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Spinal Cord Injury - Lecture notes Chapter 60

Adult Health Nursing II (Grand Canyon University)

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Spinal Cord Injury. Chapter 60

● Trauma or damage to spinal cord

○ Injury happens below the trauma
● Highest in men ages 16-30
● Increased in older adults
● Decreased mortality
● Long term issues remain
○ Disruption in growth and development
○ Altered family dynamics
○ Economic loss
○ Round the clock care.
○ Complications can arise.
● Etiology
○ Motor vehicle collisions
○ Falls
○ Violence
○ Sport injuries
■ Football, soccer, baseball, hockey
○ Other miscellaneous cases.
● Pathophysiology
○ SCI due to cord compression by
■ Bone displacement
■ Interruption of blood suppy
■ Traction from pulling on cord
○ Penetrating trauma-tearing and transection
○ Secondary injury- lose function of nerves. That’s why we give steroids
○ On going progressive dammage that occurs after primary injury
Spinal Shock
● Characterized by
○ Decreased reflexes
○ Loss of sensation
○ Absent thermoregulation
○ Flaccid paralysis below level of injury
● Last days to weeks
○ We can’t answer family questions about what the patient’s future will be like.
○ Just because they can’t walk now, doesn’t mean they might not walk in the future
○ May be quad, para, wheelchair bound
○ May have issues with breathing, urination. Cervical has more issues than lumbar.
Neurogenic Shock
● Characterized by
○ Hypotension
○ Bradycardia
● Loss of SNS innervation

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○ Peripheral vasodilation
○ Venous pooling
■ Sequential hose, heparin, lovenox
○ Dec cardiac output
■ If someone already has a history of heart failure then this happens to
them, it could cause things to get worse.
○ T6 or higher injury
Classification of sci
● Classified by
○ Mechanism of injury
○ Level of injury
○ Degree of injury
● Major mechanisms of injury are
○ Flexion
○ Hyperextension
○ Flexion-rotation
○ Extension-rotation
○ Compression.
○ Compare them always
Level of injury
● Skeletal vs. neurologic level
● Level of injury may be
○ Cervical
○ Thoracic
○ Lumbar
○ Sacral
● Tetraplegia (quadriplegia)
○ Most likely cold but do not know it because they can’t detect it
○ They will need help with social coping
○ Muscle atrophy will be an issue.
● Paraplegia
○ More mobility
○ More indepence
○ Will have wheelchairs but can move them better
○ Mentally, how are they doing?
○ They don’t have just one problem
● Degree of Injury
○ Complete
■ Total loss of sensory and motor function below level of injury
○ Incomplete (partial)
■ Mixed loss of voluntary motor activity and sensation
■ Some tracts intact.
● LOOK AT SYNDROMES ASSOCIATED WITH INCOMPLETE SCI
● Brown Seguard

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● Incomplete SCI central cord syndrome

○ Damage to central spinal cord
○ Most commonly cervical region
○ More common in older adults
○ Motor weakness and sensory loss
○ Lower extremitiesdasfkda
○ Fdsafdsajk
○ Gaba pentin?
● Worry about complete and incomplete, that’s it
● Clinical manifestations
○ Related to level and degree of injury
○ incomplete→ variable
○ Sequelae more serious with higher injury
○ The higher up the injury the more manifestations you will see.
Cauda Equina Syndrome
● Result form damage to cauda equine (lumbar and sacral nerve roots) “boom on your
butt”
● Asymmetcial distal weakness
● Flaccid paralysis of lower extremities
● Complete loss of sensation in saddle area (bowel, bladder, butt, genitals)
● Areflexic (flaccid) bladder and bowel
● Severe radicular, asymmetric pain.
● Clinical Manifestations
○ Closely correspond to level of injury
○ Above level of C4
■ Total loss of respiratory muscle function
■ Quad cough “hit them in the front with your palm to stimulate diaphragm”

● Was it actually severed or swollen?

● Was pain a part of this?
● You will see vital signs showing pain, even if they are not symptomatic because they are
numb.

