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Note: This guideline is currently under review.  

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IntroductionDefinition of termsSCI pathophysiology & presentationComplete/incomplete injuryCause of injuryPathophysiologySigns & symptoms of acute SCIInitial assessment Admission locationSpinal immobilisationNeurological assessmentVital signs (and autonomic control)Blood pressureTemperatureThromboprophylaxisPostural hypotensionJoint contracturesAutonomic hyperreflexia (Dysreflexia)Sexual functionPsychologicalPotential complications and managementFamily centred careSpecial considerationsCompanion documents Evidence tableHow do you assess for urinary incontinence?What are 3 things to consider when caring for a person with functional urinary incontinence?What is the appropriate nursing care for a patient with urinary incontinence?How would you manage a patient with urinary incontinence?

Introduction

Spinal cord injury (SCI) in children is a rare injury that can result in permanent loss of motor and sensory function, and dysfunction of the bowel and bladder. Impairment of these functions result in significant social and psychological consequences for the child and their family. SCI is often associated with a traumatic brain injury. In children and adolescents SCI is most commonly a result of road traffic accidents, falls or diving into water.

Children with SCI experience multiple health care problems including autonomic instability, complications of immobility and bowel or bladder dysfunction. Management in the acute phase is aimed preventing further spinal cord injury, maintaining physiological stability, and commencing routine care of the skin and establishing good bladder and bowel care.

Aim

This guideline is aimed the acute management of children with injury to the spinal cord.

Definition of terms

AIS: ASIA (American Spinal Injury Association) Impairment Scale. An international classification system for level of impairment as a result of spinal cord injury. There are five classifications for traumatic spinal cord injury: A-E.Quadriplegia (also referred to as tetraplegia): dysfunction of arms, legs, bowel & bladder due to SCI in the cervical regionParaplegia: dysfunction of lower body toàn thân, bowel & bladder due to SCI in the thoracic, lumbar or sacral regionSpinal shock: Temporary areflexic state with loss of autonomic control, and muscle tone below the level of the injury which lasts up to six weeks after injury. It usually occurs in spinal cord injury to cervical & upper thoracic spinal cord. Functional recovery may improve after spinal shock resolves.Neurogenic shock: hypotension as a result of bradycardia and vasodilation due to loss of thoracic sympathetic innervation following SCI. Profound effects are noted if injury is level of T6 or above. Most dramatic effects noted in the first few weeks with most patients stabilizing in 7-10 days

SCI pathophysiology & presentation

Complete/incomplete injury

A complete SCI results in loss of all motor and sensory function below the level of injury (AIS A). An incomplete SCI results in preservation of sensory function below the level of injury (AIS B), or a combination of varying degrees of sensory and motor preservation below the level of injury (AIS C or D). 

Cause of injury

The spinal cord can be injured by transection, distraction, compression, bruising, haemorrhage or ischaemia of the cord or by injury to blood vessels supplying it. These injuries can all result in permanent cord injury and may be complete or incomplete.Concussion of the spinal cord can result in temporary loss of function for hours to weeks

Pathophysiology

Injury results from primary & secondary insults Primary injury occurs the time of the traumatic insultSecondary injury occurs over hours to days as a result of a complex inflammatory process, vascular changes and intracellular calcium changes leading to oedema and ischemia of the spinal cord. Irreversible damage occurs to nerve cells leading to permanent disabilitySpinal cord injury may occur without evidence of bony injury on Xray or CT. Paediatric injuries are more commonly associated with injury to ligaments discs and growth plates and often require a MRI to define the injury pattern. 

Signs & symptoms of acute SCI

Flaccid paralysis below level of injuryLoss of spinal reflexes below level of injuryLoss of sensation (pain, touch, proprioception, temperature) below level of injuryLoss of sweating below level of injuryLoss of sphincter tone and bowel & bladder dysfunction

Management

Initial assessment

See major trauma-primary survey guideline (link) and cervical spine injury guideline (link) for initial assessment

Be aware the loss of thoracic sympathetic innervation (T1-T5) may inhibit tachycardia and vasoconstriction as signs of hypovolaemia. Thus haemorraghic injuries may not be indicated by the usual signs.

Referrals

Neurosurgical, orthopaedics & trauma service should be notified prior to or on admission to the Emergency departmentRehabilitation service to be notified within 24 hours of admission

Admission location

These patients will usually require admission to PICU (Rosella)If not requiring PICU admission, then this will usually be Cockatoo (Neurosurgical ward) unless multiple abdominal injuries are present, in which case the child will be admitted to Platypus (General surgical ward)

Spinal immobilisation

See cervical spine injury guideline (link)

Initial care - immobilisation:
Immobilize the entire spine of any patient with known or potential SCIImmobilize neck with a hard collar. See guideline for cervical spine assessment (link)Use log roll with adequate personnel to turn patient while maintaining spine alignmentFor children < 8 years of age use an airway pad to promote neutral cervical spine position (link to resource)Remove from spinal board on arrival in ED or as soon as resuscitation allows Maintain neck in neutral position by use of a hard collar, but change to two-piece collar for comfort and avoidance of complications (e.g. pressure area, venous obstruction, aspiration) within 6 hours of admission. 
Early surgery:
Surgery may be required in the situation of a reversible compression injury, or deteriorating neurology with a spinal injury amenable to some form of reduction and or fixation. 
Halo & Orthotic devices:
Some patients may have Halo devices applied by surgeons, or a brace made by orthotics to maintain correct alignment of the spine. These devices are fixed to the child’s chest.Ensure you know how to open devices to perform chest compressions in the sự kiện of a cardiac arrest, and that spinal immobilisation is maintained manually throughout any resuscitation 
Move patient using slide sheets or pat slide with adequate number of personnel to maintain spinal alignment No pharmacological agent has been proven to limit damage and optimize recovery of function. If steroids have already been given, cease them when resuscitation completed. Aim for normal perfusion pressure and oxygenation of SC. Once the extent and stability of the injury has been determined a documented plan should be formulated to ensure immobilisation and stabilisation. 

