Spinal Cord Injury

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  1. What is the major risk factor for traumatic brain injury (TBI)
  2. Mechanism of Injury
    • Acceleration: when immobile head struck
    • Deceleration: head is moving and object it hit is still
    • Rotation injury when head twists as it hits
    • Acceleration-deceleration injury: Moving object hits immobile head which then hits second object
  3. Types of TBI
    • Blunt Trauma
    • --Brain actually moves inside skull as struck, as it's only tethered at the base
    • --Disruption to small blood vessels occurs as it scrapes the inside of the skull
    • Penetrating Trauma
    • --Velocity of object and fracture of bone creates the damage
    • --High velocity (bullets) produce shock waves
    • Coup-Contrecoup (Counterblow in French)
    • --Injury is to side opposite of the side hit
    • Scalp Injury
    • --Lacerations, hematomas
    • Skull Fractures
    • --Linear
    • --Depressed: adds pressure to brain
    • --Basilar: at back of skull-->raccoon eyes. 
    • Brain Injuries
    • Concussions: Short decrease in LOC, amnesia
    • Contusions: May be severe, will be localized
    • Diffuse Axonal Injuries: small injuries all over the brain r/t anorexia, anemia, hypoxia, post cardiac arrest. May--> posturing (flexion/extension). 
    • Decreased LOC is primary S&S
    • May present with posturing, increased ICP
  4. What do you need to know about epidural hematoma?
    • Between skull and dura mater usually associated with skull fracture:
    • --Forms large clot, usually quickly (arterial)
    • --Unconscious immediately after HI
    • --Awakens with lucid interval
    • --LOC rapid deteriorates, needs prompt attention.
    • --Quickly becomes comatose
    • --Confirm with CT scan
    • --Prompt intervention is essential
  5. Subdural Hematoma?
    • Subdural Hematoma (blood collects between the dura mater and arachnoid mater)
    • Acute/subacute: will cause bleeding in area of edema
    • --S&S appear 24-48 hours after injury
    • --Comprise ¼ of all TBI
    • --Onset of S&S is slower than Epidural Bleed
    • --May have variable change in LOC (fluctuates)
    • --HA, irritable and confused
    • Chronic: common with ETOH
    • --Occurs with atrophy, so more room for bleeding
    • --Appears recovered then gets hemiparesis, pupil changes
    • --Surgical evacuation with drains left in
  6. Intracrerbral bleeds?
    • Bleeding directly into parenchymal tissue of the brain
    • Can't be resected
  7. Reperfusion injuries?
    • From rapid reversal of ischemia
    • Cell wall damage from oxygen free radicals
    • Occurs after massive hypotension (like cardiac arrests or awaking from anesthesia)
  8. Nuring care for Traumatic Brain injury
    • Airway, airway, airway
    • Circulatory support
    • Protect cervical spine, keep ICP low
    • F&E, Elimination (IV lines, foley catheter)
    • Nutritional support (feeding tubes)
    • Complication management
    • Some are surgically managed
    • Rehabilitation for nearly everyone. 
  9. Things to know about Spinal Cord Injuries
    • 10,000 new injuries each year, males 16-30 most common
    • Auto,  motorcycle, gunshot or knife wounds
    • Non-traumatic injuries
    • Spondylosis
    • Osteoporosis
    • Tumors
    • Vascular diseases
  10. Mechanisms of injury for spinal cord injury
    • Flexion rotation
    • Hyperextension (diver's fracture)
    • Compression fractures
    • C1 (odontoid process) fractures
    • C2 (hangman's fracture)
    • Most common are C1-C2, C4-C5, T11-T12
    • Early cord edema can make exact location difficult to recognize (even reflexes are distorted)
  11. Pathyphys of spinal cord injury
    • Rarely torn or transected by direct trauma
    • Due to cord compression by bone displacement, interruption of blood supply to cord, traction from pulling on cord
    • GSW and Stab wounds can cause tearing and transection
    • Primary injury- initial disruption of axons as a result of stretch or laceration
    • Rectal tone is a good diagnositc for spinal cord injury
  12. Pathophys of secondary injury r/t spinal cord injury
    • Damage from ischemia, hypoxia, microhemorrhage and edema
    • Molecular level- cell death occurs, can continue for weeks or months after initial injury
    • Complete cord damage in severe trauma related to autodestruction of cord initial care and management critical to limit processes
    • Edema- can cause permanent damage within 24 hours, can develop secondary to inflammatory response, can compress cord and increase ischemic damage. Think about admin Decedron. 
    • Extent of injury and prognosis for recovery most accurately determined at least 72 hrs or more after injury
  13. SnSs of SCI
    • Reflexes altered
    • Cord bladder? 
    • Automatic bladder
    • Autonomic dysreflexia with exaggerated ANS reflexes related to full bladder/bowel distention with massive HTN (vasoconstriction) fever,dilated pupils. This is life threatening!!
    • Muscle spasms
    • Spinal Cord Shock: hypotension, multiorgan destruction.
  14. SnSs of spinal cord shock
    • Affects about 50% with acute SCI
    • Temporary neurologic syndrome lasting days to months. 
    • Decreased reflexes below level of injury
    • Loss of sensation below level of injury
    • Flaccid paralysis below level of injury
    • May mask post injury neurologic function
    • Active rehab. may still begin
  15. What is neuorgenic shock
    • Due to the loss of vasomotor tone caused by injury
    • Characterized by hypotension and bradycardia- important clinical clues
    • Loss of sympathetic nervous system tone innervation causes peripheral vasodilation, venous pooling, decreased cardiac output
    • Usually with cervical or high thoracic injury 
  16. Care for spinal cord injury?
    • Care at accident scene
    • Care in ED and radiology
    • Early hospital care
    • --Halo Traction
    • --Respiratory support
    • --Cardiovascular support  (hypotension)
    • --Aspiration risk
    • --Safety
    • --Depression management
    • --Nutritional support
    • --Neuro assessments
  17. Possible nursing diagnosis?
    • Pretty much all of them
    • Management of constipation becomes important. Intervention is typically digital stimulation.
  18. Nursing management for SCI pt.
    • Maintain airway, oxygenation, suction, ventilation
    • Immobilize spine- skeletal traction via tongs (Crutchfield or Gardner-Wells), halo traction
    • Monitor VS, fluid balance, neuro assessment
    • Prevent complications of immobility- rehab starts on admission- specialty beds
    • Medications- Methylprednisolone considered within 8 hours of injury possible neuro risks and potential risks
    • relieve edema- corticosteroids, anti-inflammatories
    • prevent discomfort- analgesics, sedatives, muscle relaxants
    • Prepare for surgery- possible decompressive laminectomy, spinal fusion

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Spinal Cord Injury
2013-02-19 17:25:19

Adult MedSurg 2
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