Spinal Fractures and Cord Injuries

Spinal Fractures

• Spinal fractures involve breakage of vertebrae in cervical, thoracic, or lumbar spinal columns
• Traumatic injuries such as falls or sports injuries can cause spinal fractures
• Rapid deceleration from motor vehicle collisions can cause spinal fractures
• Pathologic causes include osteoporosis or metastatic cancer
• Spinal fractures may lead to neurological impairment
• Timely diagnosis and treatment prevent spinal cord injuries

Leading Causes of Spinal Cord Injuries in California

• Car Accidents
• Acts of Violence
• Medical Conditions and Procedures
• Sports and Recreational Activities
• Slip and Falls

Spinal Cord Injury Levels and Effects

• C4 injury results in tetraplegia and complete paralysis below the neck
• C6 injury results in partial paralysis of hands and arms, as well as the lower body
• T6 injury results in paraplegia and paralysis below the chest
• L1 injury results in paraplegia and paralysis below the waist

Neurological Injury Severity (ASIA Scale)

• Complete ASIA A involves no sensory/motor function below the neurological level
• Incomplete ASIA B involves sensory function (S4-S5) but no motor function below the neurological level
• Incomplete ASIA C involves less than grade 3 motor function below the neurological level
• Incomplete ASIA D involves grade 3 or more motor function below the neurological level
• Incomplete ASIA E is considered neurologically intact

Incomplete Spinal Cord Injury Syndromes

• Anterior Cord Syndrome involves damage to the anterior spinal artery, compromising blood flow and typically resulting from acute compression. It's common with flexion injury, causing motor paralysis and loss of pain/temperature sensation below the injury level, while sensations of touch, position, vibration, and motion remain intact
• Brown-Séquard Syndrome involves damage to half of the spinal cord, typically from penetrating injury resulting in contralateral loss of pain and temperature sensation and ipsilateral loss of motor function, light touch, pressure, position, and vibratory sense
• Cauda Equina Syndrome involves damage to the lumbar and sacral nerve roots, causing asymmetric distal weakness, patchy sensation, possible flaccid paralysis of lower extremities, loss of sensation in the saddle area, areflexic bladder/bowel, and severe asymmetric pain
• Central Cord Syndrome involves damage to the central spinal cord, often in the cervical region, more common in older adults, and caused by hyperextension injury in people with degenerative disease, causing motor weakness and altered sensation in upper extremities, burning pain, and typically sparing lower extremities
• Conus Medullaris Syndrome involves damage to the lowest part of the spinal cord, possibly preserving, weakening, or causing flaccidity in the legs, with decreased sensation in the perianal area, areflexic bowel/bladder, and impotence

Emergency Management: Etiology

• Blunt trauma from diving, falls, motor vehicle crashes, pedestrian accidents, and sports injuries may lead to compression, flexion, extension, or rotation injuries of the spinal column
• Penetrating trauma from gunshot or stab wounds may cause spinal cord stretching, tearing, crushing, or laceration

Emergency Management: Assessment Findings

• Potential findings include bowel/bladder incontinence, changes in sensation, decreased rectal sphincter tone, muscle weakness/paralysis/flaccidity, and neurogenic shock causing hypotension, bradycardia, and cool/warm dry skin
• Additional findings include numbness/paresthesia; pain, tenderness, deformities, or muscle spasms; priapism; respiratory distress/difficulty breathing; and urinary retention
• Examine wounds, cuts, and bruises on the head, face, neck, or back

Emergency Management: Interventions

• Ensure a patent airway and adequate breathing, maintaining SaO2 >90% with appropriate oxygen delivery
• Maintain SBP >90 mm Hg, establishing IV access with 2 large-bore catheters to infuse normal saline or lactated Ringer's solution
• Immobilize and stabilize the cervical spine
• Control external bleeding
• Obtain appropriate imaging
• Ongoing monitoring includes vital signs, level of consciousness, motor and sensory function, O2 saturation, cardiac rhythm, and urine output
• Anticipate the need for intubation if in respiratory distress or gag reflex is absent
• It recommends maintaining a normal temperature