Autonomic dysreflexia
● Clinical manifestations
○ Urinary
■ Neurogenic bladder
● Bladder dysfunction related to abnormal or absent bladder
innervation
○ No reflex detrusor contractions (flaccid, hypotonic)
○ Hyperactive reflex detrusor contractions (spastic)
○ Fdasdaf
○
○ Infection big concern

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○ Incontinence problem
○ Surgical bladder procedure
○ Straight cath
○ Teach them Kegels

● GI
○ Gastric distention
○ Development of paralytic ileus
○ Gastric emptying may be delayed
○ A
○ Do a cbc
○ Worrieda bout bleeding
Integumentary
Potential for skin breakdown
Poikilothermism
Interupption of SNS
Dec ability to sweat or shiver below the level of injury
More common
Can’t tell you they’re hot so monitor
Peripheral vascular problems
Venous thrmoboembolism
Pulmonary embolism-leading cause of death
Nociceptive Pain
Pain that is dull or aching it, moving it hurts extra
Hypersensitive to stimuli
Neuropathic pain
Located at or below level of injury
Hot, burning, tingling, pins, and needles, cold, shooting
May be extremely sensitive to stimuli

Diagnosts
CT scan, cervical x-rays, MRI, comprehensive neurologic exam, ct
angiogram.

Interprofessional Care
Pre hospital
Immediate goals
Patent airway
Adequate ventilation/breathing
Adequate circulating blood volume
Prevent extension of spinal cord damage
Immobilization
Rigid cervical collar

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Backboard with straps

Spinals immobilization with penetrating trauma not recommended
Maintain systolic BP greater than 90 mmHg
Acute Care
Initial care
Cervical injury requires more intense support
Obtain history, emphasizing inciden
Assess extent of injury
Initial assessment
Managing abcs and vitals signs
Medical intervention and diagnostics additional assessment
○ Brain injury and or vertebral artery injury
○ History of unconsciousness
○ Signs of concussion
○ Increased intracranial pressure
● Musculoskeletal injuries
● Trauma to internal organs
● Initial survery, whats obvious and wrong with them.
● Neuro checks.

● Move patient in alignment as a unit (logroll with at least 2 people)

● Surgical therapy
○ Used following acute SCI to fix instability and decompress the spinal cord
○ Surgery within first 24 hours associated with improved neurologic outcome
○ Posterior approach
○ Anterior approach
○ Fusion
○ Assess breathing and airway
○ Facial edema for lying down all day
○ Innervation problems in airs
○ Shoulders could ache
● Drug therapy
○ Mannitol
■ Osmotic diuretic
○ Low-molecular-weight heparin
■ Prevent VTE
○ Vasopressor agents (Levo and Norepi)
■ Maintain mean arterial pressure greater than afdklasjfd
● Fluid and nutritional maintenance
○ Paralytic ileus may occur, requiring NG tubes
○ Monitor fluid and electrolytes
○ Nutrition should be started within 72 hours
■ Individualized solutions/additives
■ High-protein, high calorie diet

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■ Possible parenteral nutrition

○ They might not be eating, so consider TPN
● Bladder Management
○ Neurogenic bladder initially
■ Indwelling urinary catherter
● Strict aseptic technique
● Inc fluid intake
■ Intermittent catheterization program
● Every 4-6 times daily
● Monitor for signs and symptoms or urinary tract infections
■ May be straight cathed rest of life.
● Temperature control
○ Dafda
● Stress Ulcers
○ PPI and H2 blockers will take whole life
● Autonomic Dysreflexia
○ Massive uncompensated cardiovascular reaction mediated by sympathetic
nervous system
■ SNS responds to stimulation of sensory receptors-parasympathetic
nervous system unable to counteract these responses
■ Hypertension and bradycardia.
■ Straight cath,
■ Take care of the problem they have, could cause a stroke if you don’t do
anything
○ Manifestations
■ Flushing
○ Interventions
■ Get rid of the problem
○ Neurogenic
■ Incontinent or can’t bleed
○ Drugs
■ Antispasmotic drugs
■ Small volume enema
○ Spasticity
○ Neurogenic skin
■ Reposition
■ Pain
■ Medicate
○ Grief and Depression
■ They are not the same person and they have lost so much
■ Empathy helps
○ Geri
■ Inc incidence

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