UNIT 2: Spinal Cord Injury (MST 1)

Question 1

What is the etiology and patho of a spinal cord injury (SCI)

Answer 1

1. Usually the result of a trauma
   
   • Degenerative loss of motor, sensory, and autonomic function
   • Partial or complete
2. Cell death may continue for weeks or months after inital injury
   
   • Apoptosis (programmed cell death)
3. Edema secondary to inflammatory response is harmful because of lack of space for tissue expansion
   
   • Compression of cord and extension of edema above and below cord injury increases risk of ischemic damage

Question 2

How can an SCI affect a patient?

Answer 2

1. Physical
2. Psychosocial
3. vocational
4. finicially
   
   • Cost of care and economic losses

Not only for the patient but caregiver as well.

Question 3

Can central nervous system function be regained following an SCI?

Answer 3

NO

Question 4

The extent of injury and prognosis for recovery for most SCI patients are determined at least….. how long after injury?

Answer 4

72 hours

Question 5

What is spinal shock?

Answer 5

Characterized by
1. loss of deep tendon and sphincter reflexes
2. loss of sensation
3. flaccid paralysis below level of injury
2. Can last days to weeks.
3. Masks post injury neuologic funciton so they may end up with more movement than what they appear to have while in “spinal shock”

Question 6

What is neurogenic shock?

Answer 6

1. Can occur in cervical or high thoracic injury (T6 or higher). It occurs from unopposed parasympathetic response due to loss of SNS innervation
2. Causes Peripheral vasodilation, venous pooling, decreased cardiac output
3. Can last 1 to 3 weeks
4. Patient will be warm/dry/pink

PIPE PROBLEM

Question 7

What are manifestations of neurogenic shock?

Answer 7

1. Significant hypotension (under 90mmHg)
   
   • Hypotension can result in poor perfusion and oxygenation to the spinal cord and worsen spinal ischemia
2. Bradycardia
3. Temp dysregulation
4. warm, dry, pink
5. PIPE PROBLEM

Question 8

Skeletal level of injury is…

Answer 8

Injury is the betebral level where there is most damage to vetebral bones and ligaments.

Question 9

Neurologic level of injury in SCI is…

Answer 9

1. Lowest segment of spinal cord with normal sensory and motor function on both sides of the body.
2. The level of injury may be cervical, thoracic, lumbar or sacral. Cervical and lumbar injuries are most common because they are associated with the greatest flexibility and movement.
3. If the cervical cord is involved paralysis of all four extremeites occur, resulting in tetraplegia (formerly termed quadriplegia)

Question 10

What should we know about cervical spine injuries?

Answer 10

1. If the cervical cord is involved, paralysis of all four extremities occurs, resulting in tetraplegia. The degree of impairment in the arms following cervical injury depends on the level of injury.
2. The LOWER the level, the more function is retained in the arms

Question 11

If the thoracic, lumbar or sacral spine cord is damaged….. what should we know

Answer 11

If the thoracic lumbar, or sacral spinal cord is damaged, the result is paraplegia (paralysis and loss of sensation in the legs). shows affected structures and functions at different levels of cord injury.

Question 12

C4 injury results in…

Answer 12

1. Tetraplegia
2. Results in complete paralysis below the neck

Question 13

C6 Injury results in…

Answer 13

1. Results in partial paraylsis of hands and arms as well as lower body

Question 14

T6 Injury results in…

Answer 14

Paraplegia results in paralysis below the chest

Question 15

L1 injury resutls in…

Answer 15

Paraplegia, results in paraylsis below the waist.

Question 16

What is complete cord involvement in a SCI?

Answer 16

1. Results in total loss of sensory and motor function below the level of injury.

Question 17

What is incomplete (partial) cord involvment in a SCI

Answer 17

Results in a mixed loss of voluntary motor activity and sensation and leaves some tracts intact.

