Clinical Guidelines (Nursing)

Spinal cord injury (acute management)


    • Introduction

      Spinal cord injury (SCI) in children is a rare injury that can result in permanent loss of motor and sensory function, and dysfunction of the bowel and bladder. Impairment of these functions result in significant social and psychological consequences for the child and their family. SCI is often associated with a traumatic brain injury. In children and adolescents SCI is most commonly a result of road traffic accidents, falls or diving into water.

      Children with SCI experience multiple health care problems including autonomic instability, complications of immobility and bowel or bladder dysfunction. Management in the acute phase is aimed at preventing further spinal cord injury, maintaining physiological stability, and commencing routine care of the skin and establishing good bladder and bowel care.

       

      Aim 

      This guideline is aimed at the acute management of children with injury to the spinal cord.

       

      Definition of terms

      • AIS: ASIA (American Spinal Injury Association) Impairment Scale. An international classification system for level of impairment as a result of spinal cord injury. There are five classifications for traumatic spinal cord injury: A-E.
      • Quadriplegia (also referred to as tetraplegia): dysfunction of arms, legs, bowel & bladder due to SCI in the cervical region
      • Paraplegia: dysfunction of lower body, bowel & bladder due to SCI in the thoracic, lumbar or sacral region
      • Spinal shock: Temporary areflexic state with loss of autonomic control, and muscle tone below the level of the injury which lasts up to six weeks after injury. It usually occurs in spinal cord injury to cervical & upper thoracic spinal cord. Functional recovery may improve after spinal shock resolves.
      • Neurogenic shock: hypotension as a result of bradycardia and vasodilation due to loss of thoracic sympathetic innervation following SCI. Profound effects are noted if injury is at level of T6 or above. Most dramatic effects noted in the first few weeks with most patients stabilizing in 7-10 days

       

      SCI pathophysiology & presentation

      Complete/incomplete injury

      • A complete SCI results in loss of all motor and sensory function below the level of injury (AIS A). 
      • An incomplete SCI results in preservation of sensory function below the level of injury (AIS B), or a combination of varying degrees of sensory and motor preservation below the level of injury (AIS C or D). 

      Cause of injury

      • The spinal cord can be injured by transection, distraction, compression, bruising, haemorrhage or ischaemia of the cord or by injury to blood vessels supplying it. These injuries can all result in permanent cord injury and may be complete or incomplete.
      • Concussion of the spinal cord can result in temporary loss of function for hours to weeks

      Pathophysiology

      • Injury results from primary & secondary insults 
      • Primary injury occurs at the time of the traumatic insult
      • Secondary injury occurs over hours to days as a result of a complex inflammatory process, vascular changes and intracellular calcium changes leading to oedema and ischemia of the spinal cord. Irreversible damage occurs to nerve cells leading to permanent disability
      • Spinal cord injury may occur without evidence of bony injury on Xray or CT. Paediatric injuries are more commonly associated with injury to ligaments discs and growth plates and often require a MRI to define the injury pattern. 

      Signs & symptoms of acute SCI

      • Flaccid paralysis below level of injury
      • Loss of spinal reflexes below level of injury
      • Loss of sensation (pain, touch, proprioception, temperature) below level of injury
      • Loss of sweating below level of injury
      • Loss of sphincter tone and bowel & bladder dysfunction

       

      Management

      Initial assessment

      See major trauma-primary survey guideline (link) and cervical spine injury guideline (link) for initial assessment

      • Be aware the loss of thoracic sympathetic innervation (T1-T5) may inhibit tachycardia and vasoconstriction as signs of hypovolaemia. Thus haemorraghic injuries may not be indicated by the usual signs.

