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“These are patients that are at risk of developing respiratory failure,” he says. “Remember that these patients have lost their ability to cough with any kind of force, so their cough is very weak and ineffectual. They need assistance of nursing and respiratory therapy staff members to mobilize their respiratory secretions. That’s why they have such a high risk of atelectasis.”

Interventions in the acute care period are aimed at reducing inflammation and swelling, and promoting perfusion and blood flow to the spinal cord, while preventing further injury through immobilization, according to Marcia Bixby, RN, MS, CS, CCRN, clinical nurse specialist for surgical critical care, Beth Israel Deaconess Medical Center, Boston.

Emergency medical services teams usually immobilize patients with cervical collars, taped to a backboard for transport from the field. It is then the nurse’s role to assure that proper alignment is maintained at all times. This includes proper sizing and fitting of cervical collars, as well as collar and skin care every shift.

SCI patients also are at high risk for pressure ulcers and skin sores. Nurses should check to make sure that collars are properly fitted. “These patients have very vulnerable skin and especially in centers that don’t see a lot of spinal cord injuries; the nursing staff may overlook this skin sore vulnerability. This is probably the highest risk patient population for the development of serious skin sores, so proper attention to padding and positioning and protecting the skin is incredibly important,” Lammertse says.

“You prevent pressure sores with log rolling and looking at the posterior part of the picture, assessing for redness,” Bautista says. “Especially if it’s a penetrating trauma, you look at the front and see if there’s a hole, but you also want to see if there’s a hole in the back. Another thing to remember: People who have neck or back injuries will be collared and boarded. The idea is to get them off the board as soon as possible. 85 If you do a log roll while in the ED and if things look all right, you can take off the board.”

Risks and responses

SCI patients are likely to have low blood pressure, and the treatment of choice, Lammertse says, is to give medications, called pressors, to raise patients’ blood pressure.

Bautista says that hypotension is most common with cord injuries that are T-6 and above.

“That is where your sympathetic nervous system innervates,” she says. “So, if you have a T-6 injury and above, you’ve lost that sympathetic response and you will become bradycardic and hypotensive. Ideally, you want a systolic pressure greater than 100. And you want a heart rate between 60 and 100.”

When they’re being suctioned, higher-level tetraplegic patients especially often go into severe bradycardia, according to Lammertse. “In some less experienced centers, there is probably too quick a reaction to consider putting a cardiac pacemaker in some of these patients, when this is usually a temporary problem and usually can be treated with medications.”

SCI patients are at high risk for deep vein thrombosis, requiring that nursing staff develop a care plan with critical time lines, Lammertse says. The standard of treatment, he says, is usually initiation of compression, including pneumatic compression sleeves on the calves right away. Within about three days, the patient should be started on low molecular weight heparin prophylaxis.

Pain management can be a difficult task for the nurse who needs to keep patients — especially patients who also have head injuries — alert enough to respond to neurological exams.

Among the many other things that nurses should look for and address are neurogenic bowel and bladder issues. Most patients have ileus in the first couple of days after an SCI, and their bladders might not work in terms of reflex function for weeks or more, Lammertse says.

Most experts recommend that methylprednisolone therapy be given within eight hours for nonpenetrating acute spinal cord injuries.

New research is taking a closer look at the increased incidence of sepsis that comes with using the therapy, suggesting that nurses and doctors should evaluate patients’ risks for sepsis when determining whether to administer the therapy, according to Bautista.

“A lot of the national organizations have changed their recommendations for this high-dose methylprednisolone as a standard of care, saying it’s a recommended treatment instead of the recommended treatment,” Bautista says. “As nurses, we need to start thinking about that too. If nurses have an order to give methylprednisolone, we should just say to the physician, ‘Are you sure?’”