NEXUS Criteria to Exclude Spinal Cord Injury

• Used to rule out cervical spine injury in low-risk patients that would eliminate the need for further imaging or stabilization after blunt trauma
• Criteria: no posterior midline cervical spine tenderness, no evidence of intoxication, normal alertness level, no focal neurologic deficit, and no painful distracting injury
• The NSAID mnemonic stands for Neuro deficit, Spinal tenderness (midline), Altered mental status, Intoxication, and Distracting injuries
• Maintain cervical spine immobilization in a rigid collar if the patient complains of neck pain, is not fully awake, or exhibits signs/symptoms of neurologic injury until radiologic studies are completed

SCI Complications

• SCI complications include breathing problems
• SCI complications include autonomic regulation
• SCI complications include elimination problems
• SCI complications include functional ability
• SCI complications include discomfort
• SCI complications include clots
• SCI complications include grief

Quick Guide to Nursing Care for SCI Patients - Respiratory

• Potential Problems include respiratory insufficiency/failure
• Nursing Interventions involve monitoring respirations for fatigue/impending failure, pulmonary toileting, and administering bronchodilators as ordered

Quick Guide to Nursing Care for SCI Patients - Cardiovascular

• Potential Problems include acute hypotension or bradycardia
• Nursing Interventions for hypotension include maintaining MAP > 85 mm Hg for the first 7 days
• Nursing Interventions for bradycardia include monitoring heart rate and administering medications for symptomatic bradycardia
• Potential problems include Poikilothermia
• Nursing Interventions for Poikilothermia include maintaining normothermia

Quick Guide to Nursing Care for SCI Patients - Other Systems

• Maintain DVT risk minimization and initiate prophylaxis for potential DVT
• Monitor for orthostatic hypotension
• Monitor for signs and symptoms of AD
• For urinary retention, decompress the bladder via indwelling catheter insertion, as ordered, and implement intermittent straight catheterization protocol
• Monitor for abdominal distention and ensure bowel elimination with an ileus or constipation

Quick Guide to Nursing Care for SCI Patients - Support

• Contractures might occur so provide frequent ROM and administer antispasmodics, as ordered
• Provide skin care, observing under spots and braces, repositioning every 2 hours, and shifting weight every 30 minutes in upright wheelchair; if skin breakdown occurs

SCI Management: Background for Moving Patients

• This technique is used when the client cannot or it is unsafe to move
• It helps maintain spinal alignment and prevent further injury

SCI Management: Indications for Moving Patients

• Suspected spinal injury
• Unconscious client
• Team lead helps to support cervical spine
• Persons 2 and 3 help support and align the hip and shoulder
• Person 4 helps to slide spinal board under client

Tamara Johnson Case

• Tamara Johnson is a 32-year-old female
• She has a history of cervical fusion 3 months ago and chronic cervical pain

Tamara Johnson EMS Notes and Concerns

• EMS was called to a home to find a 32-year-old female on the floor
• She had a recent cervical fusion
• She is unable to move any extremities and has loss of sensation
• She was placed on a backboard with head secured and 100% NRB applied
• Her BP was 100/60,
• Concerning findings include immobility, loss of sensation, bradycardia, borderline blood pressure, and recent cervical fusion
• Biggest concerns during transport are airway management and cervical stability

ER Care for Tamara Johnson

• Arrived in a hard cervical collar
• An MRI showed significant cord compression
• Neurosurgery performed an emergent cervical laminectomy of C4-C6
• She was transferred to the ICU postoperatively, intubated

What To Do Before the Surgery For Tamara Johnson

• A, B, Cs indicate to intubate, support breathing, and support circulation
• Intubation is recommended immediately for complete SCI above C5
• Paralysis of intercostal and abdominal muscles can cause poor cough, inability to clear airway, and hypoventilation
• Neurogenic pulmonary edema can occur due to increased sympathetic nervous system activity
• D (Disability)
• ASIA Impairment Scale is needed
• Spinal Shock is possible

Cervical Laminectomy

• Performed under general anesthesia to remove part of the vertebra known as the lamina

ICU Care for Tamara Johnson

• SBP should be kept greater than 160 or MAP greater than 85 to treat neurogenic shock
• Tamara was extubated on POD#2
• Her neurological exam waxes and wanes
• She has some plantar flexion, wiggles fingers, and sensation around hips
• There are extubation considerations to take into account
• Closely monitor after extubation closely

Tamara Johnson, POD#3

• Tamara is a 32 year old female POD#3 post Emergent C4-C6 Decompressive Laminectomy
• Some findings that validate the need for re-intubation would be gurgling respirations and ineffective cough

Pharmacology Vasopressors and Inotropes.

