management of spinal cord injury outside of a specialist...
TRANSCRIPT
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Management of
Spinal Cord Injury outside
of a specialist
Spinal Injuries Centre –
The Derby Experience
Sharon Budd
Trauma Nurse
Derby Hospitals NHS Foundation Trust
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Learning Outcomes • To understand the role of the SCI Link
Worker in Derby
• To increase knowledge of certain aspects of the acute management of SCI
• To be aware of the issues relating to the development of guidelines and the implementation into practice
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Background • Initial management is key in preventing
complications both in the acute and rehabilitation phases
• Spinal injury care was not consistent or evidence based within the trust
• No local guidelines / care plans available within the acute trust
• Working group developed
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Spinal Link Worker Scheme
- Sheffield SCIC • Training provided for staff in T&O, critical
care, 4 levels of competence
• Opportunity for theoretical and practical
experience within the unit
• Identified group of staff with ‘expert’
knowledge within the organisation
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Spinal Link Worker – key aspects
• Check patient referred to SCIC as per
national guidelines (4hrs)
• Care planning
• Bowel management
• Psychological support patient and relatives
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Spinal Link Worker – key aspects
• Liasion with peer support worker/SCIC
• Monitor for complications
• Education / training across the trust
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Management aspects
• Positioning / pressure area care /
musculoskeletal
• Bowel management
• Psychological support
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Positioning
• 5% natural increase in level of lesion (cord oedema) but 7% due to poor manual handling (SCOOP for transfers)
• Legs supported on pillows lengthways
• Passive exercises – plan agreed by consultant, dependent on level of injury. Support joints to prevent hyperextension
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• Joint contractures – develop quickly eg C5
injury
• Spasm – triggers can be sudden noise,
bed clothes being removed, helped by
passive exercises, turning. Note relatives
may confuse with return of function
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• NB - Hypersensitivity / phantom pain / proprioreception
• Muscle wastage – up to 30% in 7 days, need dietician referral / supplements
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Preventing pressure sores
• Firm mattress
• 2 hourly turns / change of position / helps
other systems
• ?? to sit up (surgeon request)
• Heels elevated, support feet to prevent
foot drop (splints not used routinely)
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DVT prevention
• DVT – swelling may only be apparent 10
days after developed
• Anticoagulants (delay if surgery)
• AV boots – remove 2 hrly to check skin
Stockings – full length, re measure at 72
hrs and then weekly
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Bowel management (1)
• Spinal shock – rectum and anus are flaccid, risk of over distension
• Daily PR (latex free gloves, Instillagel if sensation present)
• Trust guidelines for competency for DRE
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• Anal reflex –stimulant enemas / digital
stimulation
• Flaccid - continue to need daily DRE
• Senna only used in initial management
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Bowel management (2)
• Do not use bed pans for any level of injury until stabilised and / or documented in the notes. Use pads and explain reason to patient
• Care – prolonged turning onto left side can lead to syncope in cervical lesions (vagal stimulation)
• NB constipation and impaction is a common cause of Autonomic Dysreflexia
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Autonomic dysreflexia
• Medical emergency, BP can reach 220 systolic
• Usually injury above T6, can occur at anytime after spinal shock subsided, often post discharge
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Autonomic dysreflexia
• Response to presence of noxious stimuli eg blocked catheter (do not try washout, further increases problem), impacted bowel, ingrowing toenail or pressure sore
• Patients have an ‘alert card’ to highlight to GP/ED
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Psychological support • Diagnosis may be delayed due to
presence of spinal shock and cord
swelling (48hrs – 6 weeks). Be honest and
consistent. Involve SCIC / peer support
• Loss of touch and positional awareness -
regular turning, touch and contact,
encourage to look at paralysed limbs
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Challenges • Initial development of the guidelines and
updating with current evidence and best
practice
• Communication of the guidelines
throughout the trust (link staff)
• Infrequency of patients and staff turnover
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Links / further reading
• www.mascip.co.uk – management
guidelines also photographs available of
transfers / positioning
• www.spinal.co.uk for relatives
• www.boa.ac.uk guidelines
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Any questions
?