 Hi, and welcome to Nursing School Explained, and this video on spinal cord injury. So first of all, passive physiologically, typically what happens there's some sort of a traumatic injury. Most of spinal cord injuries are related to motor vehicle crash, fouls, a lack of violence, such as stabbings or controlled wounds, or sports traumatic sports events, or any kind of other traumatic events you can think of. Now we have to also think about the primary degree of injury or the secondary injury that can occur. So typically primary injury occurs from the actual insult to the spinal cord itself, so the actual injury itself, and secondary injuries result from either bleeding, hemorrhage, edema, ischemia to the spinal cord, infections that may occur after the fact, after the injuries. So let's look at this here. So typically we have classifications into mechanism of injury, level of injury, and then the degree of injury. So mechanism of injury can be flexion. So this could be anything like a car accident where the head gets flexed forward. It can be a hyperextension. So for example, if I trip and fall, and I hit my chin on the table, my head gets hyperextended back. I might have a spinal cord injury. It might see you a high T spine. That can be flexion and rotation injuries. So that would be flexion and then rotation, and then extension and rotation. So extension again and rotation, and then or compression. So this could be something as a fall of a building or maybe diving into a pool and hitting the head on the ground where the vertebra get compressed. Typically the most significant injuries and the most common are the flexion and extension injuries. And they cause a lot of damage because they involve a lot of the ligaments that can tear that actually support the spinal cord and the vertebral column. And therefore the injuries can be pretty significant. Now then regarding the level of the injury. So I drew a head here and then the spinal cord and recall that there are seven cervical vertebra, 12 in the thoracic spine, five in the lumbar spine, five in the sacral area, and then four fused vertebra in the coccyx area. And depending on the level of the injury, the higher up the injury, the more significant signs and symptoms the patient will have and the more significant the possible paralysis can be. And so cervical injuries, so anything from C1 through 7 usually involves the arms and will result in quadriplegia or sometimes now it's also called tetraplegia. So that will involve the arms and usually again the higher the injury, the worse it is. And there's a saying that says C3, 4 and 5 keep the diaphragm alive. And so we have to think about the diaphragm as the major muscle of breathing. So if there is an injury to level C3, 4 and 5 that may involve the patient's ability to breathe and they may need to go on a ventilator and actually be ventilator dependent for the rest of their life, depending if it's a partial or complete injury to their spinal cord. And then entries to the thoracic, lumbar and sacral areas will usually result in paraplegia. So only the lower extremities are involved. And then regarding the degree of injury, it can either be a partial or complete loss of sensory and motor functions. And keep in mind that every extremity or on every part of our body really we have sensory and motor innervation that allow us to feel and then also contract the musculature of the extremity or that body part. And depending on the level of injury and the severity of the injury, motor and or sensory sensations or function might be impaired. And then so over here, if there's a partial degree of injury, there are basically four different syndromes that can occur and they all depend on what happens. And so I've drawn out the spinal cord here in the middle with the ventral and the dorsal horn and then in red is the area that's actually affected. So central cord syndrome is the most common and is usually related to hyperextension with swelling on the spinal cord, on the central cord. So it usually involves the middle section of the spinal cord where anterior cord syndrome is related to an anterior compression from bony fragments or disc herniation. Those are the discs that cushion us between the vertebra. If there's an injury and the disc herniate, so it moves out of its space, it can put pressure on that anterior cord and cause anterior cord syndrome. Now regarding posterior cord syndrome, that will be on the posterior side, usually a smaller area that is affected and that is usually because of an acute compression injury. And then there can be a heavy section from a penetrating injury or from secondary ischemia or hemorrhage. So that will only be affecting one part of the spinal cord and these penetrating injuries usually involve violent injuries such as gun shot wounds or stabbing injuries on one side of the spinal cord. And the signs and symptoms will be different for each one of those, but you can look those up separately. So over here, I have delineated these signs and symptoms and then associated nursing care. And they really go in order of our ABCs. So number one, we have to determine the loss of motor and sensory function along the dermatomes. And there are very helpful graphs out there, as you can see right here. And these dermatomes help us determine what nerve from the spinal cord height or level controls what part of the body. And depending on wherever the injury occurs, the patient might have loss of motor and or sensation to these certain body parts that correspond with these dermatomes. Now, certainly we need to keep the patient immobilized. That is mostly important in the acute stabilizing phase. So that would be in the trauma room or in the emergency department. And the patient will be immobilized usually with a cervical collar and on the backboard from EMS if they arrive by ambulance or helicopter. And then maybe they require a halo vest eventually as a treatment for their spinal cord injury. But it is very important to immobilize the patient because we don't want to cause any more injury than has already occurred from their traumatic injury. And then next, we always have to worry about our airway breathing and circulation. So