module 8: Spinal cord injuries, Autonomic Dysreflexia, Back pain, Osteomyelitis, & Fractures

Spinal cord injury

An injury to the spinal cord, vertebral column, supporting soft tissue, or intervertebral disks caused by trauma

Pathophysiology of SCI

• Ranges from transient concussion (which is fully recoverable) to contusion, laceration, and compression of the spinal cord tissue to complete severing of the spinal cord

  • Renders patient paralyzed below the level of injury

• Vertebra C5-C7, T12, and L1 are the most susceptible to injury due to a greater range of motion

• Primary injuries = result of initial insult or trauma; permanent damage

• Secondary injuries = result from hypoxemia, edema, or hemorrhage which damages the tissue

Risk factors of SCI

• Younger age

• Male gender

• Alcohol and illicit drug use

clinical manifestations of SCI

• Complete spinal cord lesion = loss of sensory and voluntary motor communication; paraplegia or tetraplegia

  • Incomplete spinal cord lesion = sensory and motor communication is preserved below the lesion

s/s of SCI

• Total or partial paralysis

• Loss of bowel and bladder control

• Loss of sweating

• Reduction in BP with loss of peripheral vascular resistance

• Acute back or neck pain

• Respiratory dysfunction (depending on level of injury)

Associated priorities of SCI

• Immobilization in the extended position until proper assessment and treatment is performed

  • Incomplete injury may become complete if pt continues to move after trauma event

• Neurological assessment

• X-ray

• CT scan

• MRI scan for  further workup

• Monitor respirations/pattern

• Vitals

Usual treatment of SCI

• Respiratory therapy

• Pacing

• High dose IV corticosteroids

  • Methylprednisolone

• Immobilization

  • Stabilization of vertebral column

• Reduction of dislocations

• Skeletal traction (cervical injuries)

• Surgical intervention (thoracic and lumbar injuries)

Nursing considerations of SCI

• Spinal shock

• Neurogenic shock

• VTE

  • DVT

  • PE

• Pressure injuries

• Monitor respirations and breathing pattern

• Lung sounds and cough

• Monitor for changes in motor or sensory function; report immediately

• Assess for spinal shock

• Monitor for bladder retention or distention, gastric dilation, and ileus

• Temperature; potential hyperthermia

Characteristics of central cord syndrome

• Motor deficits

  • In the upper extremities compared to the lower extremities

  • Sensory loss more pronounced in upper extremities

• bowel/bladder dysfunction

Cause of central cord syndrome

• Injury

• Edema

• Hyperextension injuries

Characteristics of anterior cord syndrome

• Loss of pain (below the level of lesion)

• Loss of temperature function (below the level of lesion)

• Loss of motor function (below the level of lesion)

• Light touch, position, and vibration sensation remain intact

Cause of anterior cord syndrome

• Acute disc herniation

• Hyperflexion injuries associated with fracture or dislocation of vertebra

• Injury to anterior spinal artery

Characteristics of lateral cord syndrome

• Ipsilateral paralysis or paresis is noted

• Ipsilateral loss of touch, pressure, and vibration

• Contralateral loss of pain and temperature

Cause of lateral cord syndrome

• Lesion is caused by a vertical transection

• Result of knife or missile injury, fracture/dislocation, or acute ruptured disk

Skeletal traction

• Used to reduce cervical fractures and align the cervical spine

• Traction is applied to via weights

• As the traction increases, the spaces between the intervertebral disks widen, allowing the disks to slip back into place

• Reduction in traction occurs after proper alignment is restored

Spinal shock

Sudden depression of reflex activity below the level of injury caused by muscles being paralyzed and flaccid

s/s of spinal shock

• Decreased BP

• Bradycardia

• Bowel distention

• Paralytic ileus

Considerations of spinal shock

• Maintain MAP of at least 85 mm Hg

• NG tube

Neurogenic shock

• Result of the loss of autonomic NS function below level of injury

• Vital organs are affected

s/s of neurogenic shock

• Decrease BP, HR, and cardiac output

• Venous pooling

• Respiratory complications

  • Decreases vital capacity

  • Retention of secretions

  • Increased PaCO2

  • Decreased O2

  • Pulmonary edema

Autonomic hyperreflexia

Acute life threatening emergency that occurs as a result of exaggerated autonomic responses to stimuli after spinal shock has been resolved

Pathophysiology of autonomic dysreflexia

• Exaggerated autonomic responses to stimuli

• Triggers:

