11.1 Complications and Management of Spinal Cord Injury

Question 1

Autonomic Dysreflexia (hyperreflexia)

Answer 1

• Seen in people with injuries T6 and above where CNS control of spinal reflexes is lost.
• Occurs 6 months after spinal shock resolves and autonomic responses return.
• It is acute and exaggerated sympathetic reflex responses

Manifestations
- Vasospasms, Paroxysmal hypertension (240/120), skin pallor, piloerector response
- Hypertension with bradycardia, vasodilation with sweating and flushed skin above the injury, headache, anxiety

• CAN BE CAUSED BY A FULL BLADDER, PAIN RECEPTORS, OR OPERATIVE/DIAGNOSTIC PROCEDURES
• CLINICAL EMERGENCY AND CAN LEAD TO SEIZURES OR DEATH.

Question 2

Spinal Shock

Answer 2

• Caused by spinal injury anywhere
• Loss of reflexes below the injury
• Can last hours to weeks

S/S
- Flaccidity
- Loss of reflexes

Question 3

Neurogenic Shock

Answer 3

• Caused by T6 or above injury
• Temporary loss of sympathetic tone
• Usually only lasts less than 3 days

S/S
- Hypotension
- Bradycardia
- Loss of ability to sweat below the injury

Question 4

Orthostatic Hypotension

Answer 4

• Occurs in T4-6 Injuries or higher
• There is a disconnect between hypothalamus and sympathetic nervous system
• There is decreased venous return causing interruption of sympathetic outflow to blood vessels in extremities and abdomen.

S/S
- Dizziness
- Pallor
- Sweating above level of injuy
- Blurred vision
- Fainting

Question 5

Vasovagal Response

Answer 5

• Vagal Nerve (10) usually unaffected by SCI
• Sympathetic nervous system cannot oppose vagal stimulation

S/S
- Marked bradycardia or even asystole
- Can be caused by deep endotracheal suction or rapid position change

Question 6

Cardiovascular Complications

Answer 6

• Neurogenic shock or loss of sympathetic nervous system
• Orthostatic hypotension can cause cerebral ischemia
• DVT and PE is high risk in the first 2-3 months (treat with SCDs, heparin, early mobilization)

Question 7

Pulmonary

Answer 7

Pneumonia/Atelectasis
- SCI can cause decompensation to respiratory function

Aspiration
- Injuries at C4 or higher can cause paralysis to diaphragm
- Phrenic nerve arises at C5, which is responsible for diaphragm inspiration, deep breathing and coughing

Question 8

GI

Answer 8

• Ileus
• NG tube for decompression of stomach
• Gastric ulcer prognosis (px)
• Bowel regime and assessment

Question 9

GU

Answer 9

• UTI
• Urinary retention and bladder distension
• Renal stones
• Assess postvoid residual with bladder scan

Question 10

Integumentary

Answer 10

• High risk for pressure ulcer due to loss of sensation/motor function
• Wounds are difficult to heal so infection is a risk
• PREVENTION IS KEY

Question 11

Treatment

Answer 11

Halo Device
- Can provide traction without need to stay in bed

Gardner Well Tongs
- Used for traction while patient is on bed

Rotorest Bed
- Specialty bed that allows weight shift of body while maintaining spinal alignment.

Question 12

Managing Symptoms of Spinal Injuries

Answer 12

• Pain
• Heart function
• BP
• Temperature control
• Nutritional status
• Bladder/Bowel function
• Spasticity

Rehabilitation
- Prevent muscle wasting
- Retain muscles by aiding in mobility and movement

Goal - Patient to have as much independence as possible

Question 13

Nursing Considerations

Answer 13

• Prevent further damage by immobilizing patient and logrolling
• Assess complications, communication issues, psychological toll on patient and family (MAJOR)

Psychological toll
- Lifestyle change
- Body image
- Independence
- Stress on relationships
- Denial, grief, anger
- Monitor for inadequate coping, withdrawal from social interactions
- Encourage patient to discuss feelings, participate in decision making, spiritual care.

