Case Study: Spinal Cord Injury Toni is a 19-year-old college student who was rock climbing and fell

30 feet to the ground. He is very athletic playing basketball and running track. His medical history is relatively negative except for the usual childhood illnesses and minor accidents. On his physical examination before school started his vital signs were as follows: BP 110/82, HR 88, RR 18. Toni was picked up at the scene of the accident by paramedics who found him lying in a supine position, unable to move any extremities and complaining of some neck discomfort. He appeared awake, alert, and oriented to his current location, the date and day of the week, and details of his fall. His responses to verbal questioning were appropriate. He complained that he could not feel or move his arms and legs. His pupils were equal and reactive to light. He showed no signs of other injury except for several scrapes on his arms. His vital signs revealed BP 110/72, HR 86, RR 18 unlabored and regular. Toni arrived at the surgical center and was found to exhibit no deep tendon reflexes of the extremities. His perception of sensory stimulus ended just above the nipple in the chest. He had some sensory perception of the arms but was not able to demonstrate any consistent pattern of perception with repeated examinations. He had some ability to tighten the biceps, but could not overcome gravity to raise his arms. He was unable to expand his chest wall minimally on midthoracic expansion. The VS were: BP 100/60, HR 68, RR 24 and shallow, temp. 99.8 F. His color was dusky and his skin was warm to touch. He expressed fear of being paralyzed. X-rays revealed Toni had a cervical dislocated fracture of C5 and C6. The thoracic and lumbar films revealed normal findings. Blood work was normal with a light respiratory acidosis pH=7.30. The neurosurgeons inserted Gardner Wells tongs and he was transferred to the ICU. 1. How should the paramedics extricate Toni? The nearest surgical center is 90 miles away, how would you recommend transporting Toni?

The EMS should use a scoop stretcher and cervical collar to extricate Toni and move him to a backboard. The scoop stretcher slides under the patient from both sides and prevents further spinal that could be produced by logrolling or lift and sliding the patient directly onto the backboard. Because of the distance to the nearest medical center the patient should be transported by air (helicopter) or by an Advance Life Support (ALS) ambulance. Aggravation of an existing axial spine injury could either cause or worsen a spinal cord injury. The theory is that keeping the axial spine in a stable anatomic position will be protective. (no source personal info) 2. Explain nursing care for Toni in the Neuro ICU. What are some complications you would anticipate?

Once the extent of injury has been determined, the patient has been stabilized, he will be admitted to the intensive care unit (ICU) where close monitoring and support of neurological, respiratory, and circulatory functions will take place. The patient is likely to develop complications from lack of innervation to vital organs. He may develop a neurogenic bowel and/or bladder. It is also likely that he will develop DVTs. It is possible that he will develop pneumonia. The patient will be transferred to the Med-Surg floor once those functions have stabilized.

3.

The second day postoperatively Toni develops warm flushed skin below the level of injury and BP 70/40 and HR 100. Explain the meaning of these changes in the VS and possible causes?

Hypotension could indicate that Toni is bleeding internally. His heart rate increased to try to elevate the blood pressure, indicating that this hypotension is most likely related to hemorrhage. Paralysis, loss of sensation in the extremities, and the broken vertebral bone, suggests that he suffered damage to his spinal cord. Damage to the spinal cord cuts off the normally continuous influence of brainstem centers on the spinal reflex centers below the level of the damage. The result of this injury is spinal shock, a condition in which all spinal reflexes below the level of the lesion are temporarily silenced. Sympathetic motor neurons no longer stimulate the heart to increase its rate and strength of contraction and no longer stimulate vasoconstriction of systemic arterioles. The loss of this sympathetic stimulation can cause the systolic blood pressure to drop below 40, thereby decreasing blood flow to vital organs and putting the patient into shock. 4. Toni stabilizes and notices muscle twitching in his legs. He still has no sensation and can make no purposeful movements. Explain the twitching.

The lower motor neurons (whose cell bodies are located in the ventral horns of gray matter) that innervate the leg muscles normally are, themselves, influenced by neurons from several locations. Upper motor neurons of the lateral corticospinal tract synapse directly and indirectly on these lower motor neurons, as do sensory neurons and interneurons involved in the muscle stretch reflex. Bilateral damage to the lateral corticospinal tracts at C5 has eliminated neuron influence on these lower motor neurons. As the spinal shock resolves, these lower motor neurons regain their own excitability, despite the loss of upper motor neuron stimulation. Often, this regained excitability is exaggerated, causing the lower motor neurons to fire off impulses inappropriately to the leg muscles. The muscle stretch reflex arcs are similarly exaggerated. This, coupled with the loss of voluntary muscle control by the higher brain centers, is referred to as spastic paralysis. Note, however, that his arm muscles may be permanently flaccid (i.e. flaccid paralysis) due to destruction of motor neurons in the parts of the spinal cord supplying these muscles. 5. Two weeks later Toni develops a weird feeling. His BP is 250/140. What is probably happening to Toni?

Toni is likely experiencing autonomic hyperreflexia. Autonomic hyperreflexia is a reaction of the involuntary (autonomic) nervous system to too much stimulation. People with this condition have an excessive nervous system response to the types of stimulation that do not bother healthy people. This reaction may include: Change in heart rate Excessive sweating High blood pressure Muscle spasms Skin color changes (paleness, redness, blue-grey skin color)

6.

The physician orders GI consult, a bowel program, intermittent catheterization. Explain the necessity of each of these measures.

Damage of the spinal cord can eliminate the command signals from the brain that normally allow for voluntary control of urination as well as defecation. The micturition reflex may return as the spinal shock resolves, since this reflex arc involves non-damaged segments of the spinal. If so, the bladder will then contract in response to increased stretch placed on its wall due to filling with urine. Toni may develop a neurogenic (or automatic) bladder - - i.e. one that is capable of periodic filling and emptying in an autonomous fashion. This same mechanism causes the bowels to lose function as well. These bowels then, due to lack of neuronal impulse, begin to loose shape and become more flattened. 7. He asks the nurse in the rehab unit about his ability to have children. How would you answer?

Toni should not worry about his ability to have children. It is possible for him to have children in the future if he so desires. It is important for him to understand he can continue to be active both sexually and recreationally despite this injury. The ongoing support of an urologist after discharge from the rehabilitation facility will be important in maintaining sexual health. (no source personal information) 8. What level of independence would you expect for Toni? At what level of injury would he have total independence?

More than likely Toni will lose at least some of his independence. How much he does depends on the type of injury to the spinal cord. A complete spinal cord injury indicates complete loss of voluntary motor and sensory functions below the level of injury. Injuries involving the cervical spinal cord will result in quadriplegia or loss of motor and sensory function involving both upper extremities, both lower extremities, bowel, and bladder. Injuries of this nature are irreversible. Patients who have experienced an incomplete spinal cord injury will have some preservation of sensory and/or motor function below the level of injury. In these patients, there is sparing of some of the spinal cord tracts, which allows neurotransmission to occur. Still incomplete spinal cord injury does not guarantee his ability to recover total independence.