Case Study: Spinal Cord Injury Case Presentation: Jason, a 23 year old male, is brought to the ED after a diving accident in which he hits his head on the bottom of a friend’s pool. After diving he didn’t come up. His friends brought him to the side of the pool and stayed with him in the water until the EMS team arrived. They said they knew to keep his neck straight when he complained of neck pain. He had an abrasion on his upper forehead. The EMS team put Jason on a backboard, and they stabilized his cervical spine with a hard Philly collar. They noted that he was awake, alert and complaining of neck pain. He was worried because he couldn’t move his legs. The EMS team began a right AC 18G IV and began normal saline at 100ml/hr. They put on a nasal canula at 2 liters/min. They noted that Jason had no sensation generally below the shoulders, but had some sensation in his arms. Because he was strapped to the backboard and somewhat anxious, they didn’t further test the motor skills in his arms. His vital signs were stable with BP and HR trending down slightly. On arrival to the ED, Jason was changed from a nasal canula to a high flow oximizer at 4L to reduce his work of breathing. His heart rate and BP were low but adequate until treatment could be started. He wanted his family and they hadn’t yet arrived. Jason’s assessment showed full biceps to elbow flexion, some triceps movement, a weak grasp with the thumbs, positive wrist extension, some shoulder rotation, some movement of the upper back, and a decreased sensation from below the shoulders with varied sensation to his arms and hands. He had no bowel or bladder control, and he had normal bowel sounds. His respiratory reserve was still limited, while his lungs were clear to auscultation. Jason said he was 6’1”and weighed 180 lbs. On arrival his vital signs were: BP 90/56 HR 58 RR 34 and labored T 98.7º PERRLA SaO2 96% Still in the ED, AP and lateral (anteroposterior and lateral) x-rays of the spine were taken using a 5-person log roll technique due to C, T, and L precautions (cervical, thoracic and lumbar). The x-rays showed an unstable C-6 compression fracture or axial loading injury (aka burst fracture). The CT of the brain showed a mild frontal contusion; the CT of the spinal cord showed the C-6 lesion with no vascular hemorrhages noted, but with some blood evident at C-6 and some bone fragments in the spinal canal. Jason’s low BP and HR could mean he was experiencing early spinal shock. A liter normal saline bolus was ordered to increase his BP and assure that he was not hypovolemic. A Foley urinary catheter was inserted and a urine sample was sent for a urinalysis and a culture. An ABG was drawn. Labs were drawn, including CBC, CMP, and Lactic acid. Methylprednisolone was started, and the IV fluids were continued. The labs resulted just before transfer were:
Day 1 LABS WBC (5-10) 8 x 103 mmol/L RBC (4.5-6) 5.5 x 103 mmol/L Hgb (13.5 – 18) 17 g/dl Hct ( 40-54) 51% Platelets (150-400) 310x103 / mm3 Lactic Acid (8.1-15.3) 2 mg/dl Potassium (3.5-5.3) 4.3mmol/L Day 1 ABG pH (7.35-7.45) PaCO2 (35-45 PaO2 (80-100) HCO3 (22-26)
7.45 34mmHg 80mm Hg 26mEq/L
He was then transferred to the ICU where a subclavian triple lumen catheter (TLC) and an art line were started. A CVP was transduced to one of the TLC ports to monitor hydration status. After assessment by Dr K, one of the neurosurgeons, a vertebrectomy and fusion was scheduled in two to three days. Another bolus of NS normal saline and a bolus of Hespan were ordered in response to his CVP of 3mm Hg (normal 4-8mm Hg). Dopamine was ordered to begin titration at 5 mcg/kg/min after the CVP was corrected to 6mm Hg with a parameter to keep the MAP above 90. Fentanyl was started at 50mcg/hour for pain control. An NG tube was ordered to intermittent low wall suction to prevent paralytic ileus. Jason denied nausea. Bowel sounds were slightly hypoactive. Jason was assessed as having flaccid paralysis with no motor or sensory function below the C-6 level lesion. Jason’s BP and HR were stabilized on Dopamine. His work of breathing continued in the tachypnea range with RR 28 and SaO2 WNL (within normal limits). Jason was beginning to be anxious with possible confusion. His SaO2 was 94%. Day 3 ABG Pre-Op pH PaCO2 PaO2 HCO3
7.35 45mm Hg 70mmHg 28mmHg
Day 3 LABS Pre-Op WBC RBC Hgb Hct Platelets Lactic Acid Potassium
9 x 103 mmol/L 5 x 103 mmol/L 16 g/dl 50% 315 x 103/mm3 4 mg/dl 3.6 mmol