Question 18

What are some examples of incomplete syndrome with SCI

Answer 18

1. Central cord
2. Brown-Sequard

Question 19

What is Central cord syndrome?

Answer 19

Hyperextension injuries or interrupted blood supply.
1. Occurs most commonly in the cervical cord region.
2. Motor weakness and sensory loss are present in both upper and lower extremitites
3. Greater loss in arms than in legs.
4. Bony abnormaility may be absent

These patients will have greaters deficits in there arms.. They may appear to be able to move there legs fine in bed but dont be fooled this patients are unable to stand on their own. Eventually with enough support they may be able to walk again with supportive devices but not always.

Have neuro surgeon talk to family if they have questions. So many unknowns.

Question 20

What is brown-sequard syndrome?

Answer 20

1. Damage to half of the spinal cord typically results from penetrating injury to spinal cord
2. Characterized by a loss of motor function and position and vibration sense on same side of injury
3. Paralysis on the same side as lesion
4. Opposite side has loss of pain and temperature sensation below level of lesion

Loss of position aka proprioseption is when people cannot tell where there limbs are or how they are lying.

Half the spinal cord affected. The side of injury will have paralysis the other half will have the loss of pain, temp and senstion.

Question 21

What are clinical manifestations of SCI?

Answer 21

1. Higher the injury, the more serious the sequalae (complication)
   
   • Proximity of cervical cord to medulla and brainstem (can tell you what kind of sequelae you might have)
   • Movement and rehabilitation potential related to specific locations of spinal cord injury
   • Patient with an incomplete lesion may demonstrate a mixture of symptoms.

Question 22

Injury at the C1-3 cause what respiratory manifestations.

Answer 22

1. Apenea
2. Inability to cough

Question 23

Injury at c4 causes what respiratory manifestations in a SCI?

Answer 23

1. Poor cough
   
   • May have to help them cough by having them lay flat on back placing hand on diaphram and move like your doing the hymlic maneuver and tell them to cough and push in
2. diaphragmatic breathing,
3. hypoventilation

Question 24

Injury at the C5-T6 causes what respiratory manifestations in a SCI patient

Answer 24

1. Decreased resp. reserve

Question 25

What cardiovascular system manifesatsion might we see in a patient with a SCI? | MAY NEED TO ADD INTERVENTIONS AFTER LECTURE

Answer 25

1. Above level T6 reduce influence of the sympathetic nervous system 2. Heart rate is slow (less than 60 beats per min) because of unopposed vagal response 3. Any increase in vagal stimulation can result in cardiac arrest. 4. Decrease venous return of blood to heart, Decreased cardiac output 5. IV fluids or vasopressor drugs may be required to support BP

Question 26

What are some interventions to help a SCI patient with cardiac system manifestations...

Answer 26

1. Compression gradient stockings, Remove every 8 hours for skin care 2. Prophylactic heparin or low molecular weight heparin 3. Asses vitals 4. Anticholinergic for bradycardia 5. Phrenic nerve stimulators or electronic diaphrgmatic pacemakers increase mobility 6. Teach cervical-level injury patietns who are not ventilator dependent 7. - Assisted coughing 8. Regular use of spirometry or deep breathing exercises

Question 27

What are clinical manifestatsion of the urinary system in a SCI patient.

Answer 27

1. urinary retention common - Urine is retained - Loss of autonomic and reflex control of bladder and sphincter - Bladder over distention can result in reflux into kidney with kidney with eventual renal failure 2. Bladder may become hyperirritable. 3. Intermittent catheterization program - UTI

Question 28

What are clinical manifestations of the GI system in SCI patients

Answer 28

1. If cord injury is above T5, primary GI problems related to hypomotility - gastric distension adn development of paralytic ileus can occur - Gastric emptying may be delayed, especially in patients with higher level SCI. - Excessive release of hydrochloric acid (HCI) in the stomach may cause stress ulcers. 2. Injury level of T12 or below decreased sphincter tone 3. As reflexes return - Bowel becomes reflexic - Sphincter tone is enhanced - Reflex emptying occurs.

