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Pathophysiology 2 > Spinal Cord Injury > Flashcards

Spinal Cord Injury Flashcards

1
Q

The Spinal Cord

A

The spinal cord controls all voluntary movement of the body and is supported & is protected by the vertebral column

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2
Q

Cervical Vertrebral Column

A

First 7

C3-C5 is where the nerves run to the diaphragm

“C3 – C5 keeps the diaphragm alive”

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3
Q

How Many Thoracic Vertebrae are There

A

12

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4
Q

How Many Lumbar are There

A

5

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5
Q

Sacral Vertebrae

A

There are five vertebrae that are fused together into one bone

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6
Q

Coccygeal Vertebrae

A

4 Bones fused together as one

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7
Q

Spinal Nerves

A

31 pairsof nerves that are attached to the spinal cord

Cervical-8 Pairs

Thoracic-12 Pairs

Lumbar-5 Pairs

Sacral-5 Pairs

Coccygeal-1 Pair

These nerves will contain motor and sensory divisions

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8
Q

Spinal Cord Injuries

A

May stem from a sudden traumatic impact to the spine that fractures, dislocates, or compresses one or more of the vertebrae

A non-traumatic SCI can be the result of arthritis, cancer, inflammation, infections, or disc degeneration

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9
Q

Incomplete Spinal Cord Trauma

A

Preservation of sensory or motor function below the level of injury including the lowest sacral segments

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10
Q

Complete Spinal Cord Trauma

A

Absence of sensory and motor function in the lowest sacral segments

Paraplegia is the result of thoracic/lumbar injury

Will result in Para or Quadrapalegia

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11
Q

Simple Vertebral Fractures

A

Single break in transverse or spinous process

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12
Q

Compressed Vertebral Fractures

A

Vertebral body has been anteriorly compressed

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13
Q

Comminuted Vertebral Fractures

A

Burst/shattered vertebra

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14
Q

Dislocated Vertebral Fractures

A

Can cause cord injury and cord severing

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15
Q

Types Vertebral Fractures

A

Simple

Compressed

Comminuted

Dislocated

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16
Q

Vertebral Compression

A
  • May be caused by downward pressure from the head through the spine
    • Ex. Diving into shallow water
  • Typically causes T12-L2 comminuted or burst fracture
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17
Q

Hyperextension-Hyperflexion

A

Whiplash type injury

Usually cervical caused by a rapid aceleration /deceleration of the head

Compresses the A/P diameter of the spinal cord

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18
Q

Rotational Spinal Cord Trauma

A

Can effect any part of the spinal column

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19
Q

Spinal Contusion

A

Bruising, local hemorrhage or edema

Can be temporary

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20
Q

Penetrating Injury

A

Knives, GSW, projectiles, explosions

Cord tearing or severing

Bone fragments will also cause vascular injury

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21
Q

High C-Spine Injury

A

Injury to C1-C2

Will result in an almost complete paralysis of the respiratory muscles and only some of the accessory muscle may remain functional

Acutely these parameters are unable to generate significant tidal volume and/or cough

Will require intubation and full ventilatory support.

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22
Q

Mid-Low C-Spine Injury

A
  • Injury to C3-C8
  • Varying degrees of muscle impairment depending on involvement/sparing of the diaphragm
  • Paradoxical breathing pattern (loss of lateral and A/P chest expansion)
    • This is caused by a loss of external intercostal muscles
  • Severely limited cough/expiratory function, as major expiratory muscles are innervated below T6
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23
Q

T-Spine Injury

A
  • There will be varying degrees of inspiratory muscle impairment depending on involvement/sparing of the intercostal muscles
  • Observe patient for lateral and A/P chest expansion of inspiration to assess external intercostal muscle function.
  • Varying degrees of expiratory muscle function depending on the level of injury.
  • Place hands on abdomen and ask patient for a strong cough.
    • Feel for abdominal muscle contraction and observe the force of the cough.
    • Don’t just look for abdominal movement.
  • Associated chest trauma and/or hemothorax are not uncommon.
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24
Q