Not all labs were WNL. Potassium was now at the low end of normal and lactic acid increased. After preparing Jason for the OR and allowing his family time to visit and ask questions, Jason and his bed and his IV pole, an ECG monitor and an O2 tank, and with his ‘Ancef on call’ in hand, were on the way to the OR. The ICU RN reported off/handed off to the OR RN and the Anesthesiologist in the OR, then left Jason with them and returned to the unit. After 5 hours the OR RN called report to the ICU RN, then brought Jason and his bed back to the ICU along with new post op orders. It was reported that the procedure involved surgical removal of the vertebral bone fragments from the spinal canal with no damage to the cord noted, and harvesting of bone shavings from Jason’s hip to fill a basket-like vertebral spacer used to replace the C-6 vertebrae. Because it was filled with his own bone, it would attract self bone growth around the spacer. After fusion of C-5 to C-7, Jason’s spine was then considered stabilized. He was returned to the ICU on a ventilator with an OETT (oral endotracheal tube). He was ‘recovered’ in the ICU instead of in the PACU (post anesthesia care unit). Usually ‘recovered’ included extubation, but the post op orders did not include that. Vent settings were on SIMV mode with FiO2 of 60%, VT (tidal volume) 600 ml, Rate 12/min, PS 10 (pressure support), and PEEP 5 (positive end expiratory pressure). Jason awakened with his first awareness of being intubated and unable to speak. He was reassured that the surgeon said that the intubation would be temporary. His family was called to the bedside after the RN completed a full motor, sensory and reflex assessment. His orders included Nexium, Lovenox, and the continuation of normal saline IVF’s, Fentanyl, Methylprednisolone, and Dopamine. Sequential compression devices (SCD’s) were ordered and air-filled heel protector boots will be picked up from Central Supply. A Stool softener is needed. Jason remained in the ICU for 10 days during which time he had two episodes of autonomic dysreflexia and one period of metabolic alkalosis. He was extubated on day 8 and at that time required an oximizer at 4L. He worked with PT, OT, and Speech and got out of bed to a cardiac chair daily after day five. He passed his swallowing evaluation and is now allowed to eat a soft diet cut into small pieces. With set-up assistance he can feed himself with the use of assistive devices created by OT. He now has an Aspen cervical collar for protection, which makes eating more challenging. He was transferred directly to the Shepherd Center from the ICU, because he met their requirements to follow commands and guarantee family participation in his rehab training. Shepherd will develop a urinary and bowel routine for Jason. He is aware that he could again be intubated, and that he may need a tracheostomy at some point. Jason is motivated to work on his breathing to avoid those complications. He goes in and out of the mourning/grief patterns with some anger/impatience showing and with some ‘denial’ occasionally.
Questions: 1. Distinguish complete SCIs from incomplete SCIs. What nursing implementations can prevent an incomplete injury from becoming a complete SCI. Complete= total loss of voluntary motor and sensory function below the injury resulting in paraplegia (loss of lower extremity functions only) or tetraplegia (loss of both upper and lower extremities (quadriplegia) Incomplete= some functions lost and others may be present 2. Describe the pathophysiology of two incomplete SCI syndromes. Most common cause of death for people with SCI are septicemia PE and pneumonia. Cervical, thoracic/lumbar injuries, and nontraumatic injuries. Secondary injury is caused by ischemia, elevated intracellular calcium, and inflammatory process. 3. What is the ASIA impairment scale. What does it provide. Include discussion of dermatomes and a supplemental scale that can be used for reflex assessment. The American Spinal Injury Association, most frequent used tool to evaluate both acute and long term progress. Testing for sensation, looking for points where normal sensation is present and start distally. Assess deep tendon reflexes. 4. Discuss the Halo stabilization device and the TLSO, clam shell brace, and the patients best served by them. What care is required. What education would you provide to the patient and the family.
5. What are the signs and symptoms of spinal shock. When might it start and how long does it last. onset 30-60 hypotension, bradycardia 6. After spinal shock resolves, autonomic dysreflexia (AD) may occur. Discuss its causes or triggers, and the interventions that are effective. Why would the RN not call the doctor right away, when the patient’s first symptoms of AD presented. A nurse would not call the doctor right away for AD because they could resolve AD through immediate interventions and management by locating and removing the stimuli, lower blood pressure, and administer prescribed meds. First sit the patient up, loose restrictive clothing, closely monitor BP, check the bladder and bowels for fullness. The 5 B's bed up, BP, bladder, bowel, and body. 7. Describe the process of turning a patient with C,T, and L precautions.
8. Differentiate upper motor neurons from lower motor neurons. Include discussion of reflex arcs, spastic paralysis and flaccid paralysis.
9. Discuss GI assessment in a patient with a complete C-8 SCI admitted 48 hours ago. How can paralytic ileus be prevented. How would you know if a gastric ulcer had developed in a quadriplegic patient. What is the rationale for prescribing Nexium.
