Acute to Rehab Spinal Cord

Injuries

Anna Brown CNC, Certificate SCI Nursing,

Grad Dip Rehabilitation Studies, La Trobe

Victorian Spinal Cord Service Austin Health

SCI – Acute to Rehab

Let the rollercoaster ride begin . . .

National Data Causes of SCI

• Land Transport 46 % – MV occupants 51%

– Unprotected road users 49%

• Falls 28 % – Low falls < 1 metre 64%

– High falls 1 metre or > 36%

• Diving & Water Related 9 %

• Struck by another person or object 9 %

• Miscellaneous causes 8 %

Lynda Norton, 2010 – Spinal cord injury, Australia 2007-08

Research Centre for Injury Studies, Flinders University

Australian Demographics Spinal Cord Injuries

• 237 new SCIs in Australia per year – VSCS admits 85 – 90 annually

– Paediatric incidence is not clear

• Segment of population at greatest risk adult men b/w 16 – 30 years

– Men > Women approx 4 : 1

– Paediatric incidence is > in boys than girls

• Most common age – 19 years

7 cervical

12 thoracic

5 lumbar

5 sacral (fused)

4 coccygeal

(rudimentary)

Vertebral Column Ligaments & Stability

The Spinal Cord – Approx. 45 cms in length

– Continuous with the brain

– Consists of millions of neurone bundles

– Extends from superior border of C 1

– The thickness of the little finger

– Consistency of toothpaste

– Encased & protected by the vertebrae

– Ends at vertebral level L 1 /2

The Spinal Nerves

31 pairs of nerves

– 8 cervical

– 12 thoracic

– 5 lumbar

– 5 sacral

– 1 coccygeal

A Spinal Cord Injury Results in

• Loss of movement

• Loss of sensation

• Interruption to ANS – sympathetic pathways

– Resulting in low BP

– Inability to control body temperature

• Altered respiratory function

• Loss of bladder & bowel control

• Altered sexual function

Classification of SCI

• Quadriplegia / Tetraplegia

– T 1 and above

• Paraplegia

– T 2 and below

• Complete / Incomplete

– Motor and / or sensory sparing

Neurological Examination

• Motor power - myotome / muscle innervation

• 0 - 5 grading

• Sensory function - dermatome level • 0 - 2 score

• Light touch / aesthesia

• Pin prick / analgesia

• Proprioception

• Reflex activity • 0 - +++ score

http://www.asia-spinalinjury.org/publications/2006_Classif_work

sheet.pdf

ASIA Standard Classification

American Spinal Injury Association

Scale of SCI Impairment

– A = Complete

– B = Motor complete / Sensory incomplete

– C = Incomplete - Below Grade 3

– D = Incomplete - Grade 3 or above

– E = Normal

Neurogenic Shock • Results from injury to the descending

sympathetic pathways

• SCI at T6 & above may have profound effects resulting in

Triad of Clinical Signs

– Bradycardia • unopposed vagal tone on heart

– Hypotension • vasodilatation & loss of sympathetic tone; expect

BP 90/60

– Hypothermia • sympathetic loss – resulting in poilkilothermia

Initial Management

• Position & alignment

– Immobilise spine board, cervical collar

– Neutral whole vertebral column

– Avoid repeating mechanism of injury

• Skin & pressure

– Pressure relief - essential

– Awareness of potential problems

– Assistive devices / equipment

Head Holding Techniques

From the Top

From the Side

Pistol grip

Spinal Immobilisation in Paediatrics

Position / alignment • Disproportionate head size in

children under 3yrs

• With toddler & infant use Occian pad / Papoose to position correctly

Papoose

Occian Pad

Management Prior to Transport

• Clinical examination – Neurological assessment

– Bradycardia & hypotension

• Oxygen /respiratory support

• Monitor temperature - Poikilothermia

– combination of hypotension & hypothermia

– appropriate environmental temperatures

• Adequate x-rays

Management Prior to Transport

• Naso-gastric tube – open drainage, monitor pH

• Urethral catheter – correct size, balloon volume

– expect 30 mls/hr output

• IV therapy

– avoid overload – expect hypotension