Sign and Symptons of Spinal Cord Injury

A

Pain or pressure in the neck or back

Weakness or paralysis in any part of the body (may develop immediately or come on gradually as swelling occurs in or around the spinal cord)

Numbness, tingling, or loss of sensation in hands, fingers, feet or toes

Loss of bladder or bowel control

Impaired breathing after injury

Hypotension with bradycardia

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25
Q

Spinal Shock

A

Can occur immediately or within several hours

Occurs with SCI above t6

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26
Q

Spinal Shock

Signs and Symptons

A

Loss of motor, sensory, reflex, and autonomic function below the level of injury

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27
Q

Spinal Shock

Results

A

Instant flaccid paralysis

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28
Q

Spinal Shock

Duration

A

Variable

R/t severity of insult

May last up to 6 weeks

Resolved when there is a return of bulbcavernous reflex activity

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29
Q

Neurogenic Shock

A

Neurogenic shock and spinal shock go hand in hand

It is a form of distributive shock

30
Q

Neurogenic Shock

Pathophysiology

A

Loss of sympathetic input to the heart and decreased peripheral vascular resistance (loss of vasomotor tone)

31
Q

Neurogenic Shock

Clinical Signs

A

Hypotension and bradycardia

Loss of ability to sweat below the level of injury

32
Q

Neurogenic Shock

Treatment

A

IV fluids and inotropes to maintain goal MAP

33
Q

Initial Management of Spinal Cord Injury

A

Emergent-Spinal precautions/logroll for the removal of the spinal board

CAB — CPR

Manage hypotension and risk of neurogenic shock

34
Q

Confirming Spinal Cord Injury

A

Visual Inspection of spine

Initial Neurological Assessment

35
Q

Long Term Management

A
  • ASIA Scale
  • SCI Respiratory Complications
  • Pulmonary Function
    • Vital Capacity (VC)
    • Peak Cough Measurement
    • NIF
  • Respiratory Interventions
36
Q

Long Term Management

Respiratory Interventions

A

MIE

LVRM

Assisted Cough

BIPAP/CPAP

Mechanical Ventilation

37
Q

Vital Capacity

A

A baseline VC measure should be done on all C or T spine patients ASIA categories A, B, or C

If VC is equal or less than 10-12 ml/kg then the patient is at high risk of ventilatory failure

38
Q

Vital Capacity and Postural Dependance

A

In quadriplegics VC increases about 49% when changed from sitting to lying position.

In paraplegics VC increases by 28% when changed from sitting to lying position.

Increase in VC due to mechanical advantage of the diaphragm.

VC should be measured in supine position.

39
Q

Peak Cough

A

Measuring peak cough flow

Different than Peak Expiratory flow because patient’s glottis is closed (allows the patient to generate high thoraco-abdominal pressures and flows)

40
Q

Peak Cough Flow

>160 LPM

A

Peak Cough Flow >160 LPM for successful extubation/decannulation

41
Q

Peak Cough Flow

>300 LPM

A

>300 LPM - normal value, should be enough to generate an effective cough

42
Q

Peak Cough Flow

160-129 LPM

A

160-290 LPM –Cough will likely be ineffective and will need to be augmented in the presence of increased secretions with MIE/LVRM

43
Q

Peak Cough Flow

<160 LPM

A

<160 LPM –Cough will likely be ineffective to mobilize secretions, cough augmentation therapy should be initiated

44
Q

Mechanical Insufflation-Exsufflation (MIE)

A

Indicated when peak cough is <290 LPM

Will deliver a deep breath then assist with cough by “sucking” the air out of the lungs

Often accompanied by chest PT and assisted cough

Set pressures: start low and increase up to 40 cmH20 based on patient comfort.