Question 29

What are clinical manifestations of teh integumetnary system in patients with a SCI

Answer 29

1. Consequence of lack of movement is skin breakdown 2. Pressure ulcers can occur quickly 3. Can lead to major infection or sepsis

Question 30

What are clinical manifestations of thermoregulation with CSF pts

Answer 30

1. Poikilothermism - Adjustment of body temperature to room temp 2. With spinal cord disruption - Decreased ability to sweat - Decreased ability to shiver 3. Degree of poikilothermism depends on level of injury biggest take away is that there temp will match the enviroment. We manage by keep the patient at a comfy temp. Not too hot, not to cold.

Question 31

What is Poikilothermism?

Answer 31

Inability to maintain a constant core temp. with the patient assuming the temp of the environment. It occurs in teh SCI because interruption of the SNS prevents peripheral temp. sensations from reaching the hypothalamus. There decreased ability to sweat or shiver below the level of injury. Which affects the ability to regulate body temp.

Question 32

Which spinal injuries are associated with a greater loss of ability to regulate temp?

Answer 32

Cervical

Question 33

What are nonoperative stablization options for SCI?

Answer 33

1. Through traction or realignment 2. Eleminate damaging motion at injury site 3. Intended to prevent secondary injury Nonoperative treatment involve stabilization of the injured spinal segment and decompression. Stabilization eliminates damagin motion at the injury site.

Question 34

What should we know about surgical therapy for tx of SCI?

Answer 34

1. Criteria for early surgery. - Evidence of cord compression - Progressive neurological deficit - Compound fracture - Bony gragments - Penetrating wounds of spinal cord or surrounding structures 2. Surgical tx is used following acute SCI to address the instability and decompress the spinal cord. Type of surger depends on the severity and level of injury, mechanism of injury, degree and location. 3. Surgery within the 1st 24 hours after SCI is safe and associated with improved neurologic outcome.

Question 35

What should we know about immobilization?

Answer 35

1. Proper immobilization involbes maintenance of a neutral position 2. Skeletal traction - Sites of tong insertion can become infection - Clean twice daily - realightment or reduction of injury - provided by rope, pulley and weights - Traction must be maintained at all times. 3. Kinetic therapy - uses a continual side-to side slow rotation - Decreases pressure ulcers and cardiopulmonary complications 4. Halo Jackets

Question 36

How do we determine neurogenic shock and how do we treat?

Answer 36

1. We can give 500- 1L of fluid. If it doesnt change anything going on with the patient we know that its neurogenic shock so we will give VASSOPRESSORS not fluids so we dont "drown them"

Question 37

With any classification of SCI what is an important percaution to put in place

Answer 37

Fall prevention use call light just use help so you dont get hurt

Question 38

What is a common complication in SCI?

Answer 38

Atelectasis have pt use IS and give pressured air?

Question 39

What is autonomic dyreflexia?

Answer 39

MEIDCAL EMERGENCY It occurs when you have a spinal cord injury at T-6 or highter. It is triggered by sustained stimuli at T6 or below from 1. Restrictive clothing 2. Full bladder or UTI 3. Pressure areas 4. Fecal impaction

Question 40

What are s/s of autonomic dyreflexia?

Answer 40

1. Increased BP- severe and rapid 2. Flushed Face 3. Headache 4. Distended neck veins 5. Decreased heart rate 6. Increased sweating 7. Vasodilation above level of injury 8. Vasoconstriciton below the level of injury- pale, cool, no sweating...

Question 41

What are our nursing inteventions for autonomic dyreflexia?

Answer 41

1. Elevate head of bed at 45 degrees or sit patinet upright 2. Notify MD 3. Assess cause 4. Immediate catheterization 5. Teach patient and family causes and symptoms In not treated IT will KILL