      Referrals

      • Neurosurgical, orthopaedics & trauma service should be notified prior to or on admission to the Emergency department
      • Rehabilitation service to be notified within 24 hours of admission

      Admission location

      • These patients will usually require admission to PICU (Rosella)
      • If not requiring PICU admission, then this will usually be Cockatoo (Neurosurgical ward) unless multiple abdominal injuries are present, in which case the child will be admitted to Platypus (General surgical ward)

      Spinal immobilisation

      See cervical spine injury guideline (link)

      • Initial care - immobilisation:
        • Immobilize the entire spine of any patient with known or potential SCI
        • Immobilize neck with a hard collar. See guideline for cervical spine assessment (link)
        • Use log roll with adequate personnel to turn patient while maintaining spine alignment
        • For children < 8 years of age use an airway pad to promote neutral cervical spine position (link to resource)
        • Remove from spinal board on arrival in ED or as soon as resuscitation allows 
        • Maintain neck in neutral position by use of a hard collar, but change to two-piece collar for comfort and avoidance of complications (e.g. pressure area, venous obstruction, aspiration) within 6 hours of admission. 
      • Early surgery:
        • Surgery may be required in the situation of a reversible compression injury, or deteriorating neurology with a spinal injury amenable to some form of reduction and or fixation. 
      • Halo & Orthotic devices:
        • Some patients may have Halo devices applied by surgeons, or a brace made by orthotics to maintain correct alignment of the spine. These devices are fixed to the child’s chest.
        • Ensure you know how to open devices to perform chest compressions in the event of a cardiac arrest, and that spinal immobilisation is maintained manually throughout any resuscitation 
      • Move patient using slide sheets or pat slide with adequate number of personnel to maintain spinal alignment 
      • No pharmacological agent has been proven to limit damage and optimize recovery of function. If steroids have already been given, cease them when resuscitation completed. Aim for normal perfusion pressure and oxygenation of SC. 
      • Once the extent and stability of the injury has been determined a documented plan should be formulated to ensure immobilisation and stabilisation. 

      Imaging

      • Multiple levels of injury in the spine are common. In the under 8 age group especially, there is a high proportion of missed craniocervical injuries with/ without associated cranial nerve involvement. 
        • plain film imaging of the entire cervical, thoracic and lumbar spines
        • Further early imaging will at least involve an urgent MRI of the entire spine looking for remediable lesions
        • CT scan may be used to further identify the extent of bony injury

      Neurological assessment

      • Neurological assessment and documentation in the EMR including:
        • Sensory level 
        • Motor function
          • After 72 hours, the ASIA guide should be completed documenting sensory and motor levels. Contact the rehabilitation registrar to assist with this assessment
        • Glasgow coma score
        • Pupil response
      • Perform hourly for 1st 24 hours then decrease to 4 hourly if condition stabilised
      • Note evidence of brain injury as well as spinal cord injury

      Vital signs (and autonomic control)

      • Vital signs can be quite abnormal following SCI. In addition to the usual causes in trauma such as pain, bleeding and distress, this can be due to loss of autonomic control, which occurs particularly in cervical or high thoracic injuries. The autonomic nervous system controls our HR, BP temperature etc. Autonomic instability is most acute in the first few days to weeks of the injury. 
      • Particular implications of autonomic instability to be aware of are:

      Heart rate

      • Bradycardia can easily occur , for example on endotracheal tube or tracheostomy suction, due to unopposed vagal activity (Thoracic sympathetic input may have been damaged)
      • Patient needs continuous HR monitoring in PICU or ward 
      • Treatment with anticholinergic medication is often required

      Blood pressure

      • Loss of autonomic control results in loss of vasomotor tone. Patient may be quite vasodilated and hypotensive. This phase of neurogenic shock can last up to several weeks. Hypotension should be treated to prevent secondary poor perfusion of the spinal cord.
      • Blood pressure monitoring should be:
        • Continuous in PICU 
        • At least hourly in the ward
      • Ensure patient is adequately fluid resuscitated but not overloaded
      • Patient may need vasopressor drugs such as nor-adrenaline or intravenous fluids to maintain BP (but excessive fluids will cause pulmonary oedema). Patients requiring vasopressors should be managed in PICU

