Spinal Cord Injury
& Disorders (SCI/D) Service
M. Kristi Henzel, MD, PhD
Staff Physiatrist, SCI/D
Debbie Rovito, APRN, CNS
Clinical 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, subacute, and life-long care to Veterans with
SCI/Disorders
23 VA SCI/D Centers serve
~42,000 veterans with SCI/D
Puerto Rico
Spinal
Spinal Cord
Cord Injury
Injury and
and Disorders
Disorders Center
Center
SCI/D CENTERS
• Referral base:
Local trauma centers/hospitals - Veterans
Department of Defense – Active duty
Spoke sites - Veterans
Local primary care providers including CBOCs
• Standards of care:
VHA Handbook 1176
CARF (Rehab Accreditation) standards
Consortium for Spinal Cord Medicine Clinical Practice Guidelines
• Acuity:
Acute medical conditions
Complications of chronic SCI
Respite care
Annual 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 PLUGS
CAN 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
SNS
(tonic
stimulation)
PSNS
SNS
T1-T5
SNS
(~T5-L2)
SNS
(tonic
stimulation)
SCI
SNS
T1-T5
PSNS
+
R=8mL/pr4
+
+
+
+
Increased Afterload
X
+
vasoconstriction +
+
+
+
SNS
(~T5-L2)
Noxious
stimuli
from
below
SCI level
AUTONOMIC DYSREFLEXIA:
CAUSES
Distended bowel or bladder
UTI, 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:
LEVEL OF INJURY (T6 AND ABOVE FOR AD) :
SYMPTOMS:
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.
1
2
3
4
5
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7
8
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10
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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:
@30 MIN:
@60 MIN:
@90 MIN:
@120 MIN:
BP AND PULSE:
EARLY INTERVENTIONS: (circle if done Sit Up
Loosen clothes/remove shoes or
Check skin/ sheets/body position/tubes
and note any change in BP)
splints
MD CALL :
At initiation of protocol
Call 2
Call 3
(fill out if done) TIME:
TIME:
TIME:
RESPONSE:
RESPONSE:
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
Time:
Result BP:
Wipe off when BP at baseline/episode
Time:
Result BP:
chest
ends/or symptoms of hypotension
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
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
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:
TIME:
RESULTS:
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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