Radiological Examination

Full vertebral column views

AP views Lateral views

CT scan MRI SCIWORA MRI essential

STATEWIDE-ROLES 6 Australian Spinal Units

Princess

Alexandra

Royal

Adelaide

Royal

Perth

Prince of

Wales

RNS

Austin

Health

Acute Management

• Cardiovascular

• Respiratory

• Vertebral column stabilisation

• Skin integrity & pressure management

• Gastro intestinal, including establishing bowel routine

• Nutrition

• Bladder management

• Prevention of complications – VTE, respiratory, pressure injuries

• Psychosocial . . .

Acute Management

• Psychosocial – Consistent, objective information

– Psych review & support through grieving & immobility

– Relative / family support

– Prepare for the transition to rehab.

– Team approach

REHABILITATION STARTS

ON DAY 1

The next stop . . . rehabilitation

Continuing on the rollercoaster ride . . . onto rehabilitation & community

Functional / Neurological Level of SCI

– Level of spinal cord injury – ASIA scale grading

– Associated injuries / complications

– Age & aging factors

– Gender - body proportions

– Cultural factors / family support

– Motivation / emotional status

– Carer factors

Activities of Daily Living (ADLs)

• OT, Nursing, Physio

– Showering, hygiene & grooming

– Dressing - upper / lower limb

– Feeding, meal preparation

– Domestic skills

– Communication skills

– Home modifications

– Community access

Mobility / Transfers

• Physio, Nursing, OT

– Muscle strengthening & endurance

– Balance / stretches

– Transfers – hoist, slide-board or lift

• bed to chair

• bed to commode / toilet / shower seat

• car / transport

Mobility / Transfers

• Physio, Nursing, OT

– Bed mobility

– Wheelchair mobility

– Gait training

– Posture / pressure management

Posture, Pressure & Skin Care

– Know sensory level / deficits

– Assess all potential sites of pressure

– Nutritional status if ‘at risk’

– Suitable bedding → mattress, protective &

assistive devices

– Wheelchair & suitable cushion

– Transfer skills

Bladder & Bowel Management

Nursing with input from physio & OT

– Bladder training

• Intermittent catheters – hand function necessary

• SPC / IDC

• Regular surveillance

– Bowel training

• Establish a routine – time of day, suitable to lifestyle, prevents unplanned bowel actions

• 5 ‘Rs’ - right time, place, consistency, amount & reliable trigger

Patient Education

• Information / empowerment

• Readiness for learning / rehabilitation

• Teaching techniques

• Modules of relevant information

• Balance of theory & practice

• Problem solving skills

• Written information - later reference

Community Integration

– Home modifications

• bathroom, access

– ‘Role’ in family & community

– Vocational options

– Transport options

• driving, maxi taxis, public transport

– Leisure & socialisation

Leisure Options

• Snow skiing

• Water-skiing

• Wheelchair rugby

• Basketball

• Netball

• Pistol shooting

• Darts

• Bowling – lawn & 10pin

• Sailing

• Driving a car

• Computer / internet

Re-integration What are the obstacles?

Rehabilitation of the SCI Person

• Successful rehab dependent on – Team approach

– Patient education → theory & practice

– Discharge planning

– Appropriate equipment

– Housing → suitable modifications

– Community reintegration & resources

– Support & follow up

• Community spinal nurses

• Annual review – Country & Metro Clinics

Spinal Cord Injury

• ‘Life for most of us is a matter of adjusting to change. Yet few of us are prepared to adjust to all the changes in life caused by a spinal cord injury (SCI). Even under the best of circumstances successful adaptation to the results of SCI requires courage, perseverance, faith, support from family & friends, & quality rehabilitation.’

Lex Frieden

Foreword in Zejdlik C.P., (1992) Management of Spinal Cord Injury