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AM Report

AM Report. 11/7/06 Matthew Dougherty. Issues to consider. Tracheal injury Esophageal injury Vascular injury Cord injury Instability of spinal column Shock. Pt arrives in ED…. Time: 1341 R antcub PIV in place NS bolus is running Vitals Temp: 91.3 ° F Pulse: 80 RR: 22 BP: 98/58.

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AM Report

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  1. AM Report 11/7/06 Matthew Dougherty

  2. Issues to consider • Tracheal injury • Esophageal injury • Vascular injury • Cord injury • Instability of spinal column • Shock

  3. Pt arrives in ED… • Time: 1341 • R antcub PIV in place • NS bolus is running • Vitals • Temp: 91.3° F • Pulse: 80 • RR: 22 • BP: 98/58

  4. ABC’s • Airway: pt noted to be talking but pooled blood noted in posterior pharynx. Pt placed in C-spine collar prior to transport. • Breathing: RR 22, BS noted to be clear B. No stridor or wheezing noted. No tracheal deviation noted. 94% on RA. • Circulation: Pulse 80, BP 98/58, pulses 2+ in all extremities, unable to palpate carotid pulse on L secondary to swelling. No significant hemorrhage from neck wound noted.

  5. Disability and Exposure • Disability: GCS 15 at scene. No change in GCS on initial presentation to OSH. PERRLA B 3mm to 2mm B. Pt groans when shoulders pinched. Small circular movements of arms noted. No movement or sensation in lower extremities. Poor rectal tone toned. Erectile penis noted. • Exposure: Pt had small entrance wound just lateral to the cricoid cartilage on the left side of the neck. Slightly larger posterior exit wound noted on L side.

  6. Nurses notes in outside ER • 1348: Ancef started and run with bolus over 10 minutes. Neuro exam demonstrates some upper extremity movement. No lower extremity movement or sensation. Lateral neck x-ray taken.

  7. ER Course • 1401: results of x-ray demonstrate fracture of C5 vertebrae with numerous bone fragments noted in soft tissues of the neck. Significant subcutaneous emphysema noted in neck. • 1404: Pt intubated with 6.0 cuffed ET tube • 1415: Receiving second NS bolus. P 78, BP: 96/30 • Norepi ordered

  8. ER Course • 1420: P 70, BP 111/33 • Norepi started • 1430: P 96, BP 118/60. • Fent started for sedation • 1450: O neg transfusion started • 1520: Temp: 91.4°F, P 69, BP 127/65 • 1543: Temp: 91.4°F, P 79, BP 126/51 • Pt transported to SCVMC

  9. Arrival at SCVMC • 1900: VS: Temp: 94.1°F (R), P 50, BP 90/41. • Norepi 2 mcg/min • Fent 4 mcg/kg/hr • On arrival, pt had received 2.3 L NS and unknown quantity of PRBC’s

  10. Shock • Septic: hyperdynamic physiology • fever • decreased systemic vascular resistance • an elevated cardiac output • widened pulse pressure • warm, dry extremities • Hemorrhagic shock • Normotensive/hypotensive • compensatory tachycardia • poor urine output • cool extremities

  11. Neurogenic shock • Spinal cord injury can result in significant compromise of cardiovascular control • Impaired control of the autonomic nervous system • Hypotension • Bradycardia • Autonomic dysreflexia • Long term consequences • DVT

  12. Immediate response to spinal cord injury • Blood pressure rises acutely • Release of norepinephrine from the adrenal glands • Pressor response from mechanical disruption of vasoactive tracts in the cervical and upper thoracic spinal cord.

  13. Evolution of the condition • Followed by a period of decreased sympathetic nervous system activity • interruption of the descending sympathetic tracts • hypotension • bradycardia • hypothermia

  14. Neurogenic shock • Neurogenic shock • urine output is preserved • skin is typically warm • decreased pulmonary and systemic vascular resistance • tachycardia is absent • decreased cardiac output

  15. Hypotension and cervical SCI • Decreased compensatory vasoconstriction • skeletal muscle and splanchnic vascular beds • venous pooling in the lower extremities • reduces venous blood return, stroke volume, and blood pressure. • resting SBP are commonly 80-100 mm Hg • decreases of 20-30 mm Hg in with changes from a supine to an upright position may be common • increases of 20-30 mm Hg may be secondary to autonomic dysreflexia