45
Q

Manually Assisted Cough

Patient Position

A

Supine or sitting with head of bed (HOB) at the desired angle

46
Q

Manually Assisted Cough

Assister hand Position

A

Standing beside the patient (or straddling the patient and placing the heel of 1 hand over the abdomen midline 2” below bottom of the breast bone

Place second hand on top and interlock fingers

47
Q

Manually Assisted Cough

Action

A

Patient takes a deep breath and tries to cough

At the beginning of the cough the assister will push in and up evenly frimly and quickly

48
Q

Other Respiratory Management

A

Chest PT

CPAP/BIPAP

Mechanical Ventilation

49
Q

ASIA Impairment Scale

Score A

A

Complete

No Sensory or motor function present in sacral segemnts S4-5

50
Q

ASIA Impairment Scale

Score B

A

Sensory Incomplete.

Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-5 (light touch or pin prick at S4-5 or deep anal pressure) AND no motor function is preserved more than three levels below the motor level on either side of the body.

51
Q

ASIA Impairment Scale

Score C

A

Motor Imcomplete

Motor function is preserved at the most caudal sacral segments for voluntary anal contraction (VAC) OR the patient meets the criteria for sensory incomplete status (sensory function preserved at the most caudal sacral segments (S4-S5) by LT, PP or DAP), and has some sparing of motor function more than three levels below the ipsilateral motor level on either side of the body.

(This includes key or non-key muscle functions to determine motor incomplete status.) For AIS C – less than half of key muscle functions below the single NLI have a muscle grade ≥ 3.

52
Q

ASIA Impairment Scale

Score D

A

Motor Incomplete.

Motor incomplete status as defined above, with at least half (half or more) of key muscle functions below the single NLI having a muscle grade ≥ 3.

53
Q

ASIA Impairment Scale

Score E

A

Normal.

If sensation and motor function as tested with the ISNCSCI are graded as normal in all segments, and the patient had prior deficits, then the AIS grade is E.

Someone without an initial SCI does not receive an AIS grade.

54
Q

Function of Accessory Muscles

A

Expands upper rib cage

55
Q

Abdominals Innervation and Function

A

T6-12

Tone supports diaphragm

Abdominal pressure for cough

56
Q

Internal Intercostals Innervation and Function

A

T1-7

Pulls rib cage down and in

Decrease intrathoracic volume

57
Q

External Intercostals Innervation and Function

A

T1-7

Pulls rib cage up and forward

Increases lateral diameter

Increase AP diameter

58
Q

Diaphragm Innervation and Function

A

C3-5

Increases Vertical Diameter

59
Q

Scalene Innervation and Function

A

C2-8

Elevates Ribs

60
Q

Trapezius Innervation and Function

A

C3-4

Elevates Rib Cage

61
Q

Sternocleidomastoid Innervation and Function

A

C1-3

Elevates Sternum

62
Q

T11 or Below Level of Injury

Cough and VC

A

Cough: Normal

Vital Capacity: Normal

63
Q

T5-T10 Level of Injury

Cough and VC

A

Cough: Poor

Vital Capacity: 75-100%

64
Q

T2-T4 Level of Injury

Cough and VC

A

Cough: Weak

Vital Capacity: 40-50%

65
Q

C5-T1 Level of Injury

Cough and VC

A

Cough: Non-Functional

Vital Capacity: 30-40%

66
Q

C5-T1 Level of Injury

Cough and VC

A

Cough: Non-Functional

Vital Capacity: 30-40%

67
Q

C4 Level of Injury

Cough and VC

A

Cough: Non-Functional

Vital Capacity: 10-15%

68
Q

C1-3 Level of Injury

Cough and VC

A

Cough: Absent

Vital Capacity: 0-5%

69
Q

Theories on Why there is a Postural Change in VC

A

There are 2 theories on why there is the change in VC

  1. The increase is due to the mechanical advantage of the diaphragm. When these patient lie down their abdominal content will push up on the diaphragm, placing it in a position where it can generate more force. When the patient is upright the diaphragm is in a lower resting position as the abdominal content sag out and therefore there is less volume change per contraction
  2. The increase in VC is due to the reduction in RV in the recumbent state
70
Q

How to Assess PResence of Diaphram Use

A

Observe patient’s abdominal excursion during tidal breathing for presence of diaphragm use

Pathophysiology 2 (9 decks)

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