We've Got Your Back
Nurses help ease mental trauma, provide intensive care and attention to patients with spinal cord injury
By Lisette Hilton
January 10, 2005
When asked to share those heart-stopping stories about experiences with patients on their units, nurses who care for spinal cord injured patients say all their patients fit the bill.
Nurses are usually the ones charged with attempting to reassure these patients, “who are absolutely terrified,” says Mimi Sutherland, RN, MS, BSN, CNRN, nurse surgical coordinator, Jackson Health System, Miami.
“We’ve had patients range from [expressing] total denial, to ‘let me die.’” Sutherland says. “The nurses have to have a considerable amount of expertise in managing that range of emotion of both the patient and the family, once they realize they’re paralyzed.”
It’s one thing to feel like you can’t move, Sutherland says. It’s another to ask a nurse when she’s going to perform a procedure, only to find out that she’s already done it.
The first 48 hours of care after an spinal cord injury is a tough time, nurses admit. But good nursing care is critical in the acute phase of injury, when these patients are so physiologically vulnerable to complications.
“The first 48 hours is critical to prevent further injury and complications and to monitor for changes in neurologic level. Rehabilitation begins at the time of injury to prevent complications such as pressure ulcers, infections, and pulmonary compromise,” says Kelly Johnson, RN, MSN, CFNP, CRRN, CNAA, vice president of patient care services at Craig Hospital in Englewood, Colo., one of the major spinal cord injury centers in the United States.
These cases often are complicated, according to Daniel Lammertse, MD, medical director of Craig Hospital.
“Although spinal cord patients are commonly young and previously healthy, they are rendered extremely vulnerable to medical complications. They have lost not only sensation and movement, but they have also lost a lot of autonomic function,” he says.
The good news in what is a devastating injury is that myriad advances in health care have contributed to positive outcomes for people with traumatic SCI. Johnson says that in the early stages of care, these include improvements in prehospital care, trauma and acute care, neurodiagnostic, and improved diagnosis and treatment in the acute management of SCI.
The advances, which nurses should know about, have been instrumental in improving morbidity and mortality rates, she says. “Pharmacologic advances have improved health outcomes for individuals with SCI on many levels: prehospital and trauma management; prevention of complications such as infection and deep vein thrombosis; and acute and long-term management issues such as pain and spasticity.”
“There is a lot of special attention that these folks need from skilled nursing staff in the critical care units, intensive care units, neurointensive care units — wherever nurses may be seeing these patients. Since these patients are quite vulnerable to medical complications, there is a lot of nursing care planning and intervention that can go a long way to reduce the risk of those problems,” Lammertse says.
SCI is a low-incidence disability, according to Lammertse, which happens to about 10,000 people in the United States a year. So, unless nurses are in big-city trauma centers, they might not see many of these patients.
On the lookout
“It’s important for nurses — especially if they don’t see many of these patients — to go through a mental checklist of all the things that they need to be thinking about,” he says.
That mental checklist encompasses the cascade of events that happen along with many spinal cord injuries, such as respiratory issues, the need for spinal immobilization, blood pressure and heart rate issues, elevated risks of deep vein thrombosis and pressure ulcers, pain management, and more.
Cynthia Bautista, RN, PhD, CNRN, neuroscience clinical nurse specialist, Yale-New Haven Hospital, New Haven, Conn., says that patients with around a C-4 and above injury have probably eradicated the phrenic nerve and will no longer be able to move their diaphragms.
Lammertse says that respiratory therapists and nurses need to closely monitor vital capacity and inspiratory force of especially those patients who are high-level paraplegics and all tetraplegics.
“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?’”
Patients often come into the emergency department with more than a spinal cord injury. They might have chest trauma, head injury, or other orthopedic or soft tissue injuries.
Nurses should realize that because the spinal cord injury robs the patient of sensation in much of the body, the patient might not feel the symptoms of other injuries.
Stay informed
Bautista says she wishes that more nurses knew about the spinal cord injury guidelines created in March 2002. The American Association of Neurological Surgeons and the Congress of Neurological Surgeons created these 22 guidelines on the management of the acute spinal injury and spinal cord injury.
