Spinal Cord Injury
EMERGENCY NURSING
Objectives
After this presentation we will able to:
1-Discuss the nursing assessment of patients with spinal
cord and/or vertebral column trauma.
2-Identify appropriate nursing diagnoses and expected
outcomes associated with patients with spinal cord
and/or vertebral column trauma.
3-Plan appropriate interventions for patients with spinal
cord and/or vertebra! column trauma.
Spinal Cord Injury
complete Vs. incomplete lesions.
1-INCOMPLETE SPINAL CORD
LESIONS
- incomplete structural damage.
preservation of some motor or sensory
function below the level of the injury.
Sacral sparing(Perianal sensation, anal
sphincter tone, and great toe flexor
function).only in absence of spinal shock.
- 4 subtypes ( syndromes ):
A-central cord syndrome (the most
common)
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Spinal tract involved ??
Etiology: hyperextention injuries Swelling in
the center of the cord -> bony abnormality may
be absent .
-Symptoms : loss of sensory and motor
function below the level of the lesion
-greater loss in arms than in legs.
B- anterior cord syndrome,(common).
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Spinal tract involved:
spinothalamic,corticospinal(pyramidal)
Etiology :acute anterior cord compression,disruption of
blood flow.
Symptoms :loss of motor function, loss of pain
temperature, crude touch ,crude pressure. Intact
proprioception ,fine touch fine pressure ,vibration.
C- posterior cord syndrome (rare)
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Spinal tract involved : posterior tract ( dorsal )
Etiology: acute posterior cord compression .
Symptoms :loss of proprioception ,fine touch ,fine
pressure ,vibration ,intact pain, temperature, crude
touch ,crude pressure.
D- Brown Sequard syndrome (uncommon)
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Spinal tract involved :dorsal on same side
,spinothalamic
on
the
opposite
side
,corticospinal on the same side .
Etiology: transverse hemisection of the cord
(usually penetrating injury )
Symptoms :loss of
motor function
proprioception ,vibration (epailateral)
Loss of pain and temperature ( contralateral)
2-complete SPINAL Cord LESION
-results in loss of all motor and sensory function
below the level of the lesion.
-shock is frequently the initial response resulting
in loss of motor, sensoty, and reflex function
below the level the injury.
-The patient may also develop neurogenic shock
resulting in loss of autonomic function.
Complete spinal cord lesion
Complete spinal cord lesion
Sings AND Symptoms
- loss of motor function below the level of the injury;
initially
flaccid paralysis.
- Bilateral external rotation of the legs at the hips
- Loss of sensory function below the level of theinjury; loss of
pain, touch, temperature, deep pain, vibration, and
proprioception.
- Neurogenic shock.( Loss autotonomic nervous system function)
- Hypotension ,bradycardia .?
- Poikilothermia .
- loss of voluntary bowel and bladder function .
- loss of reflexes, if spinal shock is present .
- priapism.
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NURSING CARE OF THE PATIENT WITH A
SPINAL CORD AND VERTEBRAL COLUMN
TRAUMA
1- Assessment
history
-General: MIVT
-Specific :1-neck or back pain ?
2-Spontaneous movement in
extremities or altered sensation?
( hematoma ,edema )
2-physical assessment
assessment of airway ,breathing , circulation, and disability.
- Inspection:
assess breathing effectiveness and rate of respirations.
-C3 - C5 interferes with diaphragmatic function.
- C6 spare the diaphragm, edema formation and hemorrhage
may affect respiratory effort.
-T2-T8 may spare the diaphragm but result in loss of
irnercostal muscle function.
Physical assessment cont…
- Palpation
- Palpate pulse rate and quality.
- palpate skin temperature.
- assess all four extremities for muscle strength.
Physical assessment cont…
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-assess sensory function
The use of a touch stimulus to determine levels of sensory
function should begin at the area of no feeling and proceed
toward the area of feeling. This will aid in localizing the level
of injury .
C5 Top of shoulder.
T4 Nipple line.
T10 Umbilicus.
L4 Great toe.
Physical assessment cont…
•gently palpate the vertebral column for pain,
tenderness, or step deformities between
vertebrae.
•palpate the anal sphincter for presence or
absence of tone.
•Assess for sacral sparing.
