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  1. •

  2. 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

  3. Spinal Cord Injuries • Who’s 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

  4. Spinal Cord Injuries • Causes (in order of frequency) • MVA • Gunshot wounds/acts of violence • Falls • Sports injuries

  5. Spinal and Neurogenic Shock • Below site of injury: • Total 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

  6. Classification of SCI • Mechanism of injury • Flexion (bending forward) • Hyperextension (backward) • Rotation (either flexion- or extension-rotation) • Compression (downward motion)

  7. Pathophysiology of SCI • Insert stuff here • Insert picture here

  8. 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


  10. 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

  11. 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

  12. 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.

  13. 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.

  14. 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.

  15. 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!

  16. 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.

  17. 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

  18. 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.). 

  19. Cardiovascular system • C1 – T5 shows decreased or absent SNS influence. • BRADYCARDIA AND HYPOTENSION (due to vasodilation)

  20. 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

  21. 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!

  22. 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

  23. 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

  24. 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?)

  25. 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

  26. 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 you’re doing, he will answer accordingly. • Assess for head injury and ICP • X-ray, CT scan, EMG

  27. Surgical Therapy • Reduces injury and stabilizes the SC • Done for • Compression • Bony fragments in the cord • Compound fracture • Penetrating trauma

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

  29. 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

  30. Other drug therapy • Symptom-reducing drugs for • GI problems - zantac, tagamet, pepcid • Bradycardia - atropine • Hypotension - vasopressors • bladder spasticity - anticholinergics • autonomic dysreflexia – blood pressure reduction

  31. Function of Motor Neurons • Upper motor neurons

  32. Function of Motor Neurons • Lower motor neurons

  33. Diagnoses and Interventions • Impaired Gas Exchange r/t muscle fatigue and weakness • Decreased Pao2, increased PaCO2 • Fatigue • Diminished breath sounds

  34. 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

  35. 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

  36. Decreased cardiac output • Related to venous pooling of blood and immobility as evidenced by • Hypotension • Tachycardia • Restlessness • Oliguria • Decreased pulmonary artery pressures

  37. 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

  38. 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

  39. Constipation • Related to location of injury,  fluid intake, diet, immobility AEB • Lack of BM in over 2 days •  bowel sounds • Palpable impaction • Hard stool or incontinence

  40. 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

  41. 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!!!

  42. Urinary Retention • Related to injury and limited fluid intake as evidenced by • Decreased output • Bladder distention • Involuntary emptying of bladder

  43. 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