SPINAL CORD INJURY

BY
CARLA A. HARMON RN MSN

Spinal shock vs. Neurogenic

Spinal Shock
Time of occurrence is Immediately after SCI (experienced by approx. 50% of
people with acute SCI)
Clinical Manifestations
Complete loss of motor, sensory, reflex, ANS (bradycardia, hypotension,
hypothermia
Flaccid paralysis - no movement, no tone, no reflex
Deficit is below the injury
Nursing care:
Assess for return of reflex: stroke the bottom of foot - plantar reflex
(Babinski)
any return of reflex activity is good SCI is beginning to resolve
Assess for sensory
Spinal shock cannot occur again, but at risk for neurogenic shock

Spinal shock vs. Neurogenic

Spinal shock (spinal shock syndrome)

Occurs immediately as the cord's response to the injury
Complete but temporary loss of motor, sensory, reflex, and
autonomic function
Often lasts less than 48 hours but may continue for several weeks
Muscle spasticity, reflex activity, and bladder function begin in
patients with cervical or high thoracic injuries when spinal shock
is resolved

Spinal shock vs. Neurogenic

Neurogenic Shock
Type of distributive shock: fluid shifts from central vascular space to
interstitial space - loss of vasomotor tone caused by injury- pooling of
blood within the extremities lacking sympathetic tone this will lead to
hypovolemic shock
( NEUROGENIC SHOCK S&S hypotension, bradycardia, skin is
warm and dry)
may occur within above T6
severe bradycardia; warm dry skin; severe hypotension
notify physician immediately- treated symptomatically by restoring
fluid to circulating blood volume.

Spinal shock vs. Neurogenic

Physical Assessment/Clinical Manifestations
ABCs (airway, breathing, circulation) is the priority
Breathing: The patient with a cervical SCI is at high risk for respiratory
compromise because the cervical spinal nerves (C3-5) innervate the
phrenic nerve, which controls the diaphragm. A significant head injury,
pneumothorax (air in the chest cavity), hemothorax (blood in the chest
cavity), and/or fractured ribs may also cause respiratory distress. Injuries
to the occiput (back of the head) and C2 are more likely to occur in the
older adult who fell from a low height. Endotracheal intubation with
mechanical ventilation may be necessary to prevent respiratory arrest.

Spinal shock vs. Neurogenic

Assess for indications of intra-abdominal hemorrhage or hemorrhage or

bleeding around fracture sites. Indicators of hemorrhage include hypotension
and tachycardia with a weak and thready pulse.
Level of Consciousness (LOC): Use the Glasgow Coma Scale
Detailed assessment of the patient's motor and sensory status to assist in
determining the level of injury and serve as baseline data for future
comparison.
*The level of injury is the lowest neurologic segment with intact or
normal motor and sensory function.
Quadri- - involve all four extremities, seen w/ cervical cord and upper
thoracic injury
Para- - involve only lower extremities; seen w/ lumbosacral and lower
thoracic injury
plegia = paralysis
paresis = weakness

Spinal shock vs. Neurogenic

ASSESSMENT
Sensory
Absence of tactile sensation
To test sensory abilities, ask the patient to close his or her eyes.
Touch the skin with a clean safety pin or cotton-tipped applicator,
and ask whether he or she can feel the pinprick or light touch.
Compare bilateral responses. Examination beginning in the area
of reported loss of sensation and ending where sensation becomes
normal.
hypoesthesia (decreased sensation) or hyperesthesia (increased
sensation)

Spinal shock vs. Neurogenic

Motor
Flaccid paralysis (inability to move) of all voluntary muscles
The American Spinal Injury Association (ASIA) recommends a six-point
grading scale, with 0 being no movement and 5 being normal strength against
full resistance
Ask the patient to:
flex and extend the elbows/wrists/fingers & knees/ankles/toes
elevate both arms and legs off the bed
touch each finger to the thumb, wiggle toes
move one or both hips
It is not unusual for these reflexes, as well as all movement or sensation, to be
absent immediately after the injury because of spinal shock. After shock has
resolved, the reflexes may return if the lesion is incomplete or involves upper
motor neurons.

