

 http://www.rexdonald.com/facts.html
 http://www.cureparalysis.org/statistics/
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
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
Spinal Cord Injuries
 Causes
(in order of frequency)
 MVA
 Gunshot
wounds/acts of violence
 Falls
 Sports
injuries
Spinal and Neurogenic Shock
 Below
 Total
site of injury:
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
Classification of SCI
 Mechanism
 Flexion
of injury
(bending forward)
 Hyperextension (backward)
 Rotation (either flexion- or extensionrotation)
 Compression (downward motion)
Pathophysiology of SCI
 Insert
stuff here
 Insert picture here
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
http://www.scirecovery.org/sci.htm
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

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
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.
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.
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.
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!
Clinical Manifestations of SCI
 Respiratory
– 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.
 C1
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

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.).
Cardiovascular system
– T5 shows decreased or absent SNS
influence.
 BRADYCARDIA AND HYPOTENSION
(due to vasodilation)
 C1
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
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!
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
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
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?)
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
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
Surgical Therapy
 Reduces
 Done
injury and stabilizes the SC
for
 Compression
 Bony
fragments in the cord
 Compound fracture
 Penetrating trauma
Drug Therapy
 Vasopressors
(Dopamine) to keep
mean arterial pressure greater than
80mm to 900mm/Hg so that
PERFUSION TO CORD is improved.
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
Other drug therapy
 Symptom-reducing
 GI
drugs for
problems - zantac, tagamet, pepcid
 Bradycardia - atropine
 Hypotension - vasopressors
 bladder spasticity - anticholinergics
 autonomic dysreflexia – blood pressure
reduction
Function of Motor Neurons
 Upper
motor neurons
Function of Motor Neurons
 Lower
motor neurons
Diagnoses and Interventions
 Impaired
Gas Exchange r/t muscle
fatigue and weakness
 Decreased
Pao2, increased PaCO2
 Fatigue
 Diminished
breath sounds
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
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
Decreased cardiac output
 Related
to venous pooling of blood and
immobility as evidenced by
 Hypotension
 Tachycardia
 Restlessness
 Oliguria
 Decreased
pulmonary artery pressures
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
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
Constipation
to location of injury,  fluid
intake, diet, immobility AEB
 Related
 Lack
of BM in over 2 days
  bowel sounds
 Palpable impaction
 Hard stool or incontinence
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
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!!!
Urinary Retention
 Related
to injury and limited fluid intake
as evidenced by
 Decreased
output
 Bladder distention
 Involuntary emptying of bladder
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
Risk for AUTONOMIC
DYSREFLEXIA
 Assess
for HTN, bradycardia,
headache, sweating, blurred vision,
flushing, nasal
stuffiness/congestion
 Reduce or eliminate noxious stimuli
such as impaction, urine retention,
tactile stimulation and skin lesions
or pain!
Autonomic dysreflexia
 Elevate
HOB 43 degrees
 Identify cause and eliminate
 Take BP and pulse
 Administer antihypertensives as ordered
if hypertensive.
 Call physician if interventions not
effective
 TEACH CLIENT AND CARGIVERS
HOW TO PREVENT THIS!
Other diagnoses
 Impaired
physical mobility
 Altered nutrition: < body requirements
 Sexual dysfunction
 Risk or injury r/t sensory deficits
 Altered family processes
 Risk for ineffective individual coping
 Body image disturbance
Acute intervention
Immobilization
Crutchfield
tongs
Halo
vest
Stryker bed
Roto-rest bed (side to side)

Motion sickness a problem with
these.
Respiratory dysfunction
 Intubation
if injury is high
 Decreased tidal volume and shallow
breathing lead to pneumonia and
atelectasis
 CPT and pain management
 Prone position may be risky
 Count to 10 test
 QUAD COUGH technique to assist with
ineffective abdominal muscles
Fluids and nutrition
 Paralytic
ileus common in 48-72 hours
 When bowel sounds return:
 High
calorie, high protein, high fiber diet
 Evaluate SWALLOWING before feeding!
 EATING
CAN BECOME A POWER
STRUGGLE!
Bowel and Bladder mgmt.
 Indwelling
catheter initially
 Intermittent catheterization when able
 Monitor pH of urine (should be acetic!)
 Ascorbid acid and Mandelamine (an
antiseptic) given to keep down bacteria
Temperature control
 NO
vasoconstriction, piloerection or
heat loss through sweating below level
of injury
 Do not over cool or over heat client.
They only have the remaining upper
portion of their bodies, generally, for
temperature adjustment