NCM 118 – SEMIFINALS
Traumatic Spinal Cord Injury
Spinal Cord Injury
• Spinal cord injuries (SCIs) are classified as complete or incomplete.
• A complete SCI is one in which the spinal cord has been damaged in a
way that eliminates all innervation below the level of the injury. Injuries
that allow some function or movement below the level of the injury are
described as an incomplete SCI.
• Incomplete injuries are more common than complete SCIs. Loss of or
impaired motor function (MOBILITY), SENSORY PERCEPTION, and bowel
and bladder control often result from an SCI.
Mechanisms of Injury
• Sources of force include direct injury to the vertebral column (fracture,
dislocation, and subluxation [partial dislocation]) or penetrating injury
from violence (gunshot or knife wounds).
• Although in some cases the cord itself may remain intact, at other times
it undergoes a destructive process caused by a contusion (bruise),
compression, laceration, or transaction (severing of the cord, either
complete or incomplete).
• The causes of SCI can be divided into primary and secondary mechanisms
of injury:
1. Primary Mechanisms
• Hyperflexion: a sudden and forceful acceleration (movement) of the
head forward, causing extreme flexion of the neck.
• Hyperextension - The head is suddenly accelerated and then
decelerated.
• Axial loading or vertical compression injuries resulting from diving
accidents, falls on the buttocks, or a jump in which a person lands on
the feet.
• Excessive rotation results from injuries that are caused by turning the
head beyond the normal range.
• Penetrating trauma is classified by the speed of the object (e.g., knife,
bullet) causing the injury.
2. Secondary Mechanism
• Hemorrhage - may be manifested by contusion or petechial leaking
into the central gray matter and later into the white matter.
o Systemic hemorrhage can result in shock and decrease
perfusion to the spinal cord
• Ischemia (lack of oxygen, typically from reduced/absent blood flow)
• Hypovolemia (decreased circulating blood volume)
• Impaired tissue perfusion from neurogenic shock (a medical
emergency)
• Local edema - a occurs with both primary and secondary injuries,
contributing to capillary compression and cord ischemia
Assessment
History
When obtaining a history from a patient with an acute SCI, gather as much
data as possible about how the accident occurred and the probable mechanism
of injury once the patient is stabilized.
Questions include:
• Location and position of the patient immediately after
the injury
• Symptoms that occurred immediately with the injury
• Changes that have occurred subsequently
• Type of immobilization devices used and whether any
problems occurred during stabilization and transport to
the hospital
• Treatment given at the scene of injury or in the
emergency department (ED) (e.g., medications, IV
fluids)
• Medical history, including osteoporosis or arthritis of the
spine, congenital deformities, cancer, and previous
injury or surgery of the neck or back
• History of any respiratory problems, especially if the
patient has experienced a cervical SCI
Physical Assessment

Initial Assessment

• The initial and priority assessment focuses on the patient's ABCs

(airway, breathing, and circulation).
• Evaluate pulse, blood pressure, and peripheral perfusion such as pulse
strength and capillary refill.
• Assess for indications of hemorrhage
• Use the Glasgow Coma Scale to assess patient’s LOC
• Spinal shock, also called spinal shock syndrome - the patient has
complete but temporary loss of motor, sensory, reflex, and autonomic
function that often lasts less than 48 hours but may continue for
several weeks.

Collaborative Problems
Sensory Perception and Mobility Assessment

• Tetraplegia (also called quadriplegia) (paralysis) and quadriparesis

(weakness) involve all four extremities, as seen with cervical cord
and upper thoracic injury.
• Paraplegia (paralysis) and paraparesis (weakness) involve only the
lower extremities, as seen in lower thoracic and lumbosacral
injuries or lesions.
• The patient may report a complete sensory loss, hypoesthesia
(decreased sensation), or hyperesthesia (increased sensation).