      Temperature

      • The loss of temperature control e.g. ability to sweat, shiver, vasodilate, vasoconstrict or position self to maintain temperature. Consequently, the child will take on the temperature of the environment
      • Hypothermia is common
      • Temperature measurement should be preformed 4hrly in the acute stage of admission
      • Ensure adequate clothing or bedding in cool environment
      • Ensure artificial cooling in a hot environment

      Breathing

      • Respiratory difficulty is common in the early stages of spinal shock but will ultimately depend on injury level 
        • C1-C4: paralysis of diaphragm and intercostal muscles: will need mechanical ventilation via endotracheal intubation or tracheostomy. May need long-term ventilation of phrenic/diaphragm pacing
        • C5-T6: paralysis of intercostals, diaphragm OK – may need some form of respiratory support
        • T6-12: abdominal muscles paralysed, may have some decreased function
      • Asses respiratory status including pattern, effort, ability to cough, auscultate chest, Monitor SpO2 ETCO2, ABG
      • Intubate & ventilate if respiration is inadequate
        • Maintain strict ventilator associated pneumonia (VAP) prevention strategies
      • Nurse head up, but tilt entire bed so that spine remains in line & immobilised-do not just simply raise head of bed up
        • Note at later stage of admission when patient is allowed to sit up, that if abdominal muscles are paralysed, breathing difficulty may be worsened when sitting up and eased when semi-recumbent 
      • Give O2 as required
      • Ensure abdomen not distended (NG should be inserted)
      • Refer to physiotherapist to establish a regimen of chest physiotherapy, assisted coughing and BiPAP. 

      Skin

      See Pressure injury prevention guideline (link)

      A patient who has a SCI is at high risk of damage to their skin integrity. The SCI causes loss of sensation of pain, pressure & temperature. The patient may also have lost motor control and have poor autonomic nervous system function. The end result is a lack of sensory warning mechanisms, an inability to move and circulatory changes all impacting on skin integrity.

      • High risk for pressure areas, measures need to be implemented to assess and prevent skin breakdown:
        • A baseline skin assessment should be completed on admission
        • For all patients a Pressure Injury Prevention Plan must be commenced
        • Pressure mattress (low air loss or alternating pressure) or gel mat if approved
          • Air or alternating pressure mattresses should not be used for unstable spines
        • Reposition 2 hourly 
          • This should occur from the time of admission
          • Reduce friction and shear during repositioning and transfers
        • If skin breakdown occurs it can progress rapidly. Pressure must be kept off this area. Refer to stomal therapy for advice on appropriate dressing
      • Take care with water temperature for washes, and use of hot or cold devices against skin
        • The patient will not feel the temperature extreme, or be able to withdraw from it
      • Hygiene
        • Daily wash to keep skin clean
          • Dry thoroughly after washing
          • Do not leave patient in damp/wet bed
          • Commence bowel regime as outlined below
        • Hard collar needs to be removed & skin underneath checked & washed daily
          • Manually immobilised head whenever the hard collar is off
          • Collar fit & position to be checked each shift
          • Inspect the skin of the occiput each shift
        • Refer to surgeons & orthotics for advice on access to skin under halo jackets and braces
      • Adequate nutrition is important for good skin integrity. Enteral nutrition is preferred.
      • Skin should be fully inspected once per shift