  16. Bradycardia and cervical SCI • Parasympathetic input to the heart • vagus nerve remains intact • Cardiac arrest has occurred in acute SCI • often precipitated by tracheal stimulation and hypoxia

  17. Cervical SCI • Among patients with thoracolumbar injuries, 13-35% have bradycardia • ASIA Grades C and D • 35-71% develop bradycardia • few have hypotension or require pressors • rarely have primary cardiac arrest. • American Spinal Injury Association [ASIA] grades A and B • Nearly 100% develop bradycardia • 68% are hypotensive • 35% require pressors • 16% have primary cardiac arrest

  18. Physical exam findings indicitive of neurogenic shock • Transient loss of all motor, sensory and reflex function caudal to the level of the injury • Bulbocavernosus reflex or anal wink reflex • Definitive neurologic status cannot be assessed until the cessation of spinal shock • Resolution of neurogenic shock usually occurs within 48 hours of injury

  19. Bulbocavernosus reflex • bulbocaverosus reflex refers to anal sphincter contraction in response to squeezing the glans penis or tugging on the Foley;          - reflex involves S-1, S-2, and S-3 nerve roots and is spinal cord- mediated reflex arc;    - following spinal cord trauma, presence or absence of this reflex carries prognostic significance;          - in cases of cervical or thoracic cord injury, absence of this reflex documents continuation of spinal shock                or spinal injury at the level of the reflex arc itself;                - period of spinal shock usually resolves w/ in 48 hours and return of bulbocavernosus reflex signals                        termination of spinal shock;Prognositic Significance:    - complete absence of distal motor or sensory function or perirectal sensation, together with recovery          of the bulbocavernosus reflex, indicates a complete cord injury, and in such cases it is highly          unlikely that significant neurologic function will ever return;          - therefore, if no motor or sensory recovery below the level of frx is present, pt has a complete                spinal cord injury and no further distal recovery of motor function can be expected;          - on other hand, any spared motor or sensory function below level of injury is consideredincomplete spinal cord injury;          - potential for recovery of incomplete lesion is determined by part of the cord most severely injured

  20. Treatment of neurogenic shock • Careful monitoring of cardiovascular and fluid status • pressors to maintain systemic vascular resistance and provide inotropic support • careful fluid resuscitation • massive neural discharges increase systemic and pulmonary vascular pressures • may be worsened by overly judicious use of fluids • Symptoms usually improve within days to weeks as compensatory changes occur in the vascular beds, skeletal muscle, and renin-angiotensin aldosterone system. • Maitain MAP of at least 85 mm Hg • maintain spinal-cord perfusion and help prevent secondary ischemia

  21. Treatment of neurogenic shock • Keep atropine and a transvenous pacer at patient's bedside for emergencies • Bradycardia usually resolves 2-6 weeks after the SCI. • Before performing any procedure that increases vagal tone, correct hypoxia with 100% oxygen and premedicate with atropine • full lung expansion before suctioning may decrease vagal tone • therefore, provide a full breath with a ventilator or bag-valve-mask

  22. Treatment of neurogenic shock • Succinylcholine • cardiac arrest and hypokalemia can result from hypersensitivity of muscle-cell membranes • avoided in patients with SCI • DVT due to venous stasis is common in the SCI population • most common in acute postinjury period. • fever of unknown origin

  23. Cervical spinal cord injury and the need for cardiovascular intervention. Arch Surg. 2003 Oct;138(10):1127-9 • Retrospective review. Level I trauma center. • Data included • level of spinal cord injury • Injury Severity Score • lowest heart rate • systolic blood pressure in the first 24 hours • High (cord level C1-C5) or low (cord level C6-C7) level cord injury • Outcome: use of a cardiovascular intervention • pressors • chronotropic agents • pacemakers

  24. Cervical spinal cord injury and the need for cardiovascular intervention. Arch Surg. 2003 Oct;138(10):1127-9 • Total: 83 patients • 62 in the high (C1-C5) • 21 in the low (C6-C7) level • Neurogenic shock • 31% of patients with high CSCI • 24% of patients with low CSCI • Cardiac intervention • 24% of patients with high injury • 2 required placement of a pacemaker • 5% of patients with low injury (P=.02)