Nursing Interventions
Cardiovascular and Respiratory Assessment Managing the Airway and Improving Breathing
Airway management is the priority for a patient with cervical spinal cord
• Cardiovascular dysfunction results from disruption of sympathetic injury!
fibers of the autonomic nervous system (ANS), especially if the
injury is above the sixth thoracic vertebra.
• Bradycardia, hypotension, and hypothermia occur because of loss
of sympathetic input.
• A systolic blood pressure below 90 mm Hg requires treatment
because lack of perfusion to the spinal cord could worsen the
patient's condition.
• Autonomic dysreflexia (AD), sometimes referred to as autonomic
hyperreflexia, is a potentially life-threatening condition in which
noxious visceral or cutaneous stimuli cause a sudden, massive, Managing the Airway and Improving Breathing
uninhibited reflex sympathetic discharge in people with high-level
SCI Cough Assist

• Place hands on the upper abdomen

over the diaphragm and below the ribs.
Assessment of Patients for Long-Term Complications
• Have the patient take a breath and
• Assess skin integrity with each turn or repositioning. cough during expiration.
• Lock elbows and pushes inward and
• Monitor for signs of VTE with vital signs, including lower-extremity upward as the patient coughs.
deep vein thrombosis (DVT).
• Repeat the coordinated effort, with rest periods as needed, until the
• Bones can become osteopenic and osteoporotic without weight- airway is clear.
bearing exercise.

• Heterotopic ossification (HO) - bony overgrowth, often into muscle. Monitoring for Cardiovascular Instability
Assess for swelling, redness, warmth, and decreased range of
motion (ROM) of the involved extremity. • Maintain adequate hydration through IV therapy and oral fluids as
appropriate, depending on the patient's overall condition.

• Carefully observe for manifestations of neurogenic shock -

manifests as hypotension, bradyarrhythmia, and temperature
dysregulation due to peripheral vasodilatation following an injury
to the spinal cord
 Drug Therapy for SCI

• Tizanidine - Centrally acting skeletal muscular relaxants, may help

control severe muscle spasticity.

− cause severe drowsiness and sedation in most patients

• Intrathecal Baclofen (ITB) (Lioresal) – given instead of Tizanidine

− Monitor for common adverse effects, which include

sedation, fatigue, dizziness, and changes in mental
status.
− Seizures and hallucinations may occur if ITB is suddenly
withdrawn.

• Celecoxib (Celebrex) - may be prescribed to prevent or treat

heterotopic ossification
Monitoring for Cardiovascular Instability • Calcium and bisphosphonates - may prevent the osteoporosis that
results from lack of weight-bearing or resistance activity.
Drugs for Cardiovascular Instability

• Dextran - a plasma expander, may be used to increase capillary

Surgical Management
blood flow within the spinal cord and prevent or treat hypotension.
• Surgery within 24 hours of injury to stabilize the vertebral spinal
• Atropine sulfate - is used to treat bradycardia if the pulse rate falls
column, particularly if there is evidence of spinal cord compression.
below 50 to 60 beats/min.
• Cervical fusion - the surgeon reduces the fracture by placing the
• Dopamine or other vasoactive agent – given IV sympathomimetic
bone ends in proper alignment.
agents if hypotension is severe.
• Metal wiring is then used to secure bone chips taken
Preventing Secondary Spinal Cord Injury
from the patient's hip or other source of bone grafting.
• Assess the patient's neurologic status, particularly focusing on MOBILITY
• For thoracic and lumbar fusions, metal or steel rods (e.g.,
(motor) and SENSORY PERCEPTION function, vital signs, pulse oximetry,
Harrington rods) are used to keep the bone ends in alignment after
and altered COMFORT, at least every 1 to 4 hours,
fracture reduction.
• Document your assessments carefully and in detail, particularly changes
in motor or sensory function. Failure to do so may prevent other staff
members from quickly recognizing deterioration in neurologic status.
• Keep the patient in proper body alignment to prevent further cord injury
or irritability.
• Devices such as traction, orthoses, or collars may be used to keep the
spine immobilized during healing and rehabilitation.

Spinal Immobilization and Stabilization

• Place a hard cervical collar immediately and maintained until

a specific order indicates that it can be removed.

− Inspect skin beneath the collar DAILY

− Maintain neck alignment
Specific Nursing Interventions
• Halo fixator device - worn for 8 to 12 weeks.
Patients with an SCI are especially at risk for pressure injuries due to
− This static device is affixed by four pins (or screw) into altered sensory perception of pressure areas on skin below the level of
the outer aspect of the skull. the injury.
− To realign the vertebrae, facilitate bone healing, and
prevent further injury • Assess the condition of the patient's skin, especially over pressure
points, with each turn or repositioning.
• When sitting in a chair, patients usually perform frequent
“wheelchair push-ups” to relieve skin pressure.
• Contractures may be prevented or minimized with splints and
range-of-motion exercises.
• Teach or reinforce teaching for bed MOBILITY skills and bed-to-chair
transfers.
• All patients with an SCI require bowel and bladder retraining,
including adequate fluids and stool softeners to prevent constipation.