Question 14

Leading cause of Death in SCI

Answer 14

• Pneumonia and other respiratory conditions followed by heart disease, subsequent trauma, and sepsis

Incomplete Paraplegia Leading Cause of Death
- Cancer and suicide
Complete Paraplegia leading cause of death is suicide

Question 15

Trigeminal Neuralgia

Answer 15

• Neuropathic disorder that causes episodes of intense pain in the face
• Caused by enlarged blood vessel (cerebral artery) compressing against the trigeminal nerve injuring the myelin sheath and causing hyperactivity. This causes stimulation and the inability for pain signals to be shut off.

Other Causes
- Aneurysm, tumor, arachnoid cyst, traumatic events like car accidents.

Treatment
- First line of defense is anticonvulsant (carbamazepine) (Phenytoin)
- Antidepressants may help with neuropathic pain and used to counteract medication side effects. (Duloxetine)
- Opiates
- Nerve blocks

Nursing Care
- Assess triggers
- Hygiene
- Nutrition
- Degree of pain

Question 16

Bells Palsy

Answer 16

• Facial paralysis from dysfunction of cranial nerve 7 (facial nerve) of affected side.
• Can be mistaken for brain tumor, stroke, Lyme’s disease.
• Idiopathic unilateral facial nerve paralysis.
• RAPID ONSET USUALLY OVERNIGHT
• Diagnosed by process of elimination from stroke, etc.

Treatment
- Prednisone
- Acyclovir (antiviral) because it bells palsy may be linked to herpes and varicella
- Smile surgery to restore peoples ability to smile

Nursing Care
- Focus on pain, nutrition, altered body image, corneal abrasions, hyperesthesia.

Question 17

Guillain-Barre Syndrome (GBS)

Answer 17

• Demyelination of peripheral nerves and edema.
• Acute immune mediated polyneuropathy.
• Medical emergency due to ventilatory failure and circulatory disturbances.

S/S
- Causes ascending paralysis that starts at the feet and hands, then migrates to the trunk.
- Can also cause changes in pain sensation and dysfunction of autonomic nervous system.
- LIFE THREATENING IF RESPIRATORY MUSCLES OR AUTONOMIC NERVOUS SYSTEM IS AFFECTED.
- TRIGGERED BY INFECTIONS (SWINE FLU)

Question 18

GBS S/S AGAIN????

Answer 18

• Lower motor neuron paralysis
• Progressive ascending muscle weakness of limbs producing flaccid paralysis
• Can ascend to quadriplegia and then respiratory insufficiency.
• Autonomic NS instability which can cause orthostatic hypotension, arrythmias, facial flushing, circulatory dysfunction, urinary retention.
• Recovery occurs proximal to distal.

Diagnosis
- Rapid muscle paralysis with absence of fever
- CSF analysis
- Electrodiagnostic to test nerve and muscles

Treatment
- SUPPORTIVE CARE (RESPIRATORY INTUBATION MAY BE NEEDED AND MOST IMPROTANT), and treating body attacks on nervous system.

Medications
- Plasmapheresis - Filters antibodies out of the blood stream to hasten recovery
- IVIG - Neutralizes harmful antibodies and inflammation causing diseases. Should be started within 2 weeks of onset of symptoms

• IVIG is used first due to ease of administration and safety
• Can cause hepatitis and renal failure if used longer than 5 days.
• CORTICOSTEROIDS NOT EFFECTIVE

Question 19

GBS Collaboration

Answer 19

• Multidisciplinary approach
• ADL’s, occupational therapy for mobility (wheelchair, special cutlery), physiotherapist to assist functional movement and to regain strength, endurance, gait quality. Speech therapist to regain speaking and swallowing ability

Question 20

Post-Polio Syndrome

Answer 20

• Poliomyelitis
• Viral illness that causes destruction of motor cells of the anterior horn of spinal cord and motor strip of frontal lobe.

S/S
- New onset of weakness, pain, and fatigue

Treatment
- Lifestyle modification
- Adaptive devices to preserve energy

Question 21

Tetanus

Answer 21

• “Lockjaw”

S/S
- Muscle rigidity
- Cramps, muscle spasms, stiffness, headache.

Medication
- Sedation, antianxiety, muscle relaxants.
- Goal is to decrease muscle spasms and increase comfort.
- Beta blockers and anti-dysrhythmics for cardiac complications.

Nursing Care
- AGGRESSIVE SUPPORT