Critical Rehabilitation of The Patient With Spinal Cord Injury
Fries, J. M. (2005). Critical Rehabilitation of The Patient With Spinal Cord Injury.
Critical Care Nurse Quarterly 28 (2), 179-187.
Reviewed by: Carol L. Leedom MSN, RN
Patients with spinal cord injuries (SCI) are not always admitted to rehabilitation facilities/units as early as desirable because of multi-trauma they may have experienced. Many are returning to critical care units (CCU) secondary to complications. This article reviews the need for the critical care nurse to be skillful in early rehabilitation techniques in order to prevent complications in persons with SCI. Fries speaks to the need to prevent decubitus ulcers and contractures rather than treating them, as these wounds have devastating and far reaching implications for the patient with SCI. As helpful as the new specialty beds are, not all agencies have them, and they do not replace the need for turning the patient and inspecting the skin every 2 hours. It is also crucial that shearing of the skin does not occur when changing the patient’s position. All patients with SCI need to have frequent turning, some kind of bed overlay and all bony prominences protected. CCU nurses need to know how to care for the skin under splints, vests or under tongs to prevent rashes and/or infections.
Additionally, active and passive range of motion and positioning are critical to the prevention of contractures as well as decubitus. Physical and occupational therapy needs to be involved very early in the care of patients with SCI, even if on ventilators or in CCU. These specialists can implement early splinting and positioning maneuvers that will help prevent decubitus ulcers and contractures. As with all aspects of the care of patients with SCI-family involvement, peer support, and education-are critical.
Fries discusses the need to keep an appropriate call light within the “use” of the patient. There are many types available that are pressure or motion, sip and puff or voice activated. The major drawback to all of these is the need to reposition the device every time the patient is repositioned, and finding the right device for the patient.
The article further discusses the need for early vertebral stabilization to improve circulation, and respiratory function. Early stabilization also helps with early mobilization which helps prevent deep venous thrombosis, skin problems and contractures. Together, these may improve functional outcomes. It is also important for the critical care nurse to know how, or who, can change the devices/splints/casts after stabilization.
Hayes, J. S. & Arriola, T. (2006) Pediatric Spinal Injuries. Retrieved January 31, 2006, from
http://www.medscape.com/viewarticle/521467?src+mp.
This article is a brief, but clear, overview of the care of children with spinal cord injury (SCI). The authors review the types of SCI, the signs and symptoms and the anatomy of the spine. While these are well known to those in the SCI field, their description is clear, concise, and provide an excellent review.
The differences in children from 0-8 years of age are reviewed. There is a clear discussion of the head to body ratio, which causes increased force on the neck when the head is jerked; the greater flexibility of the spine and supporting structures allows for more stretching; growth plate damage can lead to bone damage and future growth issues; lack of ossification can lead to increased subluxation and distraction.
The explanation of the types and mechanisms of injury are explained, including longitudinal compression (vertebral crushing), hinging (sudden, extreme bending) and shearing (combined hinging and twisting). These injuries not only cause SCI but cause instability in the spine requiring stabilization, frequently surgical.
Medical management of pediatric SCI needs to start immediately. Patients who present with head injuries and/or other critical injuries may delay early diagnosis of SCI. Preserving as much spinal function as possible depends on early diagnosis and treatment. Suspicion must always error on the side of early diagnosis. Immobilization must be immediate and continue until proof of injury (or not) has been determined. Children tend to be harder to diagnose due to age variations and the increase in cord injury without x-ray abnormality in children. Treatment with high dose steroid needs to be instituted early in the patient’s hospitalization, if indicated. This therapy is still somewhat controversial.
Early and continuous assessment is paramount in all patients with SCI, but especially children. Children are notoriously difficult to assess due to language issues, age, and wide variations in growth and development.
The child with SCI may present with other critical injuries (head, chest, abdomen, and bone). These issues must be dealt with early and continuously. Additionally, the SCI issues must be addressed early to prevent secondary and devastating complications, such as decubitus ulcers, contractures, urinary tract infections, and deep venous thrombosis.
Research is ongoing in SCI and children’s issues are being researched just as vigorously. Stem cell research and transplanting GABA secreting cells are being investigated for future care and cure of SCI.
Carol L. Leedom MSN, RN, is professor of nursing, California State University, Chico.
The editor of Abstracts from Selected Literature welcomes your input. If you are interested in writing a review or have comments, questions, or suggestions, please contact Carol. L. Leedom at CLeedom@csuchico.edu.