Critical Care - Spinal Cord Injury

A spinal cord injury or se for short refers to damage to the spinal cord, which is a collection of nerve fibers that transmit information between the brain and the body.

Spinal cord injuries can result from a mechanical force that damages the neurological tissue. Its blood supply or both, which can result from traumatic events such as motor vehicle crashes, falls or injuries from recreational activities in sports.

As the nurse, you'll provide patient centered care for critically ill patients with spinal cord injuries. Spinal cord injuries involve both primary and secondary mechanisms.

The primary injury is the damage that occurs from a sudden trauma to the spine. It's characterized by contusion or bruising, compression or crushing, under pressure, laceration or tearing, transection or severing of the spinal cord and distraction where a stretching force causes two adjacent vertebrae to be pulled apart.

Primary injuries involve several mechanisms including hyperflexion, hyperextension rotation, axial loading and penetrating trauma.

Hyperflexion injuries occur from a forward and downward head motion. In contrast, hyperextension injuries involve backward and downward head motion.

Both of these injuries are common in the cervical area of the spine which has the most mobility rotation. Injuries are a twisting motion of the spine, axial loading or compression injuries occur when a force is applied vertically to the spinal cord causing compression fractures and burst fractures of the vertebrae which send bony fragments into the spinal cord.

Lastly, penetrating trauma like a wound that comes from a stabbing gunshot or shrapnel from an explosion can also cause spinal cord injuries.

Now, after the primary injury occurs, the secondary injury begins and involves a series of events that result in further neurologic damage.

Over weeks and months, the acute phase begins with depolarization of the neurons damaged by the trauma and an imbalance of ions like potassium and sodium leading to a disruption and transmission of nerve signals and cellular edema.

This is followed by an accumulation of glutamate, an excitatory neurotransmitter that in turn contributes to an influx of intracellular calcium which leads to apoptosis or cell death.

This is also accompanied by free radical formation, continued release of inflammatory cytokines and increasing edema. After this comes the subacute phase which involves scar formation by glial cells and remodeling at the site of injury.

Finally, the chronic phase begins as the glial scar matures. Clinical manifestations of spinal cord injuries vary depending on the location of the injury and whether the injury is incomplete or complete incomplete injuries result in a mix of sensory and motor loss below the level of the injury.

Whereas complete injuries result in total loss of both sensory and motor function below the level of the injury. For example, an injury between C one and T one leads to tetraplegia, also called quadriplegia, which may involve loss of function of the limbs and trunk, as well as loss of innervation to the diaphragm requiring mechanical ventilation.

On the other hand, an injury between T two and L1 leads to paraplegia where upper limb function remains intact, but there's paralysis of both lower limbs.

There can also be a loss of accessory respiratory muscle function as well as bowel and bladder dysfunction. Now, immediately after the injury, patients with spinal cord injuries can experience spinal shock, which involves flaccid paralysis and a complete loss of sensory motor bowel, bladder and reflexive activity below the injury with injuries at or above the level of T six.

Neurogenic shock can also develop resulting in interrupted sympathetic outflow and unopposed parasympathetic activity. This leads to bradycardia, massive peripheral vasodilation, hypotension, venous pooling, decreased venous return and decreased cardiac output leading to impaired organ perfusion and an increased risk of venous thromboembolism.

Patients with injuries at or above the level of T six can also experience autonomic dysreflexia. This is a neurologic emergency that occurs when a noxious sensory stimulation such as a distended bowel or bladder tight clothing or pain from a pressure injury stimulates sympathetic neurons.

But because the spinal cord injury blocks the inhibitory impulses above T six, the patient can experience massive vasoconstriction and symptoms like severe hypertension, facial flushing and diaphoresis above the level of the injury, anxiety and a throbbing headache.

If left untreated cerebral hemorrhage and seizures can also occur when caring for your critically ill patient with a spinal cord injury.

Your goals of care include promoting hemodynamic stability, preventing complications and providing emotional support. Begin by assessing your patients airway breathing and circulation or ABC S and placing them on a continuous monitor for any emergent lifethreatening findings activate emergency protocols as needed.

Also be sure to institute spinal precautions to prevent further injury to your patients spine, including applying a cervical collar to immobilize the neck, keeping their head in a neutral position.

And using the log roll technique during repositioning, prepare for application of cervical traction tongs or other stabilization devices depending on the level of injury.

Also perform regular neurological assessments including testing, bilateral motor and sensory function and reflexes. You will also take steps to promote hemodynamic stability and ensure tissue perfusion is adequate to support spinal tissue preservation and healing continuously, monitor BP, heart rate and cardiac output and administer IV fluids, titrate vasopressors to maintain your patients mean arterial pressure or map within the target range and administer inotropic medications to prevent and treat bradyarrhythmia.

Depending on the degree and location of injury. Patients may require respiratory support due to a weak cough, reflex, difficulty clearing secretions or impaired lung expansion for your patient with injuries affecting the diaphragm and other muscles of respiration that requires intubation and ventilator support.

Coordinate with the respiratory therapist to determine ventilator settings that optimize oxygenation and watch them closely for signs of ventilator associated pneumonia or ventilator induced lung injuries.

Assess their lung sounds as well as their respiratory rate and depth and monitor continuous pulse oximetry and capnography.

So, any deterioration in pulmonary status can be detected early. Additionally, institute measures to reduce the risk of complications from immobility.

Regularly reposition your patient and assess their skin for signs of breakdown and pressure injury like redness that doesn't blanch when pressed use, pressure reducing devices like cushions to protect bony surfaces or an alternating pressure mattress also minimize the risk of venous thromboembolism by administering prescribed anticoagulant medications and applying anti embolism, stockings or sequential compression devices.

Lastly collaborate with physical and occupational therapy to prevent contractures and optimize function and mobility if bladder and bowel function is affected, provide regular bladder emptying through intermittent catheterization as needed and avoid constipation and fecal impactions.

By initiating a bowel program closely watch for signs of autonomic dysreflexia and immediately work to resolve the stimulus like emptying their full bladder, removing a fecal infection and loosening any tight clothing.

Also be sure to support your patient emotionally recognize that theyll experience disturbances in body image and self concept and provide opportunities for them to express their feelings, refer them to counseling services as indicated and collaborate with social work and case management to support their lifestyle adaptation.

Finally, notify the health care provider. If your patient's condition worsens or if you identify new signs and symptoms.

All right, as a quick recap, a spinal cord injury or sci refers to damage to the spinal cord, which is a collection of nerve fibers that transmit information between the brain and the body.

Spinal cord injuries can result from a mechanical force that damages the neurological tissue, its blood supply or both. As the nurse, you'll provide patient centered care for critically ill patients with spinal cord injuries.