  • Distended bladder

  • Distention or contraction of visceral organs

    • Bowel

  • Stimulation of the skin

Risk factors of autonomic dysreflexia

• SCI

• Spinal shock

Clinical manifestations of autonomic dysreflexia

• Paroxysmal HTN

• Profuse diaphoresis above injury

• bradycardia

s/s of autonomic dysreflexia

• Severe pounding headache

• Nausea

• Nasal congestion

Associated priorities of autonomic dysreflexia

• Remove the triggering stimulus

• Immediately place in sitting position to lower BP

• Empty bladder

• Examine for fecal mass and remove

• Skin assessment for pressure or broken skin

Usual treatment of autonomic dysreflexia

• Antihypertensives

  • Slow IV

Low back pain

• Caused by musculoskeletal problems such as

  • Acute lumbosacral strain

  • Insatiable lumbosacral ligaments

  • Weak muscles

  • Unequal leg length

  • Intervetebral disc problems

Pathophysiology of low back pain

• The spinal column has rigid units = vertebrae and flexible units = intervetebral discs, held together by joints, ligaments, and muscles

• Spinal curves absorb vertical shocks from movement

• Abdominal and thoracic muscles are important in lifting and minimize stress on the spinal units

• Intervertebral discs change with age

  • Fibrocartilage becomes dense and irregularly shaped with time; disc degeneration

• Low lumbar discs, L4 and L5-S1, are subject tot he greatest mechanical stress and degeneration

Cauda equina syndrome

compression of a bundle of spinal nerves from the lower spinal cord

• Results from the compression of the cauda equina, a bundle of spinal nerves from the lower portion of the spinal cord

• Requires immediate attention before nerve damage occurs

Risk factors of low back pain

• Depression

• Smoking

• Alcohol abuse

• Obesity

• Stress

Clinical manifestations of low back pain

• Acute back pain (lasting <3 months)

• Chronic back pain (lasting 3< without improvement)

• Fatigue

• Pain radiating down the leg

  • Radiculopathy = pain from a diseased spinal nerve root

  • Sciatica = pain from inflamed sciatic nerve

• Affected gait, spinal mobility, reflexes, leg length, motor strength, and sensory perception

• Cauda equina

Associated priorities of low back pain

• Focused history and physical exam

  • Gait evaluation

  • Neurologic testing

• X-ray, CT scan, MRI, etc.

• Assess posture, position changes, and gait

Usual treatment of low back pain

• Analgesics, rest, and avoidance of strain

• Activity modification

• NSAIDs and short term muscle relaxants

• Opioids (1-2 weeks)

• Thermal applications

• Spinal manipulation (chiropractor)

• Cognitive behavioral therapy

• Exercise regiments

• Spinal manipulation

• PT

• Acupuncture

• Massage

• Avoid stress to back

Nursing considerations of low back pain

• Positioning

• Location, severity, duration, characteristics, radiation (radiculopathy), leg weakness

• How the pain occurred and has been managed by the patient

• Work and recreational activities

• Spinal curvature, back and limb symmetry

• Palpate paraspinal muscles

• Movement ability and effects on ADLs

• DTRs, sensation, and muscle strength

s/s of cauda equina

• Sever or progressive neurologic deficit

• Recent bowel or bladder dysfunction

• Saddle anesthesia

  • Paresthesias in the but and inner thighs

Osteomyelitis

• An infection of the bone that results in inflammation, necrosis, and formation of new bone

• Can be

  • Hematogenous (bloodborne spread)

  • Contagious-focus (contamination from surgery, fracture, or trauma)

  • With vascular insufficiency

Pathophysiology of Osteomyelitis

• Infections caused by staph aureus, MRSA, streptococci, enterococci, or pseudomonas

• Initial response is inflammation, increased vascularity, and edema; after 2-3 days, thrombosis of local blood vessel occurs causing ischemia with bone necrosis

• Infection spreads to tissues and joints, and may cause a bone abscess

  • Abscess contains dead bone tissue and cannot heal, but instead new bone growth forms around the dead bone tissue

  • Chronic infection of the bone tissue = chronic osteomyelitis

Risk factors of Osteomyelitis

• Old age

• Poor nourishment

• Obesity

• Impaired immune function

• Chronic illness

• Long term corticosteroid therapy

Clinical manifestations of Osteomyelitis

• Sudden onset of sepsis manifestations

  • Chills

  • High fever

  • Rapid pulse

  • General malaise

• Infected area becomes painful, swollen, and extremely tender

• Constant, pulsating pain that intensifies with movement

• Pus

Associated priorities of Osteomyelitis

• Early x-ray

• MRI

• Blood studies

• Bone biopsies

• Ability to adhere to prescribed therapeutic regimen— antibiotic therapy

• Signs and symptoms of infection, localized pain, edema, erythema, fever, drainage

Usual treatment of Osteomyelitis

• IV antibiotics

• Prophylactic antibiotics

• Surgical debridement

  • All dead, infected bone, tissue, and cartilage must be removed for permenant healing