• The changes in CO/CI, SVR, PCWP, MAP, and HR in response to Dopamine
• The changes in CO/CI, SVR, PCWP, MAP, and HR in response to Dobutamine, Epinephrine, Milrinone, Norepinephrine, Phenylephrine, and Vasopressin

Potential Interventions for Tamara Johnson

• Administer vasoactive medications, chest percussion, and apply graduated compression stockings within range of to improve MAP. The client should then be assessed after intervention
• Neck should not be hyperextended because cervical stabilization is needed
• Intermittent straight cathing and a fecal system should be provided
• Turning every 4 hours is contraindicated so that stability

Postoperative Care: Key Areas

• Respiratory
• Cardiovascular
• Gastrointestinal
• Urinary
• Integumentary
• Thermoregulation
• Metabolic Needs
• Peripheral Vascular Problems

Respiratory System Management

• Endotracheal Tube, Tracheostomy
• Trach Care, Suctioning, Pulmonary toileting, Cough assist
• Collaborate with Resp Therapy for weaning from mechanical ventilation when appropriate
• Ventilator ABG - collaborate with HCP, RT for ventilator adjustments VAP prophylaxis

Cardiovascular System

• Bradycardia and Hypotension
• MAP ideally is kept above 85, ideally 85-90 for the first week post SCI
• Titrate Norepinephrine/Dopamine in the acute phase and may transition to midodrine later
• Orthostasis – Use graduate/compression stockings and abdominal binder
• VTE prophylaxis for 3 months post injury

Gastrointestinal

• Ileus is common
• Stress Ulcer Prophylaxis
• NGT/Small bore feeding tube/PEG tube can all be used for enteral nutrition
• Depending on the level of injury – the patient may be able to swallow
• Consult with a dietitian for nutrition supplements to meet caloric needs

Bladder and Bowel Management

• Urinary Retention
• Avoid foleys
• Intermittent Catheterization, 4-6 times daily
• Constipation
• Bowel regimen
• Adequate fluid intake, Fiber

Integumentary

• 20%–50% of people with a new SCI will develop at least one pressure wound during their acute hospitalization
• The odds of acquiring a pressure sore during acute hospitalization are 4.5x greater for people with complete SCI than those with incomplete SCI
• During the first year after SCI, the probability of experiencing a pressure sore is ~41%
• People with neurological disorders, particularly SCI, have a 25%–85% lifetime risk of developing a pressure injury

Thermoregulation

• Avoid fevers
• Environmental temperature
• Be cautious with blankets for sleep (too hot)
• Be cautious removing towels during bathing (too cold)

Peripheral Vascular Problems

• VTE
• Hypercoagulability
• Venous Stasis
• Venous Endothelial Injury
• Remember patient may not feel pain and/or tenderness

Sexuality Considerations in SCI Patients

• Sexuality is an significant issue for all patients, regardless of age or gender.
• Open discussion about sexual rehabilitation is essential.
• Support should be provided by a nurse or rehabilitation professional trained in sexual counseling.
• Prevent dislodging an indwelling catheter.
• External catheter users should refrain from fluids and remove the catheter before sexual activity.
• Teach patients about the risk of autonomic dysreflexia (AD).
• Bowel program should include evacuation on the morning of sexual activity.
• Educate on the possibility of incontinence during sex.
• Women may need water-soluble lubricants to address decreased vaginal secretions.
• Some women with residual pelvic innervation can achieve normal orgasm.
• The Eros device may help with orgasmic dysfunction.