      Bladder

      Urinary bladder function may be affected by SCI. The muscles and sphincters of the bladder are normally controlled by neurological input and spinal reflexes. Loss of this normal neurological control of the bladder is commonly referred to as a neurogenic bladder. The aim of bladder care is to prevent infections, minimise and contain incontinence and find an appropriate way to empty the bladder. This will need to be related to the child’s developmental level, lifestyle, and family needs. For the adolescent patient sexual function also needs to be considered.
      • Bladder dysfunction depends on the level of spinal cord injury
        • Some patients will have a contractile/reflex bladder which contracts when the bladder muscle (detrusor) is under a certain amount of pressure. Depending on the urethral sphincter function these patients will leak in between catheters.
        • Some patients will have an acontractile/flaccid bladder that stretches and holds a large volume of urine but the bladder muscle (detrusor) does not contract and bladder emptying occurs usually by overflow
        • Some patients will have a combination bladder
      • In the early acute phase of the SCI an indwelling urinary catheter will be used. Always use lignocaine lubricant to insert catheter.
      • Once patient has stabilised and opioids reduced consider change to intermittent catheter 4-6/24.
        • Refer to Urology to enable Stomal therapy involvement to assist in establishing a routine
      • Long term management can include clean intermittent catheterisation (by carer or child if able); condom drainage or other options used more for adults dependant on care, such as bladder tapping or use of a suprapubic catheter
      • Occasionally if clean intermittent catheterisation is difficult or impractical a mitrofonoff stoma might be considered
      • Some patients will be prescribed Oxybutin to reduce bladder spasm & thus increase holding capacity & continence between catheters
      • Complications:
        • Recurrent UTI
        • Renal & bladder calculi
        • Vesico ureteric reflux
        • Latex allergy development due to increased latex exposure: use latex free catheters
      • Prevention of complications:
        • Maintain good hydration to reduce the risk of UTI & Kidney stones
        • Good hand hygiene by carers, and ensuring goog hygiene of the patients perineal area to reduce infection
      • Priaprism (erection) may occur in boys and is usually self-limiting & not a contraindication to catheterisation. Referral to urology if priaprism prolonged

      Bowels

      Bowel function will be affected by loss of neurological control of its function (neurogenic bowel). In addition, medications such as antibiotics and opioids, immobility, alterations is food, fibre and fluid intake may affect function. Patients are at risk of constipation, impaction and diarrhoea. It is important to achieve regular bowel emptying. Constipation is not only troublesome but can also trigger major complications such as autonomic hyper-reflexia (dysreflexia).

      • Commence bowel management as soon as bowel sounds are present and enteral/oral feeds begin
        • In the acute phase of spinal shock:
          • Aperients should be commenced with enteral feeding
          • Refer to Dietician early to ensure adequate nutrition, fluid & fibre in the feeds
        • When spinal shock has resolved (and helpful if patient able to sit)
          • Refer to stomal therapy for assistance in establishing a bowel routine if the ward/rehabilitation routine is not satisfactory in the early phase; or when discharge is being discussed. 
          • Routine will depend on age, bowel function, level of injury, pre injury function & family/carer support
      • Bowel dysfunction: 
        • Some patients may have a ‘reflex’ bowel. Although peristalsis will move stool through bowel, the anal sphincter may not relax. It may need stimulation to relax & allow passage of stool
        • Some patients may have a ‘flaccid’ bowel. Reflexes that move stool through the bowel are impaired and the anal sphincter is relaxed preventing stool being held in the rectum
        • Some patients have a combination of bowel function problems
      • Constipation
        • Caused by: insufficient fluid & fibre intake, insufficient aperients, ineffective evacuation of stool, medications (anticholenergics, opioids), immobility 
        • Treatment: increase fluids & fibre, increase aperients
      • Impaction
        • Caused by: chronic constipation. Will often have liquid overflow
        • Treatment: contact stimulant, movicol or osmotic laxative; Assisted evacuation only if necessary (e.g. microlax, large volume enema, manual disimpaction)
      • Diarrhoea
        • Change in diet, antibiotics, bacteria, excess aperients, high impaction
        • Treatment: adjust diet, reduce aperients, stool specimen, abdominal x-ray if impaction suspected; possibly consider probiotics
      • Type of bowel management aperients:
        • Contact stimulants help to move faeces through the bowel (peristalsis) e.g., senokot. 
        • Bulking agents regulate bowel by increasing water content e.g. metamucil
        • Softeners increase water penetration of stool e.g. coloxyl very good for children
        • Iso-osmotic laxative e.g. Movicol,
        • Osmotic laxative e.g. lactulose
        • Suppositories & enemas can stimulate bowel action & lubricate faeces for easier evacuation e.g. microlax, glycerol suppositories
        • Other: if above management suggestions are ineffective discuss with stomal therapy to consider peristeen bowel washout system or Malone stoma-bowel washouts

