Neuro - Ch 63 - Management of Patients with Neurologic Trauma

a life-threatening emergency in spinal cord injury patients that causes a hypertensive emergency

an injury to the skull or brain that is severe enough to interfere with normal functioning

occurs when the head accelerates and then rapidly decelerates or collides with another object and brain tissue is damaged, but there is no opening through the skull and dura

a temporary loss of neurologic function with no apparent structural damage to the brain

bruising of the brain surface

a condition that involves total loss of sensation and voluntary muscle control below the lesion

a lightweight vest with an attached halo that stabilizes the cervical spine

an injury to the scalp, skull, and/or brain

a condition where ther is preservation of the senosry or motor fibers, or both, below the lesion

bladder dysfunction that results from a disorder or dysfunction of the nervous system; may result in either urinary retention or bladder overactivity

paralysis of the lower extremities with dysfunction of the bowel and bladder from a lesion in the thoracic, lumbar, or sacral regions of the spinal cord

an insult to the brain subsequent to the original traumatic event

an injury to the spinal cord, vertebral column, supporting soft tissue, or intervertebral disks caused by trauma

paralysis of both arms and legs, with dysfunction of bowel and bladder from a lesion of the cervical segments of the spinal cord

severing of the spinal cord itself; transection can be complete (all the way through the cord) or incomplete (partially through)

above C4

quadriplegia, with diaphragmatic breathing and gross arm movements

because its many blood vessels constrict poorly

tearing away of the scalp, life threatening emergency

hematoma below the outer covering of the skull
-usually absorb on their own and do not require treatment

a break in the continuity of the bone

a splintered or multiple fracture line

when bone fragments are embedded into brain tissue

fracture at the base of the skull
-allows CSF to leak from the nose and ears

tear in the dura or scalp

dura is intact

-hemorrhage from the nose, pharynx, or ears
-blood under the conjunctiva
-Battle's sign (ecchymosis over the mastoid)
-CSF otorrhea (basilar)
-CSF rhinorrhea (basilar)
-halo sign

meningeal infection can occur if organisms gain access to the cranial contents via the nose, ear, or sinus through a tear in the dura

an associated brain laceration or contusion

1. CT scan - fast accurate, acute lesions
2. MRI - more accurate but takes longer
3. cerebral angiography - id hematomas and contusions

usually not surgical and if after observation it is determined that no brain injury is present the patient can return home

usually require surgery

age 16-30
male (82%)
alcohol and drug use

C5-C7
T12
L1

the initial insult or trauma and are usually permanent

contusion or tear injury, in which the nerve fibers bein to swell and disiintegrate

ischemia, hypoxia, edema, and hemorrhagic llesions, which in turn result in destruction of myelin and axons. these are believed to be the principal causes of spinal cord degeration at the level of injury and now thought to be reversible during the first 4-6 hours

-central
-lateral
-anterior
-peripheral

refers to the lowest level at which sensory and motor function are normal. below the neurologic level, there is total sensory and motor paralyss, loss of bladder and bowel control, loss of sweating and vasomotor tone, and marked reduction of BP from loss of peripheral vascular resistance

1. x-rays and CT scans
2. MRI if a ligamentous injury is suspected, because significant spinal cord damage may exist even in the absence of bony injury
3. If MRI contraindicated, a myelogram to visuaize the spinal axis
4. continuous ECG monitoring if a SCI is suspected, because bradycardia and asystole (Cardiac standstill) are common

methylprednisolone

high-dose corticosteroid, when given within 8 hours after SCI, has been found to improve motor and sensory outcomes in the long term

electrical stimulation of the phrenic nerve in a patient with a high cervical spine injury

intramuscular diaphragmatic pacing, implanted via laparoscopic surgery

restoration of normal position

rare reduced after correct alignment has been restored. can then use a halo vest

usually treated with surgical intervention followed by immobilization with a fitted brace.
-traction not indicated before or during surgery, due to the relative stability of the spine in these regions

