managing&spinal&cord&injury& patients&in&the&icu& spinal cord...
TRANSCRIPT
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MANAGING SPINAL CORD INJURY PATIENTS IN THE ICU
Presented by:
Dorea Fowler, RN, BSN, CRRN,CCM
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OBJECTIVES
• Describe Levels of injury related to SCI
• Explain common medical changes related to SCI
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SPINAL CORD INJURY
Any damage to the spinal cord that blocks communication between the brain and body.
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SPINAL CORD
• Types of Messages – Sensory
• Touch, pressure, pain, temperature and propriocepMon
– Motor – Reflexes
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FACTS & STATISTICS Model SCI Care System Data, 2014
PREVALENCE
• 12,500 annually
AGE
• Average age is 42 yrs
GENDER
• 79% are males
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ETILOGY
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CERVICAL BONES (C1 – C7 )
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CERVICAL NERVES (C1 – C8) C1 C2 C3 C4 C5 C6 C7 C8
Neck
Shoulder Shrug
Diaphragm
Shoulder Muscles, Biceps
Wrist Extensors Triceps
Lower Arms, Fingers
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THORACIC BONES (T1 – T12)
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THORACIC NERVES {T1 – T12} T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12
Hand
Chest; Transverse Thoracis Intercostals
Trunk; Intercostals
Abdominal
(coughing and sneezing)
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ASSIST COUGH
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LUMBAR (L1 – L5)
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LUMBAR NERVES {L1 – L5} L1 L2 Hip Flexion; Iliopsoas L3 Knee extension;
Quadriceps L4 Lower legs L5 Foot
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SACRUM
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SACRAL NERVES {S1 – S5} S1 Lower legs S2 Foot S3 Bowel, Bladder S4 Sexual FuncMon S5
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CLASSIFICATION of SCI
American Spinal Injury Association • AISA A – E • most widely accepted • “neurologic” basis
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ASIA CLASSIFICATIONS ASIA A = no motor or sensory function is preserved in the
sacral segments S4-S5. ASIA B = sensory but not motor function is preserved
below the neurological level and includes the sacral segments S4-S5
ASIA C = motor is preserved below the neurological level, and most of the key muscles below the neuro level have a muscle grade < 3.
ASIA D = motor function is preserved below the neurological level, and at least half of key muscles below the neurological level have a muscle grade =or > 3.
ASIA E = NORMAL motor and sensory testing.
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CLASSIFICATION of SCI
• Complete SCI = no motor or sensory function below the LOI.
• Incomplete SCI = any sensation present and/or any motor function below the LOI.
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INCOMPLETE SYNDROMES
Brown Sequard: damage to one side of cord – ipsilateral
paralysis, loss proprioception
– contralateral loss of pain and temperature
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INCOMPLETE SYNDROMES
Central Cord: damage to central part of cord – greater weakness
in arms verses legs
– sacral sensation
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INCOMPLETE SYNDROMES
Posterior Cord:
Lesion within posterior 1/3 of cord
Sensory and motor function intact
Loss of proprioception
Anterior Cord:
Lesion within anterior 2/3 of cord
Paralysis with loss of pain and temperature
Proprioception intact
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INCOMPLETE SYNDROMES
• Caudal Equina Syndrome – L1 and below – AmbulaMon possible because quadriceps spared
• Conus Medullaris – Injury to the sacral cord and lumbar nerve root – Lower extremity motor and sensory loss – Arflexic bowel and bladder – Usually can ambulate
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SPINAL SHOCK
Loss of all spinal reflexes below the level of injury.
Loss of all motor function. Loss of sensation. High dose steroids
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Neurogenic SHOCK
Hypotension, bradycardia, and decreased preload to the heart in addition to spinal shock.
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Cervical FixaMon
• TracMon • Halo and Vest • Surgery
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HALO-‐ VEST
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PROPER NURSING CARE OF THE HALO-‐VEST
Nursing Care: • Care of skin beneath the vest:
alcohol. • Pin-site care: soap and water. • Assure wrench taped to vest at all
times.
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CERVICAL FUSION & WIRING
Anterior and/or Posterior Fusion. • Hard collar must be worn at all times for
6-8 weeks post op
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NURSING CARE: CERVICAL FUSION
• Turn every two hours utilizing the “log-rolling” method.
• Monitor surgical incision sites for signs/symptoms of infection.
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THORACIC/ LUMBAR FUSION
• Rods, plates or cages are used for thoracolumbar injuries.
• In conjunction with a supportive brace to maintain alignment and prevent torsion movements.
• Bracing decisions are made to allow for rehab and ADL retraining.
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JEWITT BRACE & TLSO
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AUTONOMIC NERVOUS SYSTEM DYSFUNCTION
• Bradycardia • Hypotension • Poikilothermia • Pneumonia/
Atelectasis • Deep Vein
Thrombosis
• Autonomic Dysreflexia
• Stress Ulcers/ GI Bleed
• Bowel • Bladder • Skin
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ANS DYSFUNCTION
Bradycardia: • ANS disruption
– Parasympathetic system dominant. • Often due to vagal stimulation. • Most prevalent in C2-4 injuries. • Extreme bradycardia may require:
– Hyperoxygenate before suctioning – 100% O2 – Pre-medication prior to suctioning with Atropine. – Pacemaker.
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ANS DYSFUNCTION
Hypotension: • Parasympathetic dominance = vasodilation. • Vasoconstrictive therapy may include inotropics
such as dopamine and neosynephrine. • Florinef and Midodrine may be used for the
treatment of severe hypotension.
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ANS DYSFUNCTION
Poikilothermia: • Interruption of sympathetic pathways to
hypothalamus. • Loss of sympathetic response below level
of injury resulting in the inability to shiver or perspire.
• Warming or cooling blankets may be used.
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ANS DYSFUNCTION
Pneumonia/Atelectasis: • Leading cause of death in SCI population. • Due to inability to cough, immobilization, artificial
ventilation, and general anesthesia. • Medical Treatment/Interventions:
– Aggressive pulmonary toiletry. – Antibiotics. – Bronchodilator therapy.
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ANS DYSFUNCTION Deep Vein Thrombosis (DVT): • Signs/symptoms
– Unilateral swelling, temp change in limb, low grade fever with unknown etiology
• IMMEDIATELY institute regimen of prophylactic anticoagulants.
• DVT may result in pulmonary embolus
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ANS DYSFUNCTION Deep Vein Thrombosis (DVT): • Vena Cava filter (Greenfield Filter)
– May cause increased edema in limb – Long term anticoagulation therapy (3-6 months)
• 3-5% of the SCI population will suffer a pulmonary embolus when taken off anticoagulation therapy.
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ANS DYSFUNCTION
Gastrointestinal:
• Gastroduodenal ulcers/GI bleeding. • Causes
– stress response and/or hypotension to the gastric lining
• Initiate methods for nutrition. • Recommend prophylactic acid reducer asap
after SCI
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ANS DYSFUNCTION
• Bowel – Neurogenic
• Flaccid vs Reflex bowels
• Bladder • Foley vs intermijent catheters
• Skin • Turn, Turn, Turn!
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The Reflex Bowel
Stool
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HEAD INJURY
Initial Head CT may be negative but ... Signs and symptoms of head injury: 1. Agitation 2. Difficulty weaning 3. Difficulty swallowing