Spinal Cord Injury & Disorders (SCI/D) Service

M. Kristi Henzel, MD, PhDStaff Physiatrist, SCI/D

Debbie Rovito, APRN, CNSClinical Nurse Specialist, SCI/D

June 21, 2013

VA SCI/D CENTERS

• SCI/D includes traumatic and non-traumatic spinal cord injuries, multiple sclerosis (MS) , and amyotrophic lateral sclerosis (ALS)

• Comprehensive system of care formalized in 1996 by the VA, that established a “Hub & Spokes System of Care” to provide acute, sub-acute, and life-long care to Veterans with SCI/Disorders

Spinal Cord Injury and Disorders CenterSpinal Cord Injury and Disorders Center

Puerto Rico

23 VA SCI/D Centers serve ~42,000 veterans with SCI/D

SCI/D CENTERS• Referral base:

Local trauma centers/hospitals - VeteransDepartment of Defense – Active dutySpoke sites - VeteransLocal primary care providers including CBOCs

• Standards of care:VHA Handbook 1176 CARF (Rehab Accreditation) standardsConsortium for Spinal Cord Medicine Clinical Practice Guidelines

• Acuity:Acute medical conditionsComplications of chronic SCIRespite careAnnual evaluations

SCI/D Hubs & Spokes• Each CENTER has inpatient and outpatient

services.

• SCI/D Centers provide :• Primary care for veterans with SCI/D in the

local area• Acute rehabilitation and tertiary care for

veterans referred from the Spoke sites

• Each SPOKE site provides primary care and outpatient services for veterans with SCI/D.

CLEVELAND SPOKE SITES

Also West Virginia, eastern Indiana, northern Kentucky

CLEVELAND SCI/D CENTER• 32 bed inpatient unit• SCI outpatient clinic, home care &

telemedicine program• MDs: Physiatry (PM&R, Internal Medicine,

Neurology• Interdisciplinary:

– Physical Tx -Rehab nursing– Occupational Tx -Recreational Tx– SCI Psychology -Social work

• Research: close affiliation with FES & APT Centers

KEY POINTS• Call us early (transfers OR consults)

• When admitting an SCI pt through Urgent Care/ED after hours, page the SCI Attending on call if questions.

• Pts are admitted to Medicine Service overnights and transferred to SCI Service the next day, IF appropriate from medical acuity standpoint.

• Difference between admission to WSCI (6B floor for SCI nursing care) vs. SCI Service (physician management on WSCI).– Nursing acuity must be less frequent than q4hrs on WSCI/6B.– WSCI has no telemetry.

KEY POINTS• Even if the patient needs to stay on medical floor

SCI Service will help with:– Prognostication and classification of SCI– Rehabilitation evaluation– Bowel program– Bladder management– Spasticity management– Skin/Wound issues– Respiratory issues– Treatment of Autonomic Dysreflexia

KEY POINTS• Prognostication – determination of functional recovery and

rehabilitation potential.

• Neurogenic Bowel – bowel care program best started early to avoid constipation, incontinence and skin breakdown.

• Neurogenic Bladder – prevention of renal failure, hydronephrosis and skin breakdown due to incontinence.

• Pressure Ulcer Prevention/Treatment – mattress type, turning q2h, avoidance of too much moisture. Wound treatments for new or chronic pressure ulcers.

• Spasticity- if acutely changed from pt’s baseline, usually something else is wrong! (i.e. UTI, pressure ulcer, etc.)

EMERGENCIES IN SPINAL CORD INJURY

There are two common SCI emergencies

AUTONOMIC DYSREFLEXIA (AD)IS AN ACUTE HYPERTENSIVE EVENT

MUCUS PLUGSCAN CAUSE ACUTE RESPIRATORY DISTRESS OR

RESPIRATORY FAILURE

Areas of Autonomic Dysfunction after Spinal Cord Injury

• Cardiovascular Function• Respiratory Function • GI function • Lower Urinary Tract Function• Sexual Function• Sudomotor Function • Thermoregulation

Why should you care about AD?

AUTONOMIC DYSREFLEXIA

• People with SCI who are at risk have injuries at T6 and above.

• Noxious stimuli cause unopposed sympathetic reflex activity below the level of injury.