  25. Function in C5 tetraplegia • Functional use of elbow flexion • with specialized assistive devices (such as wrist or hand orthotics to allow them to hold objects), they can achieve independence with feeding and grooming • can assist with upper-extremity dressing and bed mobility. • Will likely need a power wheelchair with hand controls for most of their mobility • Require assistance for most other self-care • lower-extremity dressing • bathing • transfer mobility • bladder and/or bowel tasks • Assistive technology • answer phones • use computers • televisions • driving a specially modified or adapted vehicle

  26. Annual incidence of spinal cord injury • 40 cases per million population • 11,000 new cases annually • 53% have cervical injury • 42% have lesions in the thoracic, lumbar, or sacral regions

  27. Autonomic dysreflexia • Loss of supraspinal control of hyperreflexic SNS activity is usually secondary to noxious stimuli below the level of injury (in individuals with SCI at T6 levels or above - above the major SNS splanchnic outflow). This loss can lead to autonomic dysreflexia and dangerously high blood pressures.

  28. Morbidity and mortality • Complications of loss of sympathetic control include hypotension requiring pressors, pulmonary edema because of volume overload from aggressive resuscitative efforts, bradycardia requiring atropine or transvenous pacing, primary cardiac arrest, and supraventricular tachyarrhythmias. • Direct myocardial injury can occur after SCI, as evidenced by electrical, enzymatic, and histologic changes in the heart. This phenomenon may be attributable to the surge of sympathetic mediators released from the adrenal glands and sympathetic nerve terminals immediately after injury. • The mortality rate associated with pulmonary edema is as high as 35%; this rate emphasizes the importance of DVT prophylaxis. • E-medicine

  29. Symptoms • Symptoms that patients report after acute SCI differ depending on the underlying condition. • Hypotension and bradycardia: Patients may report dizziness or even loss of consciousness, nausea, lightheadedness, and visual disturbances as a manifestation of low blood pressure and slowed pulse. Orthostatic hypotension is a sudden decrease in blood pressure when the patient rises to a relatively upright or upright position. • Autonomic dysreflexia: Symptoms include headache, sweating, piloerection, facial flushing, blurred vision and nasal congestion.

  30. Determining level of injury • Neurologic levels representing upper- and lower-extremity function (and key muscles) are as follows: • C5 - Elbow flexors (biceps) • C6 - Wrist extensors (extensor carpi radialis) • C7 - Elbow extensors (triceps) • C8 - Finger flexors (flexor digitorum profundus) • T1 - Small finger abductors (abductor digiti minimi) • L2 - Hip flexors (iliopsoas) • L3 - Knee extensors (quadriceps) • L4 - Ankle dorsiflexors (tibialis anterior) • L5 - Great toe extensor (extensor hallucis longus) • S1 - Ankle plantar flexors (gastrocsoleus complex)

  31. Exam findings in neurogenic shock • Mental status changes • Secondary to hypotension vs. hemorrhage • Signs of SNS dysfunction • pallor • flushing • sweating • skin temperature • piloerection

  32. ASIA impairment scale • A - Complete = No sacral motor or sensory sensation in segments S4-5 • B - Sensory incomplete = Preservation of sensation below the level of injury extending through sacral segments S4-5 • C - Motor incomplete = Voluntary anal sphincter contraction or sensory sacral sparing with sparing of motor function distal to 3 levels below the motor level of injury, with the majority of key muscles having a strength grade of less than 3 • D - Motor incomplete = Voluntary anal sphincter contraction or sensory sacral sparing with sparing of motor function distal to 3 levels below the motor level of injury, with the majority of key muscles having a strength grade of 3 or greater • E - Normal = Normal motor and sensory recovery (Hyperreflexia may be present.)

  33. Grading muscle strength • Grade 5 = Normal, or muscle movement through the complete range of motion (ROM) against gravity and full resistance • Grade 4 = Good, or muscle movement through the complete ROM against gravity and moderate resistance • Grade 3 = Fair, or muscle movement through the full ROM against gravity only • Grade 2 = Poor, or muscle movement through the full ROM with gravity eliminated • Grade 1 (Trace) - Palpable muscle contraction or joint movement, but not through complete ROM, even with gravity eliminated • Grade 0 = Zero, or no muscle movement or palpable contraction

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