      Nutrition

      • Insert naso/oro gastric tube early to limit risk of vomiting and aspiration as patient will often have paralytic ileus initially. NG placement also allows for enteral feeding to commence
      • Refer to Dietician early to ensure adequate nutrition, fluid & fibre in the feeds
      • Consider gastric ulcer prophylaxis
      • Re-introduce oral feeding after ensuring ability to swallow and protect airway
      • Gastrostomy may be required 

      Thromboprophylaxis

      Postural hypotension

      Patients with SCI are at risk for postural hypotension when moving from supine to sitting upright. This is due to loss of sympathetic autonomic nervous system innervation and include an inability to regulate BP normally with vasoconstriction. Do not attempt to start sitting patient up until medical approval given.
      To avoid problems with postural hypotension:

      • Anti embolic stockings and/or SCCD’s will encourage venous return from the legs
      • Abdominal binders encourage venous return through the IVC
        • Orthotics can make these to fit
      • Slowly increase bed angle to sitting position, rather than in one quick move. It may take weeks for the patient to tolerate sitting upright.
        • Involve physiotherapy team in this process

      Joint contractures

      Abnormal muscle tone and lack of movement can result in joint contractures. Referrals should be made to Physiotherapy, Occupational Therapy and Orthotics within 1-2 days of admission:

      • Physiotherapy: for range of movement exercises & positioning patient in good alignment
      • Orthotics: splints for ankles 
      • Occupational Therapy: splints for hands

      Autonomic hyperreflexia (Dysreflexia)

      • Autonomic Dysreflexia is a MEDICAL EMERGENCY that needs immediate recognition and action
      • Usually it affects those with injuries T6 or higher and generally won’t occur until a few weeks post injury (After spinal shock has subsided).
      • Autonomic dysreflexia is a condition where the autonomic nervous system has an abnormal excessive response to noxious stimuli below the level of the injury
      • Common causes of stimuli include full bladder or bowel (ineffective emptying or constipation), pressure sores, tight clothing, fractures, surgery, pain
      • Signs & symptoms include:
        • Hypertension 
          • Sudden and severe nature which requires immediate recognition and treatment
          • Hypertension may be the only manifestation of dysreflexia.
          • Note: BP for children with a SCI is normally low, so a BP that is in the high end of normal range for age is actually elevated for them
          • Bradycardia
        • Severe pounding headache
        • Skin rash (flushed, blotchy, transient)
        • Vasodilation above the level of the injury or sweating 
        • Vasoconstriction below level of injury: pale, cool skin with, goosebumps and/or piloerection 
        • Blurred vision/ pupillary dilation
        • Anxiety
        • Nasal congestion
        • Nausea
        • Note: for very young children symptoms may be vague & hard to recognise due to verbal & developmental stages
      • Manage by: 
        • Remove noxious stimuli where possible 
          • loosen clothing, remove compression stockings, abdominal binder
          • perform urinary catheterisation using lignocaine gel, ensure catheter not blocked
          • bowel disimpaction using lignocaine gel
          • look for pressure areas, ingrown toenails, evidence of fracture
        • Position child sitting upright or with head of bed elevated
        • Monitor BP & HR 5 minutely
        • Antihypertensive agents may be prescribed if not responding to above measures within a few minutes, or cause cannot be found

      Sexual function

      • Sexual function can be of great concern to families even in very young children
      • Important topic for adolescents with SCI
      • Topic needs to be discussed with family & child in age appropriate manner so that they understand implications for the child’s lifetime
      • Puberty will occur as for other children; for females pregnancy is possible, and for males treatment may be required for erection, ejaculation & fertility

      Psychological

      • A diagnosis of spinal cord injury is often devastating for children and their families. There are frequently preconceptions about spinal cord injury that need addressing and there may also be pre-existing issues for the child or family.