Spinal shock vs. Neurogenic

Chart 45-8: Assessing Motor Function in the Patient with
a Spinal Cord Injury

To assess C4-5, apply downward pressure while the patient shrugs his or her
shoulders upward.
To assess C5-6, apply resistance while the patient pulls up his or her arms.
To assess C7, apply resistance while the patient straightens his or her flexed
arms.
To assess C8, make sure the patient is able to grasp an object and form a fist.
To assess L2-4, apply resistance while the patient lifts his or her legs from the
bed.
To assess L5, apply resistance while the patient dorsiflexes his or her feet.
To assess S1, apply resistance while the patient plantar flexes his or her feet.

Spinal shock vs. Neurogenic

Cardiovascular
Loss of sympathetic input causes:
Bradycardia, hypotension, hypothermia -- cardiac dysrhythmias.
Systolic blood pressure below 90 requires treatment - lack of perfusion to
the spinal cord could worsen the patient's condition. In addition, the
Lack of sympathetic or hypothalamic control causes the patient to lose
thermoregulatory functions
body tends to assume the temperature of the environment and attempts to
compensate by increasing extracellular fluid
Respiratory
Patient with a cervical SCI is at risk for breathing problems resulting from an
interruption of spinal innervation to the respiratory muscles
Pulse oximetry for arterial oxygen saturation
Assess for respiratory complications such as atelectasis and pneumonia.

Spinal shock vs. Neurogenic

Gastrointestinal
Abdomen - for manifestations of:
internal bleeding
gastric distension
paralytic ileus - may develop w/in 72 hours of admit
Changes in bowel patterns - peristalsis decreases
absence of bowel sounds
Abdominal pain
Genitourinary
No reflex ability for bladder contraction - urinary retention
Risk for urinary tract infection from an indwelling urinary catheter;
intermittent catheterizations; or bladder distention, stasis, and/or
overflow.

Spinal shock vs. Neurogenic

Complications of prolonged immobility
muscle wasting results from long-term flaccid paralysis
muscle spasticity - can lead to contractures of the joints
condition of the patient's skin, especially over pressure points, at least twice
daily.
Assess any reddened area carefully, and monitor it daily for change.
Turn patients frequently (every 1-2 hours) and use a pressure-reducing
mattress or special bed to help prevent skin breakdown.
Heterotopic ossification - bony overgrowth, often into muscle
Assess for swelling, redness, warmth, and decreased range of motion (ROM)
of the involved extremity
Changes in the bony structure are not visible until several weeks after initial
symptoms appear.

Spinal shock vs. Neurogenic

Laboratory Assessment
Urinalysis - check for the presence of blood in urine
ABGs - monitor respiratory status (at risk for respiratory insufficiency)
Findings should be within normal limits unless the patient has a history
of heavy smoking, pre-injury pulmonary disease, or respiratory failure.
Respiratory failure is indicated by decreased oxygen levels, increased
carbon dioxide levels, and respiratory acidosis.
CBC low hemoglobin count,
leukocytosis (increased white blood cells [WBCs]),
lymphocytopenia (decreased lymphocytes)
thrombocytopenia (decreased platelets)

Spinal shock vs. Neurogenic

Imaging Assessment
CT (as soon as possible)
MRI
to determine the degree and extent of damage to the spinal cord and to
detect the presence of blood and bone within the spinal column
complete x-ray series of the spine to identify vertebral fractures,
subluxation, or dislocation.

Spinal shock vs. Neurogenic

Analysis - The priority problems for patients with a spinal cord injury (SCI)
are:
1. Difficulty breathing related to upper motor neuron injury
2. Potential for neurogenic shock related to loss or interruption of sympathetic
innervation in patients with SCIs above T6
3. Potential for further spinal cord injury related to swelling and/or fractures
4. Impaired Physical Mobility and/or Self-Care Deficit (the level depends on the
extent and level of the injury) related to decreased or absent muscle control
5. Spastic or flaccid bladder and bowel related to direct neurologic damage or
disruption in nerve impulses
6. Impaired adjustment related to disability requiring need for life change

Spinal shock vs. Neurogenic

Nursing Care
Stabilize the vertebral column as needed
Manage damage to the spinal cord
Prevent secondary effects of injury

Know These Drugs

Osmitrol (mannitol)

Methylprednisolone (Solu-Medrol)

Know These Drugs

Phenytoin

Atropine