Nursing considerations of Osteomyelitis

• Disposable medical tools (to minimize possibility of infection)

• Encourage adequate hydration, vitamins, and protein

• Relieving pain

  • Immobilization

  • Elevation

  • Handle with great care and gentleness

  • Administer prescribed analgesics

• Improving physical mobility

  • Activity is restricted

  • Gentle ROM to joints above and below the affected part

  • Participation in ADLs within limitations

Contusion

• soft tissue injury produced by blunt force

  • Pain, swelling, and discoloration: ecchymosis

Strain

• Pulled muscle injury to the musculotendinous unit

  • Pain, edema, muscle spasm, ecchymosis, and loss of function are on a continuum graded first, second, and third degree

Sprain

• injury to ligaments and supporting muscle fiber around a joint

  • Pain (may increase with motion), edema, tenderness; severity graded according to ligament damage and joint stability

Dislocation

• articular surfaces of the joint are not in contact

  • A traumatic dislocation is an emergency with pain change in contour, axis, and length of the limb and loss of mobility

Subluxation

• partial or incomplete dislocation

  • Does not cause as much deformity as a complete dislocation

RICE

• Rest

• Ice

• Compression

• Elevation

Fracture

• A complete or incomplete disruption in the continuity of bone structure and is defined according to its type and extent

• Occur when a bone is subjected to stress greater than it can absorb

Pathophysiology of Fractures

May be caused by direct blows, crushing forces, sudden twisting motions, and extreme muscle contractions

Clinical manifestations of Fractures

• Adjacent structures may have soft tissue edema, hemorrhage into the muscles and joints, joint dislocations, ruptured tendons, severed nerves, and damaged blood vessels

• Continuous pain that increases in severity

  • Numbness immediately after

• Loss of function

• Displacement, angulation, or rotation

• Shortening

• Crepitus

• Localized edema and echymosis

Associated priorities of Fractures

• Immobilization of body part

• X-ray

• Adequate splinting

  • Bandaging affected to unaffected extremity or chest

  • Sling

• Assessment of perfusion and nerve function

• Cover wound with sterile dressing (open fracture)

Usual treatment of Fractures

• Reduction = restoration of bone fragments to anatomic realignment and positioning with realignment

  • Closed uses manipulation and manual traction

  • Open uses surgery and internal fixation devices

• Immobilization until union occurs

• IV antibiotics and debridement (open)

Nursing considerations of Fractures

• Maintaining and restoring function

  • Position changes

  • Pain relief

  • Isometric exercise

  • Reassurment

Factors affecting fracture healing

• Age >40 years

• Avascular necrosis

• Bone loss

• Cigarette smoking

• Comorbidities (e.g., diabetes, rheumatoid arthritis)

• Corticosteroids, nonsteroidal anti-inflammatory drugs

• Extensive local trauma

• Inadequate immobilization

• Infection

• Local malignancy

• Malalignment of the fracture fragments

• Space or tissue between bone fragments

• Weight bearing prior to approval

Early complications of fractures

• Shock

• Fat embolism

• Acute compartment syndrome

• DVT; PE

• Infection

Late complications of fractures

• Union

• Malunion

• Nonunion

• AVN of bone

Types of fractures

• Closed

• Open

  • Type I

  • Type II

  • Type III

• Intra-articular

Closed fracture

• Simple fracture

• Fracture that does not break the skin

Open fracture

• Compound or complex fracture

• Fracture that breaks the skin or mucous membranes around it

• Type I = clean wound less than 1cm ina simple fracture pattern

• Type II = larger wound with minimal soft tissue damage; no flaps or avulsions

• Type III = most severe, highly contaminated, and has extensive soft tissue damage

  • Vascular injury or traumatic amputation

Intra-articular

Extends into the joint surface of a bone

Casts

• Ridgid external immobilizing device that is molded to the contours of the body; must fir the shap of the injured limb to provide the best support

Cast application

• Before application

  • General health assessment

  • Emotional status

  • Presenting signs and symptoms and condition of the area (prior to doing immobilzation)

• Monitoring of neurovascular status and for potential complications

• Treat lacerations and abrasions before cast, brace, splint

• Provide information about the purpose of treatment

• Prepare patient for application by explaining procedure

  • prepare them for what they might feel while being splinted or casted.

  • With the cast- It may feel weird because it is warm as you put it on and gets warmer as it dried. Then it gets hard, this may make them feel claustrophobic

The 5 P’s of casts

• Assessing for neurovascular changes using “5 Ps”

  • Pain

  • Pallor

  • Pulselessness

  • Paresthesia

  • Paralysis

• Monitoring and treating pain