• If untreated, acute elevation of BP may lead to stroke, seizures or myocardial infarction

Nervous System Organ Control

Nervous System Organ Control

Nervous System Organ Control

SNST1-T5

PSNS

SNS(~T5-L2)

SNS(tonic stimulation)

SNST1-T5PSNS

SNS(~T5-L2)

SNS(tonic stimulation)

+

Noxious stimuli from below SCI level

X

+ ++

+

+

+++

+

vasoconstriction

R=8mL/pr4

Increased Afterload

SCI

AUTONOMIC DYSREFLEXIA: CAUSES

Distended bowel or bladderUTI, Kidney stones

Menstruation, pregnancy, labor, delivery Gastric ulcer

Sunburn or insect bites Sexual intercourse, ejaculation

Scrotal compression DVT and PE

Constrictive clothing Ingrown toenail

Heterotrophic Ossification, Fractures Infection, Pressure ulcers, Pain

SIGNS AND SYMPTOMS OF AD• Sudden systolic/diastolic BP elevation 20-40 mmHg above

baseline. • Individuals with SCI Level of Injury (LOI) above T6 often

have baseline SBP’s 90-110.

• AD Symptoms:• Bradycardia• Pounding headache• Nasal stuffiness• Profuse sweating usually above the LOI• Goose bumps usually above the LOI• Flushing or blotches usually above the LOI• Blurred vision or spots• Feelings of anxiety• Cardiac arrythmias• AND THEN THERE IS SILENT AD

TREATMENT OF AD

• To stop AD you have to identify and remove the cause!• We have a protocol for that!• To order the AD protocol for an at risk patient with SCI go

to the SCI Admission Order Set.

• With a few clicks you will allow the SCI nurses to start the protocol and safely search for the cause of AD using meds such as lidocaine gel and nitroglycerine ointment.

• SCI Nursing will call when they initiate the protocol, and when they need further guidance (usually when they cannot find a cause, or they are really concerned about the patient and his blood pressure).

AD Protocol

AD Protocol

THE SCI CENTER AD PROTOCOL• Developed from Spinal Cord Consortium CPG & SCI Model

Center guidelines and local policy.

• Protocol basics CHECK BLOOD PRESSURE + PULSE Q2-5MINUTES SIT THE PATIENT UP / LOOSEN CLOTHING REMOVE SPLINTS + SHOES / CHECK SKIN + TUBES + BODY POSITION CHECK BLADDER / CATHETERS CHECK BOWEL LAST USE MEDS: LIDOCAINE GEL

for changing caths or bowel checks NITROPASTE 1 INCH:

when BP is above 150

AUTONOMIC DYSREFLEXIA WORKSHEET

NAME:

DATE: TIME: SYMPTOMS:

LEVEL OF INJURY (T6 AND ABOVE FOR AD) : TYPICAL BP AND PULSE:

VITAL SIGNS: Document TIME, BP and PULSE every 2-5 minutes. If possible use Spot LXi so all vitals are officially recorded.

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EPISODE ENDS: When the patient returns to typical baseline. Then begin follow up checks every 30 minutes for two hours. AD can return! TIME: BP AND PULSE:

@30 MIN: @60 MIN: @90 MIN: @120 MIN:

EARLY INTERVENTIONS: (circle if done and note any change in BP)

Sit Up Loosen clothes/remove shoes or splints

Check skin/ sheets/body position/tubes

MD CALL : (fill out if done)

At initiation of protocol TIME: RESPONSE:

Call 2 TIME: RESPONSE:

Call 3 TIME: RESPONSE:

NITROPASTE: IS APPLIED ANYTIME THE SYSTOLIC BP GOES ABOVE 150 AFTER EARLY INTERVENTIONS ARE TRIED AND NO CHANGE IN BP OCCURS. Place one inch on chest

Time: Result BP: Wipe off when BP at baseline/episode ends/or symptoms of hypotension

Time: Result BP:

WORKSHEET CONTINUES ON BACK 5/12DR

AUTONOMIC DYSREFLEXIA WORKSHEET CONTINUED FROM FRONT

CHECK BLADDER BEFORE BOWEL Foley tubing kinked or clogged/ reposition or bladder scan TIME: RESULTS:

IC needed for high scan/use LIDO GEL prior to insertion TIME: RESULTS:

Irrigate urine catheter if clogged/use ONLY 10-15ml NS TIME: RESULTS:

Still no flow after irrigation- change cath/use LIDO GEL prior TIME: RESULTS:

CHECK BOWEL LAST BP MUST BE BELOW 150/NO DIG STIM /NO DISIMPACTION/NO BOWEL CARE

Start with gentle rectal check/insert LIDO GEL 2 min before TIME: RESULTS:

If stool is present, hook with fingers and remove TIME: RESULTS:

If stool begins to come out on its own, BP may go down/DO NOT STIM OR DISIMPACT

TIME: RESULTS:

Sometimes because of the check, BP will go UP! If BP is above 150, apply Nitro Paste. If paste is already in use, STOP! Take a 20 minute pause let pt. rest and then recheck blood pressure

TIME: RESULTS:

After pause, if BP below 150, reapply LIDO GEL and hook and remove again. Check BP, hook and remove. Repeat. Always take a 20 minute pause when BP goes above 150

TIME: RESULTS:

EPISODE ENDS: When the patient returns to typical baseline. Then begin follow up checks of BP and pulse, every 30 minutes for two hours. AD can return! Use the grid on the front vital sign section to complete your every 30 minute checks. OFFICIAL DOCUMENTATION: Use the Nursing Treatment Note in CPRS. Select Autonomic Dysreflexia Template . 5/12DR

WRAP UP ON AD• AD ends when patient BPs return to baseline.

• If the nurse calls you to report all the usual interventions have been tried and BP remains high what should you do?

• Even when AD appears resolved, it can reoccur quickly. Nurses will continue to monitor BPs every half hour for two hours after AD ends.

• Nurses will put official AD documentation related to their utilization of the protocol in a CPRS Nursing Treatment Note using an Autonomic Dysreflexia template.

• At the bedside, the nurses use a worksheet that can guide you, also!

Case Study 54 yo man with C6 tetraplegia is admitted with

pneumonia. He is a night float admission to a medical floor but will be transferred to SCI in the morning. At 3AM, the nurse calls to report the patient’s BP is 200/90. His BP was 90/60 when you admitted him.

1. What do you ask the nurse to do?2. Once you open CPRS what do you do?3. Who do you call next?

Case Study 54 yo man with C6 tetraplegia is admitted with

pneumonia. He is a night float admission to a medical floor but will be transferred to SCI in the morning. At 3AM, the nurse calls to report the patient’s BP is 200/90. His BP was 90/60 when you admitted him.

1. What do you ask the nurse to do?2. Once you open CPRS what do you do?3. Who do you call next? By the time you arrive to see how things are going,

the early interventions have been done and it was found that the patient was turned on top of his Foley tubing. Once repositioned the bag filled with 600ml of urine and his blood pressure lowered to 90/60

Somatic Innervations of the Respiratory System

• The main respiratory muscles are the diaphragm, intercostals and abdominals.

• C1-2 SCI: diaphragm is paralyzed and ventilator is required to sustain life.

• C3–5 SCI: diaphragm is partially denervated affecting inspiration. C4–C5 SCI do not require ventilation

• C6-8 SCI: Primary inspiratory muscles are preserved, but inspiration and expiration impaired,

• T1-12: Denervated intercostal Muscles affecting expiration >> inspiration.

• T7-L2 SCI: Denervated abdominal muscles causing ineffective cough.

Respiratory Dysfunction following SCI

• Pneumonia• Atelectasis • Bronchitis • Restrictive Airway Syndrome• Sleep Apnea • Respiratory Insufficiency • Dyspnea on Exertion• Leading Cause of Death

MUCUS PLUGS•Mucus plugging may present with acute dyspnea.

•Patient may be misdiagnosed with pulmonary embolism or pneumonia

•Aggressive pulmonary toilet by RT is essential to assist with removing mucus plugs

–Chest vest–Metanebs (Continuous High Frequency Oscillation with positive pressure pulses OR Continuous Positive Expiratory Pressure +/- nebulized medications)–Mechanical In/Ex-sufflation (“Coughalator”) –Keep in mind that some high tetraplegics can quickly experience respiratory failure due to aging, use of opioids, and URIs.

•Many individuals with SCI also have OSA.

Thank you for your attention!

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