Case scenario 4:

Joseph is a 28 year old man who fell from his roof while fixing his TV antenna. He was found to have
T10- T11 fracture with paraplegia. He was initially admitted to the SICU and placed on high dose steroids
for 24 hour. He was taken to surgery 48 hours post-accident for spinal stabilization. He spent 2
additional days in the SICU, 5 days on the neuro ward and now is ready to transferred to your medical
surgical ward. He continues to have no movement of his lower extremities.

1. The goal of treatment in the acute phase of spinal cord injury (SCI) is to help Joseph survive the
injury and maintain physiologic stability through the period of spinal shock. What is spinal shock?
How is it managed?

- Spinal shock is a combination of areflexia/hyporeflexia and autonomic dysfunction that accompanies

spinal cord injury.

4 phases of Spinal Shock

 Phase 1: One to two days following the injury: Nerve cells become less responsive to sensory
input, resulting in full or partial loss of spinal cord reflexes.

 Phase 2: One to three days following injury: Initial return of some reflexes. Polysynaptic reflexes
-- those that require a signal to travel from a sensory neuron to a motor neuron -- tend to return
first. The delayed plantar reflex, a variation of the normal plantar reflex common among SCI
survivors, typically returns first. Next is the bulbocavernosus reflex, which causes the anal
sphincter to tighten in response to squeezing the clitoris or head of the penis. Many doctors test
for the bulbocavernosus reflex to assess spinal cord injuries.

 Phase 3: One to four weeks following the injury: Hyperreflexia, a pattern of unusually strong
reflexes, occurs. This is the result of new nerve synapse growth, and is normally temporary.

 Phase 4: One to twelve months following the injury: Hyperreflexia continues, and spasticity may
develop. This process is due to changes in the neuronal cell bodies, and takes much longer than
the other stages.

Management:

 Maintaining your ability to breathe

 Preventing shock

 Avoiding possible complications, such as stool or urine retention, respiratory or cardiovascular

difficulty, and formation of deep vein blood clots in the extremities

 Patient's neck and back is immobilized by using neck support and braces to prevent further
damage to the spine.

 Patient is moved in neutral position.

 Airway is maintained so patient can breath normal.

  There is swelling of the spinal cord after the injury, so, it is imperative to start medical care
within the initial 8 hours after the injury for patient's recovery.

 Intravenous catheter is inserted to inject medications to control tachycardia, bradycardia and

hypotension

 Intravenous fluid is initiated if patient is suffering with low blood pressure.

 Nasal oxygen is provided to maintain normal blood oxygenation.

2. Joseph received high dose steroid therapy every 24 hours; then placed on smaller maintenance
doses. What effect will steroids have on Joseph?

- Steroids are given after the spinal cord injury to reduce inflammation and to prevent further nerve
damage.

- Steroids used as a treatment option for spinal cord injury. But there are possible effects of steroids:

 Increased incidence of infectious and septic complications

 Increased incidence & severity of respiratory complications

 Increased incidence of pulmonary embolism

 Worsening of head injury outcome

 Increased incidence of gastrointestinal hemorrhage

 Increased incidence of pancreatitis

 Possibility of missed hollow viscus injury due to 'masking' of abdominal signs

- The major impact of steroid medications on bone is fractures (broken bones) that occur most
commonly in the spine and ribs. Steroid medications (taken by mouth) equal to or more than 5mg of
prednisone daily, taken for more than 3 months, is considered a risk for fracture. Fracture risk increases
as the daily doses of steroid medications increase. Almost 1 in 3 postmenopausal women who routinely
take steroid medications will have a spine fracture. A person on steroids is more than twice as likely to
have a spine fracture compared to a person not taking steroids.

- A person with SCI at T2-T12 level should be independent in a wheelchair and able to manage ADL’s,
including bowel and bladder care.

3. Rehabilitation teaching includes teaching Joseph how to manage his urinary drainage system. What
would this teaching include? What is the usual amount of time for the return of reflex function of the
bladder?

- Immediately after SCI, the urinary bladder becomes atonic and cannot contract by reflex activity.
Urinary retention is the immediate result. Because the patient has no sensation of bladder distention,
overstretching of the bladder and detrusor muscle may occur, delaying the return of bladder function.

- Intermittent catheterization is carried out to avoid overdistention of the bladder and UTI. Intermittent
Catheterization is a preferred method for patients who have enough hand function (usually C7 and
below, or C6 for motor incomplete injuries) to perform it independently and who can remember to
catheter on schedule. With this method, you insert a catheter into the bladder and empty it completely
every four to six hours. The goal is to catheter frequently enough to keep urine volumes in the bladder
lower than 500 ml. This method requires that you closely monitor your fluid intake, usually around 2
liters per day, otherwise you might be cathetering too frequently to make this practical.

