specific trauma injuries (spinal cord)

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specific trauma injuries (spinal cord)
2014-01-22 14:00:08
N303Critical Care,Test 1
nursing school
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  1. vertebral column
    • performs 2 major functions
    • 1. protect spinal cord
    • 2. support body frame

    • considered unstable where there is:
    • 1. lack of vertebral support
    • 2. lack of ligamentous support
    • 3. 2 or more damaged vertebral columns
  2. spinal cord
    ends at approximately L1 to L2 vertebrae, so if injured below L2, the spinal cord is spared
  3. upper motor neurons
    • originate in the cerebral cortex
    • carries motor signals from the brain to the end of the spinal cord
    • conveys impulses for voluntary muscle movement
  4. lower motor neurons
    • originates in the brain stem
    • connects UMN by synapses
    • branches out from spinal cord as spinal nerves
    • innervates with skeletal muscles
  5. meningeal layers
    • dura mater - outermost layer
    • arachnoid - middle layer
    • pia mater - innermost layer

    CSF fluid in subarachnoid space
  6. vascular supply of spinal cord
    • primary vascular source is the anterior and posterior spinal artery
    • originates from the vertebral arteries
    • any disruption in vascular supply may damage spinal cord without direct physical trauma
  7. gray matter region
    • inner region of spinal cord
    • where motor activity is transmitted from brain to the body
    • where sensory messages are relayed fro the body to the brain
  8. white matter region
    • corticospinal tract - transmits motor activity
    • spinothalamic tract - transmits pain and temp
    • posterior column (dorsal) tract - carries sensations of vibration, proprioception, touch, fine touch, pressure, and texture; ataxia can be affected
  9. laminectomy
    • decompression that alleviates pain from neural impingement stenosis
    • complications:
    • 1. nerve root damage
    • 2. CSF leak
    • 3. infection
  10. discectomy
    removal of all or part of the damaged disc and replacement with artificial disc spacer
  11. classifications of SCI
    location and whether complete or incomplete

    • complete SC transection:
    • 1. lack of sensory and motor function below level of injury
    • 2. complete transection of the cord

    • incomplete SC transection:
    • 1. preservation of some sensory and/or motor function below the level of injury
    • 2. altered sensory and/or motor function
    • 3. range of preservation varies
  12. complete spinal cord injury
    • tetraplegia (Quadraplegia):
    • complete severing of spinal cord between C1 and T1
    • loss of motor and sensory function of arms, trunk, legs, and pelvic organs
    • probably no bowel or bladder function

    • paraplegia:
    • complete severing of the spinal cord between T2 and L1
    • loss of motor and sensory function of lower extremities
    • possible bowel and bladder training
  13. incomplete SCI
    • not completely severed
    • varying degree of preservation of nerve fibers
    • symptoms of injury depends on area of spinal cord that was injured

    • incomplete injury at T12 and above (upper motor neuron injury):
    • 1. spasticity of muscles
    • 2. exaggerated tendon reflexes
    • 3. spastic neurogenic bladder
    • 4. anal sphincter ill respond

    • incomplete injury below T12 (lower motor neuron injury):
    • 1. hypotonation
    • 2. hyporeflexia
    • 3. flaccidity
    • 4. acontractile bladder and bowel
  14. cervical injuries
    • most vulnerable
    • C1-C3: can be fatal; loss of phrenic nerve innervation with diaphragm; ventilator dependent; tetraplegia
    • C4-C5: diving injuries; risk of needed ventilator
    • C7-T1: coup-contrecoup shearing
  15. thoracic and lumbar injuries
    • T12-L1: falling onto upper back or butt; calcaneous fracture
    • lumbar: only wearing a lap belt in an MVC
  16. primary injury
    • occurs at moment of impact
    • caused by hyperflexion, hyperextension, flexion-rotation, compression
  17. secondary injury (vascular injury)
    • occurs within minutes of the primary injury
    • can last days to weeks
    • manifestations: ischemia, elevated intracellular calcium, inflammatory process
  18. ischemia (secondary injury)
    • decrease circulation to injured sight
    • vasospasms
    • edema and increased interstitial pressure
    • hypoperfusion
    • neuronal death
  19. elevated intracellular calcium (secondary injury)
    • accumulation of calcium ions in injured cells
    • demyelination and destruction of the cell membrane
    • damage to cell membranes
    • neuronal death
  20. inflammatory process (secondary injury)
    • infiltration of leukocytes
    • swelling of the injured spinal cord
    • can't tell extent of injury until swelling subsides, which could take days to weeks
  21. diagnosing spinal injury
    • radiologic testing as soon as ABCs are stabilized
    • MRI
    • CAT scan - any hx of renal/kidney disease, allergy to shellfish/iodine/creatinine and BUN w/in 6 months of testing
  22. physical assessment
    • establish baseline assessment
    • eval respiratory, sensory, motor and reflex functioning
    • ASIA impairment assessment tool
    • neuro exams Q1H for 24hrs
    • monitor vital capacity, forced expiratory volume
  23. motor assessment
    • assess strength and voluntary movement
    • always begin at the head and ended at the feet
    • compare left to right side
    • assess ability to move without gravity, against gravity, and against resistance
  24. sensory assessment
    • checking for exact point of normal sensation
    • always begin distally and move proximally (feet and move to the head)
    • easier to recognize onset of stimulus rather then cessation of stimulus
    • assessed along dermatones
  25. reflex activity assessment (deep tendon reflexes)
    • assess for presence and quality of reflexes
    • complete SCI: absence of deep tendon reflexes below level of injury
    • incomplete SCI: presence of reflexes below level of injury
    • 1. incomplete SCI at/above T12 - hyperreflexia or spastic (UMN injury)
    • 2. incomplete SCI below T12 - hyporeflexia or flaccid (LMN injury)
  26. reflex activity assessment (perineal reflexes)
    • assess for presence of perineal reflexes
    • if present, indicates possibility of bowel/bladder training (UMN injury only)
    • 1. Anal wink - rectal sphincter contracts to a pinprick
    • 2. bulbocavernosus - rectal sphincter contracts to tugging on a foley catheter