“In nursing, we should be sure that we’re following these guidelines,” she says.
A new treatment option, which has not yet taken hold in the mainstream, according to Bautista, is GM-1, or Sygen. GM-1 has to be given within 72 hours of injury; so clinicians would probably think more about its administration after patients are stabilized, rather than in the first 24 hours of care. Anecdotal reports are promising for improvement in motor function but study outcomes have not been statistically significant.
Well-known patients, including the late Christopher Reeve, have had GM-1 administered.
Craig Hospital is among the U.S. sites for a Phase 2 trial on ProCord (see sidebar), an autologous incubated macrophage procedure that might improve neurologic recovery.
Lammertse is excited to be able to offer SCI patients participation in a research trial of this type, but he says it’s only an experimental therapy.
One medication in trials in Canada, minocycline, is being studied for its ability to improve neurologic outcome. Another drug, Cethrin, soon should be starting trials in Canada and North America. Given early, this drug also holds hope for improving neurologic outcome in early stages, Lammertse says.
“There is also a trial going on looking at whether early surgical decompression of the spinal cord might improve neurologic outcome,” he says. “This is something that most of us take for granted but it has never been scientifically proven.”
Spinal cord injuries not only devastate the body but also the mind, says Norma McNair, RN, MSN, CCRN, CNRN, clinical nurse specialist in the department of nursing with a focus on neuroscience at UCLA Medical Center.
SCI patients usually don’t fully realize what has happened to them in the first 48 hours of care, she says. But the “fallout” in the acute phase usually occurs when the family starts arriving in a panicked state.
“I think often in the first 48 hours, it’s very difficult to really know the prognosis. So, I think at that point, it’s unrealistic for nurses to say the patient is never going to walk again. It’s important that nurses answer patients questions honestly, provide what information they can, but not take away their hope,” McNair says. “Most patients with spinal cord injuries think they’re going to get better, and I think that’s what sustains them.”
Types of spinal cord trauma
Contusion - bruising of the spinal cord
Compression - pressure exerted against the spinal cord by accumulations of blood (hematoma) or by the spinal vertebrae >>
Paraplegic - loss of motor and sensory function affecting abdomen to legs, use of chest and arm muscles intact >>
Quadriplegic (also known as tetraplegic) - loss of motor and sensory function from the neck down
Both paraplegics and quadriplegics can have incomplete or complete injuries:
Complete - complete loss of motor/sensory function at or below the point of injury
Incomplete - function is not completely lost, and nurses need to monitor for changes that can occur from secondary injury/swelling. A person with an incomplete injury may be able to move one limb more than another, may be able to feel parts of the body that cannot be moved, or may have more functioning on one side of the body than the other.
Source: Marcia Bixby, RN, MS, CS, CCRN, clinical nurse specialist for surgical critical care, Beth Israel Deaconess, Boston, and the National Spinal Cord Injury Association
About the ProCord clinical trial
The concept behind Proneuron Biotechnologies' ProCord is to draw blood from the patient to collect macrophages, "treat and educate" them, and then in a surgical procedure inject them into the spinal cord to stimulate the repair process. Specifically, blood and skin taken from the arm of the patient are processed for 1BD days before the resulting activated macrophages are implanted in the surgical procedure.
Procord is an autologous incubated macrophage procedure in Phase 2 trials at several sites in North America and one site in Israel. For a complete list of sites, visit www.spinal cordtrial.com. The randomized-controlled study is being performed under the U.S. Food and Drug Administration's regulations to test the safety and efficacy of the procedure in patients with acute complete spinal cord injuries.
ProCord must be administered within 14 days of the injury to meet study criteria.
For more information about the study, visit www.proneuron.com/clinicalstudies/ index.html. For enrollment, e-mail clinical.trial@proneuron.com or call (866) 539-0767 or (506) 652-3486.
Source: Proneuron Biotechnologies
Lisette Hilton is freelance writer for NurseWeek.