- If this is not feasible, an indwelling catheter is inserted temporarily.

- The patient is taught to record fluid intake, voiding pattern, amounts of residual urine after
catheterization, characteristics of urine, and any unusual sensations that may occur.

Catheterization

The male patient assumes a Fowler’s or sitting position, lubricates the

catheter and retracts the foreskin of the penis with one hand while grasping the penis and holding it at
a right angle to the body. (This maneuver straightens the urethra and makes it easier to insert the
catheter.) He inserts the catheter 15 to 25 cm (6 to 10 in) until urine begins to flow. After removal, the
catheter is cleaned, rinsed, and wrapped in a paper towel or placed in a plastic bag or case.

Schedule of Catheterization

In teaching the patient, the nurse emphasizes the importance of frequent catheterization and emptying
the bladder at the prescribed time. The average daytime clean intermittent catheterization schedule is
every 4 to 6 hours and just before bedtime. If the patient is awakened at night with an urge to void,
catheterization may be performed after an attempt to void

Catheter care

When teaching the patient how to perform self-catheterization, the nurse must use aseptic technique to
minimize the risk of crosscontamination.The patient, however, may use a “clean” (nonsterile) technique
at home, where the risk of cross-contamination is reduced. Either antibacterial liquid soap or povidone-
iodine (Betadine) solution is recommended for cleaning urinary catheters at home. The catheter is
thoroughly rinsed with tap water after soaking in the cleaning solution. It must dry before reuse. It
should be kept in its own container, such as a plastic food storage bag.

Follow-up

Patients following this routine should consult a primary health care provider at regular intervals to
assess urinary function and to detect complications.

INDWELLING CATHETER

Nutrition

Drinking the proper amount of fluids can help with bladder health, by washing bacteria and other waste
materials from the bladder.

Cranberry juice, or cranberry extract in pill form, can be an effective preventative for bladder infections.
Catheter care

 Always wash your hands before and after handling your catheter.

 Make sure that urine is flowing out of the catheter into the urine collection bag. Make sure that
the catheter tubing does not get twisted or kinked.

 Keep the urine collection bag below the level of your bladder.

 Make sure that the urine collection bag does not drag and pull on the catheter.

 Unless you have been told not to, it is okay to shower with your catheter and urine collection
bag in place

 Check for inflammation or signs of infection in the area around the catheter. Signs of infection
include pus or irritated, swollen, red, or tender skin.

 Clean the area around the catheter twice a day using soap and water. Dry with a clean towel
afterward.

 Do not tug or pull on the catheter.

 The catheter is secured properly to prevent it from moving, causing traction on the urethra, or
being unintentionally removed, and care is taken to ensure that the catheter position permits
leg movement. In male patients, the drainage tube (not the catheter) is taped laterally to the
thigh to prevent pressure on the urethra at the penoscrotal junction, which can eventually lead
to formation of a urethrocutaneous fistula.

 Do not have sexual intercourse while wearing a catheter.

 At night you may wish to hang the urine collection bag on the side of your bed.

 To empty the urine collection bag

 You will need to empty the bag regularly, whenever it is half full, and at bedtime. If your doctor
has instructed you to measure the amount of urine, do so before you empty the urine into the
toilet.

Spinal shock, or depression of the reflexes, generally lasts from 1 to 2 months, when the spinal reflexes
return.

4. Joseph asks you whether he’ll be able to have sex again. What do you tell him?
A spinal cord injury presents major challenges to many bodily functions, especially those
functions that are at or below the level of the injury. With this, the SCI has affected the
bladder and bowel function and has probably also affected the sexual function.

With regards to erection:

Psychogenic= For many men after SCI, having an erection by just thinking about something sexual may
not work. This is because the area of the spinal cord responsible for erections is located between T11
and L2. Therefore, if the level of SCI is above this level, the message (sexual thoughts) from the brain
cannot get through the damaged part of the spinal cord.
Reflexogenic= Some men with SCI may still get an erection when the catheter is being
changed or when their penis is being cleaned or wiped or even by just pulling clothing or
blankets over the body. It’s important for to pay close attention to what causes an erection as
that may be useful for future occasions.