      Make appropriate referrals:

       

      Potential complications and management

      The following are the most common complications seen for these children. The prevention and management is described above under the relevant headings


      Family centred care

      • Incorporate child’s developmental level when planning care
      • The child who is unable to perform care may be able to direct it enabling a sense of control
      • Enable family to work with the multi disciplinary care team to develop culturally sensitive care
      • Provide as much information as possible regarding the child’s plan of care for the next few days/weeks
      • Involve Nursing Care Coordinator early

      Special considerations

      • Referral must be made to the rehabilitation team in the first 24 hours
      • If long term mechanical ventilation is required, phrenic nerve/diaphragm pacing may be considered

      Companion documents

      • Medical management of spinal cord injury
      • Acute traumatic spinal cord injury admission process

      Links

       

      References

      • Alexander M, Matthews D (Eds). Pediatric Rehabilitation Principles and Practice 4th Edition. Chapter 11 Spinal Cord Injuries
      • Brown, A & Carmuciano,K. (2003). Introduction to skin management in SCI. Education handout. Victorian Spinal Cord Service 
      • Brown, A & Carmuciano,K. (2003). Introduction to the neurogenic bowel. Education handout. Victorian Spinal Cord Service 
      • Brown, A & Carmuciano,K. (2003). Introduction to autonomic dysryflexia. Education handout. Victorian Spinal Cord Service 
      • Brown, A & Carmuciano,K. (2006). Postural hypotension. Education handout. Victorian Spinal Cord Service 
      • Burke D, & Murray D. (1992) Handbook of spinal cord medicine. Macmillan. London.
      • Consortium for Spinal Cord Medicine.(2008) Early Acute Management in Adults with Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals. Washington DC. Parayzed Veterens of America
      • Early acute management in adults with spinal cord injury. A clinical practice guideline for health-care professionals. J spinal Cord Med 2008; 31(4): 408-479. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2582434/
      • Hickey, J. (2009). The clinical practice of neurological and neurosurgical Nursing. Sixth Edition. Wolter Kluwer/Lippincott Williams & Wilkins. Philadelphia
      • Fries,J. (2005). Critical rehabilitation of the patient with spinal cord injury. Critical Care Nurse Quarterly. 28(2):179-187.
      • Jones, T; Ugalde, V; Franks, P; Zhou, H; White, R. (2005). Venous Thromboembolism After Spinal Cord Injury: Incidence, Time Course, and Associated Risk Factors in 16,240 Adults and Children. Archives of Physical Medicine and Rehabilitation. 86(12) Dec:2240-2247.
      • Kirshblum S, Burns S, Biering-Sorensen F, Donovan W, Graves D, Jha A, Johansen M, Jones L, Krassioukov A, Mulcahey M, Schmidt-Read M, Waring W. (2011). International standards for Neurological classification of spinal cord injury (Revised 2011). The Journal of Spinal Cord Medicine. 34(6): 535-546
      • The Queensland spinal cord injuries service (2013) Management of autonomic dysreflexia: Information for health professionals. 
      • The Queensland spinal cord injuries service (2012) Bowel management following spinal cord injury: Information for health professionals
      • The Queensland spinal cord injuries service (2012) Bladder management following spinal cord injury: Information for health professionals
      • The Queensland spinal cord injuries service (2013) Management of pressure areas following spinal cord injury: Information for health professionals
      • Vogel, L; Hickey, K; Klaas,S; and Anderson,C. (2004). Unique issues in pediatric spinal cord injury. Orthopaedic Nursing. 23(5):300-308

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      Evidence table

      Spinal Cord Injury (Acute Management) evidence table

       

      Please remember to read the disclaimer 


      The development of this nursing guideline was coordinated by Janine Evans, Rosella - PICU, and approved by the Nursing Clinical Effectiveness Committee. Updated April 2015.