airway, so if there is an injury to the head or face, let's say, and there are loose teeth that could be compromised of the airway. So we certainly have to clear the airway first before moving on, just like you would in your typical BLS or first eighth class, you always move along with your ABCs. And then regarding the respiratory syndrome. So here again, usually at level C4 or higher, which is where the phrenic nerve runs. And that's the one that mostly controls the diaphragm. So if it's an injury C4 or higher, there is total loss of the respiratory function, which is basically if we don't ventilate the patient, the patient will die from respiratory failure because there is no control of the respiratory muscles from the brain. There is no communication. But even in the lower C or T spine that innervate the intercostal or abdominal muscles that we also need for breathing and for that chest wall movement that can lead to hypoventilation and maybe inadequate respirations, as well as eventually more longer term, the patient won't be able to handle their secretions. They might lead, it might lead to electrolysis, pneumonia and any of those other lung complications that we can think about more long term. So for nursing care, certainly I already talked about ABCs. And then for respiratory system, we wanna assess the breast sounds and see because maybe there's an underlying lung injury as well. They might have a hemo or normal thorax. And then we wanna observe their breathing pattern to see exactly what is going on with their chest wall motion to see what the muscles of the respiratory system are doing because they might be injured again at a higher level of their spinal cord, where the muscles of the chest and abdomen don't really function the way that they should and allow the patient to take a deep breath. And then most of these patients will be intubated initially and if these injuries are significant enough where there's a prolonged ICU stay anticipated, they will probably get a tracheostomy. And then always incentive spirometry is important to prevent any of these complications such as adolescences and pneumonia. Now, we're looking at the cardiovascular system. Again, according to our dermatomes, if the injury is above the level of T6, there's usually dysfunction of the sympathetic nervous system. Because remember that everybody part is innervated by the sympathetic and the parasympathetic nervous system. But now if there's injury to the spinal cord, the communication of the sympathetic nervous system is interrupted. And so now the vagus nerve, the major nerve of the parasympathetic nervous system is overstimulated or there's no opposition to that parasympathetic nervous system. And so remember that the parasympathetic nervous system slows everything down. And so if we have unopposed vagal tone, it'll lead to bradycardia and peripheral basal dilation. And when we dilate our blood vessels, the blood pressure will drop. So the patient might be significantly hypotensive and can lead to neurogenic shock. And I'll be discussing this in a separate video. Now, regarding the cardiovascular system, we have to avoid vagal stimulation. So that includes inducing a gag reflex, maybe with suctioning. So we have to be extra careful with that. Even vagal stimulation, such as if the patient were in urinary retention of bowel, retention, and we'll get to that in a little bit here, that vagus nerve could be stimulated even from bearing down, which could lead to again that unopposed vagal tone. And then the patient could get so bradycardic that they actually might end up in cardiac arrest. So we have to be extra careful here. Certainly we wanna check the vital signs very frequently. And then atropine is a medication that it basically counteracts the effects of the vagus nerve. So it helps us basically induce that sympathetic nervous system response and bring the patient's heart rate up. But we can't keep the patient on this atropine. So if it's really significant bradycardia, then the patient might need a pacemaker. And in order to keep that blood pressure up, they might need vasopressors because of the significant peripheral vasodilation that's occurring here because of the level of the injury, no motor and sensory control. The patient might need IE fluids or blood transfusions depending of any other coexisting injuries or any blood loss that they might have had. And the goal is always to keep the systolic blood pressure greater than 90 or the mean arterial blood pressure greater than 65 to ensure perfusion to the important body organs such as the brain, the lungs, the heart, the kidneys. Now urinary and GI symptoms that the patient might have and they may occur right away or they might occur more in the longer term and during their ICU stay or even in rehab. So neurogenic bladder and the bowel are very common. And that basically means because now the nerve control, the innervation of the bladder and the bowel is impaired or completely gone. The patient does not get the sensation or the signal that they have to urinate or defecate. So they might be anywhere from incontinent to in urinary retention and they might have diarrhea or they might have constipation. And retention, urinary retention and constipation are very common here as well as paralytic ills because again, the digestive system, the intestines are not being mobilized or innervated. There's no control. So everything just kind of sits there and is addressed for becoming very stagnant. And that can lead to spinal shock. And again, I'll talk about that in a separate video. And then stress also can occur because certainly this is a very stressful injury and usually a longer hospitalization is required. The patient might also have dysphagia depending on the level of their injury and they might be delayed gastric emptying. So in terms of nursing care, the patient might need an indwelling catheter or a fully catheter or intermittent catheterization to empty their bladder on a regular schedule so that they don't end up in retention and suffer from spinal shock. They might need a digital rectal exam to determine is the rectum full of stool and do we have to maybe manually even remove that? They