Spinal Cord Injury Management

Ever wondered how to expertly navigate the complex world of caring for patients with spinal cord injuries? Fear not, because in our riveting discussion with Dr Hobbock, we unpack everything you need to know, from recognizing the telltale signs of spinal shock and autonomic dysreflexia to implementing effective management strategies. Master the use of corticosteroids, the role of traction, and the essential monitoring techniques to ward off further injury or infection. 

It's not just about the medical side of things though. We will also tackle the psychological impacts of these debilitating injuries on patients. We'll help you understand the guilt that often accompanies spinal cord injuries and how best to provide emotional support. Learn how to connect your patients with the right support groups, therapists, and case managers or social workers. Don't miss out on this treasure trove of key insights and practical tips that will arm you with the knowledge you need to provide top-notch care for patients with spinal cord injuries.

Chapters

• 0:41 Spinal Cord Injuries and Nursing Care
• 9:30 Supporting Spinal Cord Injury Patients

Transcript

Speaker 1: 0:42

Hey and welcome to Nursing with Dr Hobbock. Today I'm thinking about spinal cord injuries, just moving on in this series on neurological conditions. So spinal cord injuries, there's really two types. You have complete, incomplete, or you can classify them by the mechanism of injury, which can be direct or indirect. A direct injury is going to be from a blunt force trauma to the spine or a penetrating injury. So the five primary mechanisms that can result in a spinal cord injury are hyperflexion, and that's like a sudden, forceful acceleration of the head forward. Hyper extension when, say, a car is hit from behind and the patient's chin is struck, the head suddenly accelerates and then decelerates. We also have vertebral compression or axial loading, so this would be like a diving accident. Excessive rotation this is what you see in the movies when they go up and they twist somebody's head and break their neck. That's an excessive rotation. And then we have penetrating trauma. We can also have injuries to the spinal cord via a secondary injury. So hemorrhage, ischemia, hypovolemia, impaired tissue perfusion from some other reason, like neurogenic shock and local edema on the spine, can also cause spinal cord injury.

Speaker 1: 2:12

When we perform that initial assessment, we really want to just get the information about the injury as much as information about the injury as we can. Where did it happen? What was the position of the patient right after the injury, or did they have changes right after? Any changes that have happened since then? Have they been immobilized? Did anybody use an immobilizer? What kind of treatment has been given on the scene? Their medical history, of course Do they have osteoporosis or arthritis of the spine, any deformities, cancer, previous injury and, of course, any history of respiratory issues?

Speaker 1: 2:49

We're going to classify these spinal cord injuries based on the level of vertebrae. So we'll say we have the C5, c6, c7, so the cervical vertebrae, c5, c6, and C7. T12 is another common place and L1 are the most common places where we see spinal cord injuries. Of course, we're still using the ABCs for these patients and we're going to use that Glasgow Coma Scale that we talked about in the previous episode and we're watching out for spinal shock. This is something that's going to happen right away. It's the cord's response to the injury. So the patient's going to have complete but temporary loss of motor, sensory, reflex and autonomic function and that's going to last less than 48 hours but could continue for a couple of weeks. This is not the same as neurogenic shock. So keep that in mind. You need to, of course, be doing neurological assessments frequently and then, especially if the injury is C3 to C5, you're going to be doing respiratory assessments because the cervical plexus innervates through the diaphragm. So C3 to C5, think about respiratory status. If I go back real quick to that spinal shock, that's going to last 48 hours to a couple of weeks. We're not going to know if this patient has permanent damage for at least a week. We're going to have to wait for some of the swelling to go down at edema so that we can tell whether or not it's permanent. They may have more loss of sensation, loss of function, immediately following the injury than they will later on in life.