Physical assessment cont…
Test reflexes
-In the presence of spinal shock, the patient will
present with areflexia.
-A Babinski’s sign is a pathologic reflex, because
of dysfunction of upper motor neurons of the
corticospinal tract.
DIAGNOSTIC PROCEDURES
radiographic studies
- Vertebral column radiographs.
-initial cross-table lateral view of the cervical
spine.
-Additional views can determine the exact site
and nature of the bony injury.
- Thorough radiographic evaluation is indicated
if the patient has an altered mental status.
- CT scan ,MRI.
ANALYSIS, NURSING DIAGNOSES,
INTERVENTIONS.
NURSING DIAGNOSIS
Ineffective airway clearance related to ??
Interventions:
- Open airway with jaw Thrust or chin lift while
maintaining cervical spine immobilization.
- suction airway.
- Obtain blood sample for ABGs as indicated.
-Assist with endotracheal intubation
NURSING DIAGNOSIS
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Aspiration related to ??
Interventions
- Maintain spinal immobilization and stabilization
- Position patient
- Open and clear airway
- insert oro- or nasopharyngeal airway
- Consider and assist with endotracheal intubation, as
indicated
- Insert gastric tube and evacuate stomach contents.
NURSING DIAGNOSIS
Impaired gas exchange related to ??
Interventions
- Administer oxygen via a nonrebreather mask.
- Ventilate with 100% oxygen via a bag-valve-mask
device
- Monitor oxygen saturation with continuous pulse
oximetry
-Assist with intubation
NURSING DIAGNOSIS
fluid volume deficit related to ??
Interventions
- Cannulate two veins with large- bore catheters and
initiate
infusion of lactated Ringer’s solution or normal saline;
monitor rate carefully
- Consider vasopressors as needed
- insert urinary catheter
- Monitor hemodynamics
NURSING DIAGNOSIS
altered tissue perfusion
Interventions
-control bleeding
-IV infusion
-Blood transfusion
NURSING DIAGNOSIS
Ineffective thermoregulation
Interventions
-warm environment
-warm IV fluids
NURSING DIAGNOSIS
injury ,risk for injury
Interventions
- immobilization
-sedative or short-acting paralytic agent
-methylIprednisolone…
NURSING DIAGNOSIS
Ineffective coping
Interventions
- Provide support to the patient and family
- Provide information and answer questions
- Make appropriate referrals for support
NURSING DIAGNOSIS
Impaired skin integrity.
Interventions
- Remove patient from backboard as soon as
possible
- -Avoid allowing a paralyzed patient to lie on
backboard for more than 2 hours
- Consider placement on special bed
Planning and Implementation
-Immobilize vertebral column
-Suction airway, as needed
- intravenous fluids :
If neurogenic shock is present, blood pressure will not usually
be restored with fluid infusion; judicious use of
vasopressors may be indicated. Attempts to restore blood
pressure with fluid may lead to volume overload and
pulmonary edema
Steroids:-
Effects :limitation of cord edema ischemia, and
the prevention of cellular death.
Dose : 30 mg/kg IV loading dose over 15
minutes. Wait 45 minutes; then initiate a 5.4
mg/kg /hr over the next 23 hours. For
maximum effect, the initial dose must be
administered within the first eight hours of
.injury
-Insert a gastric tube.
-Provide psychosocial support.
-Keep the patient warm.
-Initiate skin care early.
-Assist with the application of skeletal tongs.
-prepare for interfacility transfer.
Evaluation and Ongoing Assessment
-Monitoring breathing effectiveness.
-Monitoring changes in sensory and/or motor
.function.
-Monitoring temperature to avoid hypothermia.
summary
· - Any polytrauma patient is suspect of having an unstable spine
fracture until the contrary is proven,
- The vital prognosis is threatened in the first days essentially by
the assault on respiratory muscles and cardiovascular
troubles induced by the breach of the autonomous
. nervous system
- Medical management is made as early as possible in the
pre-hospital setting.
- Exploration of the spine by conventional face and profile
radiographs remains the basic examination.
- The maintenance of the spinal cord blood flow is an essential
objective of the resuscitation begun in the pre-hospital setting.
THANK YOU
Reference :trauma
nursing core course 5th
edition