheet.pdf
ASIA Standard Classification American Spinal Injury Association Scale of SCI Impairment A = Complete B = Motor complete / Sensory incomplete C = Incomplete - Below Grade 3 D = Incomplete - Grade 3 or above E = Normal
Neurogenic Shock Results from injury to the descending sympathetic pathways SCI at T6 & above may have profound effects resulting in Triad of Clinical Signs Bradycardia unopposed vagal tone on heart Hypotension vasodilatation & loss of sympathetic tone; expect BP 90/60 Hypothermia sympathetic loss resulting in poilkilothermia
Initial Management Position & alignment Immobilise spine board, cervical collar Neutral whole vertebral column Avoid repeating mechanism of injury Skin & pressure Pressure relief - essential Awareness of potential problems Assistive devices / equipment
Head Holding Techniques From the Top Pistol grip From the Side
Spinal Immobilisation in Paediatrics Position / alignment Disproportionate head size in children under 3yrs With toddler & infant use Occian pad / Papoose to position correctly Occian Pad Papoose
Management Prior to Transport Clinical examination Neurological assessment Bradycardia & hypotension Oxygen /respiratory support Monitor temperature - Poikilothermia combination of hypotension & hypothermia appropriate environmental temperatures Adequate x-rays
Management Prior to Transport Naso-gastric tube open drainage, monitor ph Urethral catheter correct size, balloon volume expect 30 mls/hr output IV therapy avoid overload expect hypotension
Radiological Examination Full vertebral column views AP views Lateral views CT scan MRI SCIWORA MRI essential
Royal Perth STATEWIDE-ROLES 6 Australian Spinal Units Princess Alexandra Royal Adelaide RNS Prince of Wales Austin Health
Cardiovascular Respiratory Acute Management Vertebral column stabilisation Skin integrity & pressure management Gastro intestinal, including establishing bowel routine Nutrition Bladder management Prevention of complications VTE, respiratory, pressure injuries Psychosocial...
Acute Management Psychosocial Consistent, objective information Psych review & support through grieving & immobility Relative / family support Prepare for the transition to rehab. Team approach REHABILITATION STARTS ON DAY 1
The next stop... rehabilitation Continuing on the rollercoaster ride... onto rehabilitation & community
Functional / Neurological Level of SCI Level of spinal cord injury ASIA scale grading Associated injuries / complications Age & aging factors Gender - body proportions Cultural factors / family support Motivation / emotional status Carer factors
Activities of Daily Living (ADLs) OT, Nursing, Physio Showering, hygiene & grooming Dressing - upper / lower limb Feeding, meal preparation Domestic skills Communication skills Home modifications Community access
Mobility / Transfers Physio, Nursing, OT Muscle strengthening & endurance Balance / stretches Transfers hoist, slide-board or lift bed to chair bed to commode / toilet / shower seat car / transport
Mobility / Transfers Physio, Nursing, OT Bed mobility Wheelchair mobility Gait training Posture / pressure management
Posture, Pressure & Skin Care Know sensory level / deficits Assess all potential sites of pressure Nutritional status if at risk Suitable bedding mattress, protective & assistive devices Wheelchair & suitable cushion Transfer skills
Bladder & Bowel Management Nursing with input from physio & OT Bladder training Intermittent catheters hand function necessary SPC / IDC Regular surveillance Bowel training Establish a routine time of day, suitable to lifestyle, prevents unplanned bowel actions 5 Rs - righ time, place, consistency, amount & reliable trigger
Patient Education Information / empowerment Readiness for learning / rehabilitation Teaching techniques Modules of relevant information Balance of theory & practice Problem solving skills Written information - later reference
Community Integration Home modifications bathroom, access Role in family & community Vocational options Transport options driving, maxi taxis, public transport Leisure & socialisation
Leisure Options Snow skiing Water-skiing Wheelchair rugby Basketball Netball Pistol shooting Darts Bowling lawn & 10pin Sailing Driving a car Computer / internet
Re-integration What are the obstacles?
Rehabilitation of the SCI Person Successful rehab dependent on Team approach Patient education theory & practice Discharge planning Appropriate equipment Housing suitable modifications Community reintegration & resources Support & follow up Community spinal nurses Annual review Country & Metro Clinics
Spinal Cord Injury Life for most of us is a matter of adjusting to change. Yet few of us are prepared to adjust to all the changes in life caused by a spinal cord injury (SCI). Even under the best of circumstances successful adaptation to the results of SCI requires courage, perseverance, faith, support from family & friends, & quality rehabilitation. Lex Frieden Foreword in Zejdlik C.P., (1992) Management of Spinal Cord Injury