Critical care

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  1. Upper Motor Neurons
    Originate in the cerebral cortex
  2. Lower Motor Neurons
    Originates in the brain stem
  3. White Matter Region
    Three Major Tracts
    • Corticospinal tract
    • -Transmits motor activity
    • Spinothalamic Tract
    • -Transmits pain and temperator
    • Posterior Column (Dorsal ) tract
    • -Carries sensations of vibrations, propriception, touch, fine touch, pressure and texture.
  4. Complete Spinal Cord Injury
    • Complete spinal cord transection
    • -lack of sensory and motor function below the level of injury
    • Tetraplegia (Quadraplegia)
    • -Complete severing of the spinal cord between C1 and T1
    • Loss of motor and sensory function of the arms, trunk, legs and pelvic organs
    • Probably no bowel or bladder function
  5. Paraplegia
    • Complete severing of the spinal cord between T2 and L1
    • Loss of motor and sensory function of the lower extremities
    • Will have upper extremity function
    • Possible bowel and bladder training
  6. Incomplete Spinal Cord Injury
    • Injury did not completely sever the spinal cord
    • Preservation of some sensory and or some motor function below the level of injury
    • Could have altered sensory and or motor function
    • Symptoms of injury depends on which area the spinalcord was injured
    • This is where the tracts matter
  7. Incomplete Spinal cord injury
    • If the incomplee injury occurs at T12 and above- it will be an upper motor neuron injury
    • Manifestations:-spasticity of muscles-Exaggerated tendon reflexes-Spastic neurogenic bladder-anal sphincter will respond
    • If the incomplete injury occurs below T12 - it will be a lwer motor neuron injury
    • Manifestations: -Hypotonation - Hyporeflexia -Flaccidity - Acontractile bladder and bowel
    • Cannot have bowel and bladder training
    • There will no control , no contraction to push stool out
  8. Cervical Injuries
    • Complete = will be ventilator dependant
    • Cervical vertabrae are the most vulnerable
    • C1-C3 can be fatal-loss of phrenic nerve=ventilator dependant
    • C4-C5 most common driving injuries
    • C7-T1 - Coup -Contrecoup Shearing force mechanism of injury
  9. Thoracic and lumbar injuries
    • T12-L1 most common site of thoracic spinal cord injury
    • Usually occur from a fall onto upper back
    • a fall onto buttock
    • Calcaneous fractures
    • Lumbar usually occur from only wearing a lap belt in a MVC
  10. Primary Injury
    • Occurs at the Moment of Impact
    • Mechanism of Injury:-Hyperflexion
    • Hyperextention
    • Flexion -rotation
    • Compression
  11. Secondary Injury
    • Occurs within minutes of the primary injury
    • Is vascular injury to spinal cord
    • Can last days to weeks
    • Manifestations:Ischemis, Elevated intracellur calcium, Inflammatory process
    • Secondary - everybody gets all three
  12. Reflex activity Assessment
    Perineal Reflexes
    • Assess for presence of perineal reflexes
    • If present - indicates a feasibility of bowel and bladder training
    • Indicates a upper motor neuron injury
    • Perineal reflexes included:
    • Anal wink -eleicted when the rectal sphincter contracts
    • Bulbocavernosus - elicted when the rectal sphincter contracts to tugging on the foley catherer
  13. Shock States
    • Results of autonomic nervous system dysfunction-dysfunction of homeostasis in the body
    • The higher the spinal cord injury is, the greater the dysfunction will be.
    • Two major types of shock states in SCI
    • Spinal shock and Neurogenic shock
  14. Facts about Spinal Shock
    • Why? Results of autonomic nervous system dysfuncion
    • When? Occurs within 30-60 minutes after spinal cord injury
    • Resolves? Can last weeks or months and can be transient
    • How do you know the patient is in spinal shock?
    • Temporarily causes: Absence of all reflex activity- Flaccidity -Loss of all neurologic activity below the level of injury
  15. Neurongenic Shock
    • Occurs in SCI that are at or above T6 within 30 minutes of SCI
    • Due to sudden loss of sympathetic stimulation to the blood vessels-bradycarida
    • Massive relaxation and vasodialtion of vessels -severe hypotention
    • Loss of vasconstrictive effects - pooling of blood
    • Unable to regulate temperature -poikilothermia
  16. Neurogenic Shock
    • Manifestations:
    • Severe atrerial hypotension in the presence of bradycardia is the classis indicator of shock
    • Treatment:
    • Fluid resuscitation (0.9% NSS), vasopressor (neo-synephrine - Phenylelphrine, Atropine
  17. Hypovolemic shock
    Atrerial hypotension with tachycardia
  18. Steroid Therapy for SCI
    • Methylprednisolone (MPSS)
    • Steroids used to minimize inflammation from secondary injury
    • Given as a 24 hour infusion within 3-8 hours of the SCI
    • Discontinued if neurological sypmtoms resolve
    • Can cause increased incidence to: Pneumonia, sepsis, GI Bleed, electrolyte imbalance, and delayed healing.
  19. Autonomic Dysreflexia (AD)
    • Life-threatening medical emergency affecting SCI
    • Occurs in patients with spinal cord injuries at or above T6 level
    • Its an amplified response by the autonomic nervous system to being overstimulated
  20. AD triggers
    • Bladder distention/spasms
    • bowel imacation
    • Stimulation of the anal reflex
    • pain
    • temperature change
    • ingrown tonails
    • tight, irritation cloths
    • urinary tract infections
    • uterine contractions
  21. AD Manifestations
    • Hypertension-40mm over baseline, suspect AD
    • Profuse sweating
    • Goose bumps(known as piloerection)
    • Sudden headache
    • Blurred vision
    • Anziety and feeling of doom
  22. AD Treatment
    • First Priority is to lower the BP
    • elevate HOB to 90 degrees to cause orthostatic hypotention
    • Lossen any binding or restrictive cloths
    • relieve and bladder distention
    • implement measures to facilitate defecation
    • eliminate any irritant below the level of SCI
    • pain medication if pain is the irritant
    • anti hypertensive medications
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Critical care
2014-01-16 17:13:20
Specific Traumatic Injuries

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