Spontaneous= Some men after SCI may still get an erection when their bladder is full.
Depending on how long the erection lasts will help determine its usefulness for sexual
activity.
> The ability to get a reflexogenic erection or spontaneous erection is controlled by
nerves found in the lowest part of the spinal cord segments (S2-3-4).
> Men are also interested in the possibility of ejaculation. Like many other functions,
ejaculation is also affected by the SCI. Very few men with a complete SCI have
ejaculations. A small percentage of men with SCI report the feeling of ejaculation but
show no outward sign of semen.
> Sometimes the spinal cord injury prevents the bladder neck from closing and seminal
fluid (semen) will be ejaculated into the bladder instead of out the penis – this is
called retrograde ejaculation.

With regards to fertility:

>While it is possible for men with spinal cord injury to father children through
intercourse, some may struggle.
> Ask help from the doctor or a fertility expert
> Most problems with fertility for men after SCI are related to ejaculation

With regards to sexual intercourse:

>The most important thing to remember is that sexual function and pleasure is mostly
psychological.
>People who approach sexual intercourse with an open mind and a willingness to
experiment to find out what works and doesn’t work after their injury tend to have
the most success and reported satisfaction.

5. What are some of the noxious stimulus that can cause AD?

Autonomic dysreflexia (AD)= a rise in blood pressure resulting from a stimulus below your level of
injury. The involuntary nervous system overreacts to external or bodily stimuliYou are at risk if you have
an injury at T6 and above. This can also lead to potentially life-threatening hypertension.

>It is considered a medical emergency and must be recognized immediately.

>If left untreated, autonomic dysreflexia can cause seizures, retinal hemorrhage, pulmonary
edema, renal insufficiency, myocardial infarction, cerebral hemorrhage, and, ultimately, death.

>Complications associated with autonomic dysreflexia result directly from sustained, severe
peripheral hypertension.

Causes of AD:
 >Episodes of autonomic dysreflexia can be triggered by many potential causes.
>
Essentially, any painful, irritating, or even strong stimulus below the level of the
injury can cause an episode of autonomic dysreflexia.
>Bladder distension or irritation is responsible for 75-85% of the cases.
• Bladder irritation is commonly caused by a blocked or kinked catheter or failure
of a timely intermittent catheterization program.
>The second most common cause of autonomic dysreflexia is bowel distention, usually
due to fecal impaction. This accounts for 13-19% of cases.
The following events or conditions all can cause episodes of autonomic dysreflexia:
•Bladder distention
•Urinary tract infection
•Epididymitis or scrotal compression
•Bowel distention
•Fecal impaction
•Bowel instrumentation/colonoscopy
•Reflux or gastritis
•Invasive testing
•Hemorrhoids
•Appendicitis or other intra-abdominal pathology/trauma
•Anal fissure
•Menstruation
•Pregnancy - Especially labor and delivery
•Vaginitis
•Sexual intercourse
•Ejaculation
•Deep vein thrombosis
•Pulmonary emboli
•Pressure ulcers
•Ingrown toenail
•Burns or sunburn
•Blisters
•Insect bites
•Contact with hard or sharp objects
•Temperature fluctuations
•Constrictive clothing, shoes, or appliances
•Heterotopic bone
•Fractures or other skeletal trauma
•Surgical or diagnostic procedures

6. What are the manifestations of AD? What will be your interventions for patients suffering from AD?

Manifestations:
•Dangerous spike in blood pressure
•Anxiety and apprehension
•Irregular or racing heartbeat
•Nasal congestion
•High blood pressure with systolic readings often over 200 mm Hg
•A pounding headache
•Flushing of the skin
•Profuse sweating, particularly on the forehead
 •Lightheadedness
•Dizziness
•Confusion
•Dilated pupils

Interventions:

Bladder
Intermittent catheterization should be regular and timely; only clean catheters should be
used. Indwelling catheters should be changed routinely and regularly checked for blockage or
kinking.

Bowels
A regular bowel program is essential for the prevention of constipation, impaction, and ileus.
Prior to a bowel procedure, an anal block helps prevent autonomic dysreflexia. Topical
lidocaine may be of help.

Pressure ulcers
Routine weight shifts and skin checks are necessary to prevent ulceration. Any skin
breakdown should be addressed early by a knowledgeable wound care team or physician.

Increased Blood Pressure

The goal of emergency treatment is to lower the blood pressure and eliminate the stimuli
triggering the reaction. Emergency measures may include:
•moving into sitting position to cause the blood to flow to the feet
•removing tight clothes and socks
•checking for a blocked catheter
•draining a distended bladder with a catheter
•removing any other potential triggers, such as drafts of air blowing on the person or
objects touching the skin
•treating you for fecal impaction
•administering vasodilators or other drugs to bring blood pressure under control