    lack of these reflexes indicate LMN injury (complete SCI)
  27. spinal shock
    • results from autonomic nervous system dysfunction
    • occurs within 30 to 60 minutes after SCI and can last weeks to months and/or be transient
    • temporarily causes:
    • 1. absence of all reflex activity
    • 2. flaccidity
    • 3. loss of all neurologic activity below the level of injury
    • unable to classify SCI as complete or incomplete until spinal shock has resolved

    • end of spinal shock is marked by:
    • 1. return of DTRs
    • 2. spasticity and hyperreflexia
    • 3. clonus/muscle spasms
    • 4. increased muscle tone
    • 5. return of perineal reflexes
  28. neurogenic shock
    • occurs in SCI at/above T6 and within 30 minutes of injury
    • can cause:
    • 1. bradycardia - d/t sudden loss of sympathetic stim to blood vessels
    • 2. severe hypotension - d/t massive relation and vasodilation of vessels
    • 3. pooling of blood - d/t loss of vasoconstrictive effects
    • 4. poikilothermia - inability to regulate temp

    • clinical manifestations:
    • 1. severe arterial hypotension with bradycardia
    • treatment:
    • 1. fluid resuscitation
    • 2. vasopressor
    • 3. atropine

    • neurogenic shock - hypotension with bradycardia
    • hypovolemic shock - hypotension with tachycardia
  29. stabilizing spinal cord
    • hard cervical collar
    • log rolling
    • timely spinal cord alignment and stabilization
    • surgical:
    • 1. within 24hr for complete injuries
    • 2. within 12hr for incomplete injuries
    • manual:
    • 1. cervical tongs - screwed into skull above ears and sequential weights added
    • 2. halos - for cervical and upper thoracic injuries; 2 pins in frontal bone and 2 pins in occipital bone
    • 3. back braces -for thoracic and lumbar injuries
  30. steroid therapy
    • methylprednisolone (MPSS)
    • given as 24hr infusion within 3-8 hrs of SCI; discontinue if neuro symptoms resolve
    • can cause pneumonia, sepsis, GI bleed, electrolyte imbalance, delayed healing
  31. complications
    • atelectasis
    • pneumonia - suction only when necessary (can cause bradycardia and cardiac arrest d/t vagus nerve stim); #1 intervention is log rolling
    • aspiration
    • decreased cardiac output
    • bradycardia - use atropine
    • poikilothermia
    • imbalanced nutrition
    • skin breakdown
    • joint mobility
    • thromboembolism
    • skeletal changes
  32. heterotopic ossification
    • ectopic overgrowth of bone below level of injury
    • hip is most affected sight 
    • clinical manifestations:
    • 1. loss of ROM
    • 2. localized swelling, warmth and fever
    • preventing:
    • Indomethacin 25-50mg PO TID
  33. autonomic dysreflexia (AD)
    • occurs in patients with SCI at/above T6
    • autonomic nervous system is overstimulated and parasympathetic cannot stop it
    • triggers:
    • bladder distention/spasm and bowel impaction
    • pain/ temp changes
    • ingrown toenails
    • UTI/ uterine contraction
    • tight and irritating clothes
    • clinical manifestations:
    • severe hypertension
    • profuse sweating and goose bumps
    • sudden headache and blurred vision
    • treatment:
    • get BP lower
    • raise HOB to 90 degrees
    • pain meds/ antihypertensives
    • reverse any triggers
  34. bladder/bowel dysfunction
    • gold standard - intermittent urethral catheterization
    • adynamic ileus - occurs within first 5 days of SCI; gastric distention and absent bowel sounds; use NG tube with low suction until bowel sounds return
  35. neuropathic pain
    • phantom pain/central pain
    • treated with anti-epileptics and anti-depressants
    • pain occurs at, just above, of below level of injury
    • burning, stabbing, shooting, aching, numbness, tingling, electric shock