Matthew Motors Case

• Matthew Motors is a 26 yr old male driving a motorcycle with no helmet, hit by a car, with EMS notes smelling alcohol
• Breathing spontaneously and has No sensation or motor function below the clavicles

Risk Factors for Mathew Motor's SCI

• The patient's age
• Driving a Motorcycle
• The fact that the patient was under a high risk activity
• The nonuse of protective gear
• Alcohol and substance abuse

Tamara and Matthew: SCI

• The nurse was called to respond to Tamaran and Matthew (two case studied). The response varies based on if the patient was intubated and had loss of sensation

Findings that Correlate with Neurogenic Shock

• Heart Rate: 42
• Skin cool below shoulders
• Diaphoretic
• Temperature: 100.4

Key Points to Study

• Spinal shock vs neurogenic shock
• Nursing assessment of neurogenic shock
• Nursing interventions during neurogenic shock
• Autonomic Dysreflexia
• Nursing assessment
• Nursing interventions
• Client education

Shock: Spinal vs. Neurogenic

• Spinal Shock involves loss of sensation, flaccid paralysis and loss of deep tendon and sphincter reflexes. Can last Lasts days to weeks
• Neurogenic Shock involves Peripheral vasodilation, Venous pooling, Decreased cardiac output, Hypotension, Bradycardia, and Temperature Dysregulation. Occurs with cervical or thoracic injury (T6 or higher). Can last days, up to 3 weeks

Neurogenic Shock Treatment

• IV Fluids
• Norepinephrine
• Dopamine

Acute Care Pin Site Notes

• The client is placed in Gardner-Wells tongs under anesthesia.
• What are the responsibilities of the nurse regarding pin site care?

Transfer to Rehab Unit

• After 2 weeks in the ICU, the client is transferred to a rehab unit
• When they have he has some movement in his upper arms and feeling to the nipple line
• The Gardner-Wells tongs have been removed and he has been placed in a halo vest
• His blood pressure drops significantly when his head is raised.

HALO vests, uses and safety

• The HALO Vest allows the client to start ambulating
• With a Wrench at bedside
• For Skin inspection and to Clean crusted pin sites with prescribed solution
• Must avoid Powders or lotions under vest and use Antibiotic ointment as necessary
• The client should not be all
• Be aware that it is Not legal to drive
• It is useful to Apply sheepskin pad under vest

Transfer Orders of Patients

• High protein, high calorie, high fiber diet should be supplied as tolerated
• Intermittent catheterization every 4 hours, should increase to every 6 hours if residual bladder scan of >100 mL
• Bowel program
• Utilize a reclined wheelchair with gradual adjustments to sitting position
• Provide Anti-embolism stockings and abdominal binder when up in wheelchair
• Follow PT/OT evaluation for mobilization and ADLs.

Medication Orders often include the following...

• Muscle relaxants to reduce spasticity
• Side Effects of Muscle relaxants: Seizures, dizziness, drowsiness, fatigue, weakness, and hypotension
• Oxybutynin can relax the bladder
• oxybutynin can improves bladder compliance in patients with neurogenic shock
• Side Effects: dizziness, drowsiness, constipation, urinary retention, angioedema, decreased sweating, hot flashes

Acute Nursing Interventions for AD

• Raise the client to a sitting position, HOB greater than 45 degrees
• Remove any noxious stimuli (bladder distention, kinked foley catheter, need to straight cath, fecal impaction, restrictive clothing, etc)
• If unable to rectify quickly – give antihypertensive if ordered and notify the provider

Nursing Interventions to Prevent AD

• Maintain regular bowel routine to prevent constipation
• Monitor urine output and ensure catheter tubing is not kinked
• Reposition regularly and check for pressure points or discomfort
• Use lidocaine (urojet) before catheter insertion to reduce irritation
• Encourage wearing a medic alert bracelet to indicate AD risk

Autonomic Dysreflexia: Priority Order

• Raise the head of the bed and ask that the primary health care provider (PHCP) be notified.
• Loosen tight clothing on the client.
• Check for bladder distention or other noxious stimulus.
• Administer an antihypertensive medication.
• Document the occurrence, treatment, and response.

AD Consideration during Sexual Activity

• Can be triggered by sexual activity, especially in patients with injuries at T6 or above.
• Symptoms include sudden high blood pressure, severe headache, sweating, flushing, nasal congestion, and bradycardia.
• Empty their bladder and bowel before engaging in sexual activity to reduce risk.
• Sit up immediately and remove any tight clothing if AD symptoms appear.
• Seek emergency medical attention if symptoms do not resolve quickly.