pre hospital management of sci - anzona
TRANSCRIPT
Acute to Rehab Spinal Cord
Injuries
Anna Brown CNC, Certificate SCI Nursing,
Grad Dip Rehabilitation Studies, La Trobe
Victorian Spinal Cord Service Austin Health
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
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
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
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
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