might need frequent enemas or stool softeners to keep the stools more on the soft side so that again, they can empty easily and that they don't lead to that vagal stimulation that could be having detrimental effects over here on the cardiovascular system. And then certainly normal measures that we would take to prevent constipation such as increase in fiber in their diet and making sure that they stay hydrated. Now for the stress ulcers, the patient will usually be put on an H2 blocker or on a PPI for prophylaxis of those stress ulcers. And another important factor is the thermal regulation because now there is loss of control of the motor and sensory below the level of the injury. So now the patient is unable to regulate their body temperature so they cannot shiver or they cannot sweat below the level of the injury because there is no communication with the environment that would usually get the body feedback on how to adjust the temperature according to the outside environment. So loss of regulation below the spinal cord injury. And so we have to control the external room temperature and make sure that it's about the body temperature so the patient can be comfortable and not either be overheated or suffer from hypothermia. And then certainly we have to check the body temperature frequently. And then regarding metabolic and nutrition. So many times the patients will have an NG tube because most of the time they will have an endotracheal tube or a tracheostomy. And with any NG tube, the patient is at risk for metabolic oculosis. So we have to make sure we monitor their labs, specifically fluid and electrolytes, sodium and potassium very carefully along with their ABGs. And then they do need nutritional support, not only because of the whole stressful situation of the injury and the hospitalization, but also because eventually below the level of the injury the muscles will atrophy and there's a lot of catabolism that happens. So we have to make sure that we start nutritional support very early so that they need their nutritional needs and initiate feeding via the NG tube, maybe a gastrostomy tube, or they might need TPN total parenteral nutrition fairly shortly after their injury within 24 to 48 hours to ensure that their body doesn't break down too frequently and to make sure that they are able to heal themselves and that we support them well here in their nutritional needs. And then pain is certainly an issue because now there are two different kinds of pains that can occur, which is the nociceptive pain, which is usually musculoskeletal type pain or visceral type pain depending on the injury, but then there's also neuropathic pain from the injury to the nerves that occurred. And typically nociceptive pain is treated with Tylenol ibuprofen or opioids. And of course we want to judiciously administer opioids because of all the concerns with their breathing and their cardiovascular system. And then for neuropathic pain the most commonly prescribed medications are galapentin or norentin or pregabalin, which is also called lyrica. Now over here I also wrote down skin. So now if the patient has a spinal cord injury and their mobility will be impaired, we have to be very meticulous about their skin care, the repositioning most, I think the number is 25% of patients with a spinal cord injury will suffer from a sacral pressure ulcer. So we have to be very careful, not only during the acute phase, but also if they go home, maybe they're paraplegic and they're gonna be in a wheelchair to make sure that there's cushioned enough that they're aware of how to reposition how frequently to do that. And along with the skin also always goes to nutrition. So we have to initially assess their pre-albumin to make sure that the nutritional status is up to speed so that they don't get skin breakdown or develop these pressure ulcers. And then reflexes are also an issue. And that is mostly because now there is no control of the motor and sensory. There's no communication with the brain, the reflexes which is kind of primitive functions are still there. And so patients might get reflexes that are hyperactive and so the patient all of a sudden might get an unexpected erection which can be very embarrassing for them, or they can also have muscle twitches or convulsions. And so the treatment for that more in the long term would be muscle relaxants or antispasmodics as well as botulism injections which kind of calm down the muscles and the reflexes to kind of almost paralyze them where then now the reflexes are not so hyperactive. And then regarding diagnostic tests that those are usually in the acute phase and during the course of the hospitalization, plain x-rays, CT scans and MRIs to really determine the injury, the degree of the injury and the involvement of any ligaments or the spinal cord, any swelling, hemorrhage, ischemia that has occurred as well as the patient might also need a CT and U-gram to see if there are any concerns regarding the blood vessels to the spinal cord. And treatment usually includes surgical interventions to fix the spinal cord injuries, any broken bones with spinal fusion. So basically orthopedic type of repair of the broken parts. And if it is a cervical neck injury, the patient will sometimes get a halo ring with a traction which is basically this kind of a halo contraption that they wear that will allow the patient to be kind of elongated to take the pressure off the spinal cord and then certainly they will need to be immobilized very carefully and then we can only logroll these patients. That is super important. So you basically imagine that the patient is a log. There's one piece from head to toe and you need however many people and you need to move them so that you don't twist their spine in any way and move them as one piece so that their spinal cord remains lined up from the cervical spine all the way down to the coccyx. And then the other thing that I wrote down here is the autonomic hyperreflexia and please watch my separate video on these complications from spinal cord injury that I'll be talking about neurogenic shock, spinal shock, as well as autonomic hyperreflexia. 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