Speaker 1: 4:29

One of the classic things that you need to know about for spinal cord injury is autonomic dysreflexia. It's sometimes abbreviated AD. Autonomic dysreflexia refers to a potentially life-threatening condition where we have a stimuli, usually a visceral or cutaneous stimuli that causes a sudden, massive, uninhibited reflex sympathetic discharge. This patient usually has a high level spinal cord injury and their signs and symptoms will be a significant rise in systolic and diastolic blood pressure, accompanied by bradycardia. Blood pressure is going to skyrocket, heart rate goes down. We'll see profuse sweating above the level of the spinal cord injury, especially the face, neck shoulders, goose bumps below the level of injury. They may have some flushing in the face and neck shoulders. They may have blurred vision, spots in their visual field, nasal congestion, severe throbbing headache and then they may have pallor below the level of injury or they may have a feeling of apprehension. So keep autonomic dysreflexia in the forefront of your mind. That one is a classic for questions as far as nursing. So keep that in mind. And the first thing that you're going to do if the patient has autonomic dysreflexia is sit them upright and check their bladder. Notice that full bladder or bowel can actually be the visceral stimuli that triggers this. So if you notice that in the patient, sit them upright, check the bladder, see what's going on there.

Speaker 1: 6:07

Obviously, these patients need to be stabilized anytime you have to transfer. So make sure you're log rolling to keep that spine in alignment. You're using the cervical collar as needed. We wanna maintain their airway and we might actually see skeletal traction. Remember that skeletal traction is where the pins go into the bone and then we apply traction to that Skeletal traction. We might see skull tongs or a halo ring. You can look those up. The most important parts about traction is that the weights hang freely, you don't add weight, you don't remove weights and you keep the pin sites clean at least once a shift and monitor them for signs and symptoms of infection, aerithema, edema, exudate, those kinds of things. In the very beginning of a spinal cord injury we might see high doses of corticosteroids to help control that edema in the first eight to 24 hours. We also might see a striker frame or a really firm mattress with a board underneath for the spinal cord patient to try to support that spine.

Speaker 1: 7:12

And if the patient has a high cervical injury, again you're monitoring that respiratory function for respiratory failure. We could see further loss of sensory or motor function below the injury. That can indicate additional damage due to swelling and should be reported right away. So it's something you wanna report, stat and we're watching out for that spinal shock where we have that complete loss of all reflex and even deep tendon reflexes, motor, sensory and autonomic activity below the level of the injury and that's actually a medical emergency.

Speaker 1: 7:46

We're monitoring for hypotension and bradycardia and bladder and bowel distention. The patient could develop acute paralytic ilius, so lack of gastric activity. So we wanna assess bowel sounds frequently. If needed, we're gonna implement gastric suction. So you're gonna put in probably a Salem sump to low intermittent suction to keep that decompressed and we might use a rectal tube to release any gaseous distention. On that end, we made suction, but you've gotta be really careful that you don't trigger the vagus nerve, because that can cause cardiac arrest.

Speaker 1: 8:20

We wanna make sure that we are encouraging deep breathing, moving the patient side to side at least every two hours, if not every hour. Encouraging fluids, making sure that the patient stays well nourished we're just watching out for all of those complications of immobility that we should already know. So, scds, compression stockings we wanna get the patient moving in the bed. Deep breathing, incentives, barometry, if that's possible those things to keep an eye on. This patient is likely to go to a rehabilitation facility. We definitely wanna encourage that. The folks at the rehabs are amazing at helping improve muscle strength and coordination and helping the patient to find out how they're gonna be able to get along at home with their new life.

Speaker 1: 9:09

Finally, we need to think about psychosocial. Just because a patient has a spinal cord injury doesn't mean that well, whoop, we're gonna give up on you now. We wanna make sure that we're allowing the patient the opportunity to discuss their emotional reactions, talk about their body image, their role, performance, self-concept. These things can definitely change.

Speaker 1: 9:30

Many patients who have spinal cord injuries are young men who can feel guilty about having engaged in a high-risk behavior. There's a simulation that we run where the patient is a younger male who's gotten into a motorcycle accident and one of the things that we like to have him say is mom told me I shouldn't be riding the motorcycle without a helmet. So you're gonna wanna give them the opportunity to talk through these feelings. Get them in touch with a support group or therapy if needed, contact your social worker, case management for assistance or do what you can for the patient. That's really all I have for spinal cord injuries for today. I hope that that's helpful. Mostly the key points for you guys, and thanks for hanging out with me here on Nursing with Dr Hobbock. I'll see you next time.