-compression of the cord is evident
-injury results in a fragemetned or unstable vertebral body
-injury involves a wound that penetrates the cord
-bony fragments are in the spinal canal
-pt's neurologic status is deteriorating

spinal shock
neurogenic shock

DVT
orthostatic hypotension
autonomic dysreflexia

-usually happens during 1st 72 hours and can last several weeks
-caused by spinal cord edema
-reflects a sudden depression of reflex activity in the spinal cord (areflexia) below the level of injury. The muscles innervated by the part of the spinal cord segment below the level of the lesion are without sensation, paralyzed, and flaccid, and the reflexes are absent.
-loss of urination and defecation reflexes
-ends when the spinal cord neurons below the injury recover their ability to generate impulses. the patellar reflex, urination, and defecation reflexes will return
-treated with methylprednisolone

bladder and bowel reflexes

usually, immediately after as a result of neurogenic paralysis of the bowel. usually return within 1week

true

treatment of spinal shock

-due to the loss of ANS function below the level of the lesion
-vital organs affected, leading to decreases in BP, HR, & CO
-venous pooling in the extremities
-peripheral vasodilation
-does not perspire on the paralyzed portion of body (so observe for other signs of fever)

-pleuritic chest pain
-anxiety
-SOB
-abnormal ABGs (increased PaCO2 levels, decrease PaCO2)

-low-grade fever
-thign and calf meaurements

respiratory difficulty that requires immediate intervention, so monitor respiratory status frequently

promote adequate breathing and airway clearance
improve mobility
promote adaptation to sensory and perceptual alterations
maintain skin integrity
maintain urinary elimination
improve bowel function
prvoide comfort measure
monitor and manage complications (thrombophlebitis, orthostatic hypotension, autonomic dysreflexia)

nasogastric tube to relieve distention and to prevent vomiting and aspiration. activity usually returns within the first week

BP tends to be unstable and low for first 2 week after SCI (will return to preinjury levels but periodic episodes will still occur)
-particular problem if lesion above T7
-

-monitor VS before and during
-give vasopressors to help to treat the vasodilation
-antiembolism stockings to improve venous return
-abdominal binders to encourage venous return and diaphragmatic support

-high risk for several months
-for rest of lives if para or tetraplegic
-

once head injury and other systemic injuries have been ruled out

exaggerated autonomic responses to stimuli that are harmless ih normal people
-occurs only after spinal shock has resolved
-occurs if cord lesion above T6

the sympathetic visceral outflow level

severe pounding headache
paroxysmal hypertension
profuse diaphoresis
nausea
nasal congestion
bradycardia

1. distended bladder
2. distention or contraction of the visceral organs, especially the bowel from constipation or impaction
3. stimulation of the skin - tactile, pain, thermal, pressure ulcer, draft

1. sit them up to lower BP
2. rapid assessment to ID and alleviate the cause
3. empty the bladder
4. examine the recturm
5. examine the skin
6. remove any other triggers
7. last resort --> hydralazine hydrochloride (Apresoline), a ganglionic blocking agent

a ganglionic blocking agent if other measures do not relieve the hypertension and excruciating headache of autonomic dysreflexia

1. spasticity
2. infection and sepsis
also
-premature aging
-disuse syndrome
-atonomic dysreflexia
-depression

-incapacitating flexor or extensor spasms that occur below the level of the spinal cord lesion
-the same muscles that are flaccid during the period of spinal shock develop spasticity during recovery
-onset is usually a few weeks to 6 months after and peaks around 2 years after injury, then tends to regress
-area of the cord distal to the site of lesion becomes disconnected from the higher inhibitory centers in the brain

-baclofen (Lioresal) - antispasmodic
-diazepam (Valium)
-dantrolene (Dantrium)

drowsiness, weakness, and vertigo in some patients

maintain skin integrity
complete emptying of bladder at regular intervals
prevention of urinary and fecal incontinence
avoiding people with respiratory infections
coughing and deep breathing
yearly influenza
no smoking
high protein diet