Imaging

Multiple levels of injury in the spine are common. In the under 8 age group especially, there is a high proportion of missed craniocervical injuries with/ without associated cranial nerve involvement. 
plain film imaging of the entire cervical, thoracic and lumbar spinesFurther early imaging will least involve an urgent MRI of the entire spine looking for remediable lesionsCT scan may be used to further identify the extent of bony injury

Neurological assessment

Neurological assessment and documentation in the EMR including:
Sensory level Motor function
After 72 hours, the ASIA guide should be completed documenting sensory and motor levels. Contact the rehabilitation registrar to assist with this assessment
Glasgow coma scorePupil response
Perform hourly for 1st 24 hours then decrease to 4 hourly if condition stabilisedNote evidence of brain injury as well as spinal cord injury

Vital signs (and autonomic control)

Vital signs can be quite abnormal following SCI. In addition to the usual causes in trauma such as pain, bleeding and distress, this can be due to loss of autonomic control, which occurs particularly in cervical or high thoracic injuries. The autonomic nervous system controls our HR, BP temperature etc. Autonomic instability is most acute in the first few days to weeks of the injury. Particular implications of autonomic instability to be aware of are:

Heart rate

Bradycardia can easily occur , for example on endotracheal tube or tracheostomy suction, due to unopposed vagal activity (Thoracic sympathetic input may have been damaged)Patient needs continuous HR monitoring in PICU or ward  Treatment with anticholinergic medication is often required

Blood pressure

Loss of autonomic control results in loss of vasomotor tone. Patient may be quite vasodilated and hypotensive. This phase of neurogenic shock can last up to several weeks. Hypotension should be treated to prevent secondary poor perfusion of the spinal cord.Blood pressure monitoring should be:
Continuous in PICU At least hourly in the ward
Ensure patient is adequately fluid resuscitated but not overloadedPatient may need vasopressor drugs such as nor-adrenaline or intravenous fluids to maintain BP (but excessive fluids will cause pulmonary oedema). Patients requiring vasopressors should be managed in PICU

Temperature

The loss of temperature control e.g. ability to sweat, shiver, vasodilate, vasoconstrict or position self to maintain temperature. Consequently, the child will take on the temperature of the environmentHypothermia is commonTemperature measurement should be preformed 4hrly in the acute stage of admissionEnsure adequate clothing or bedding in cool environmentEnsure artificial cooling in a hot environment

Breathing

Respiratory difficulty is common in the early stages of spinal shock but will ultimately depend on injury level 
C1-C4: paralysis of diaphragm and intercostal muscles: will need mechanical ventilation via endotracheal intubation or tracheostomy. May need long-term ventilation of phrenic/diaphragm pacingC5-T6: paralysis of intercostals, diaphragm OK – may need some form of respiratory supportT6-12: abdominal muscles paralysed, may have some decreased function
Asses respiratory status including pattern, effort, ability to cough, auscultate chest, Monitor SpO2 ETCO2, ABGIntubate & ventilate if respiration is inadequate
Maintain strict ventilator associated pneumonia (VAP) prevention strategies
Nurse head up, but tilt entire bed so that spine remains in line & immobilised-do not just simply raise head of bed up
Note later stage of admission when patient is allowed to sit up, that if abdominal muscles are paralysed, breathing difficulty may be worsened when sitting up and eased when semi-recumbent 
Give O2 as requiredEnsure abdomen not distended (NG should be inserted)Refer to physiotherapist to establish a regimen of chest physiotherapy, assisted coughing and BiPAP. 

Skin

See Pressure injury prevention guideline (link)

A patient who has a SCI is high risk of damage to their skin integrity. The SCI causes loss of sensation of pain, pressure & temperature. The patient may also have lost motor control and have poor autonomic nervous system function. The end result is a lack of sensory warning mechanisms, an inability to move and circulatory changes all impacting on skin integrity.

High risk for pressure areas, measures need to be implemented to assess and prevent skin breakdown:
A baseline skin assessment should be completed on admissionFor all patients a Pressure Injury Prevention Plan must be commencedPressure mattress (low air loss or alternating pressure) or gel mat if approved
Air or alternating pressure mattresses should not be used for unstable spines
Reposition 2 hourly 
This should occur from the time of admissionReduce friction and shear during repositioning and transfers
If skin breakdown occurs it can progress rapidly. Pressure must be kept off this area. Refer to stomal therapy for advice on appropriate dressing
Take care with water temperature for washes, and use of hot or cold devices against skin
The patient will not feel the temperature extreme, or be able to withdraw from it
Hygiene
Daily wash to keep skin clean
Dry thoroughly after washingDo not leave patient in damp/wet bedCommence bowel regime as outlined below
Hard collar needs to be removed & skin underneath checked & washed daily
Manually immobilised head whenever the hard collar is offCollar fit & position to be checked each shiftInspect the skin of the occiput each shift
Refer to surgeons & orthotics for advice on access to skin under halo jackets and braces
Adequate nutrition is important for good skin integrity. Enteral nutrition is preferred.Skin should be fully inspected once per shift

Bladder

Urinary bladder function may be affected by SCI. The muscles and sphincters of the bladder are normally controlled by neurological input and spinal reflexes. Loss of this normal neurological control of the bladder is commonly referred to as a neurogenic bladder. The aim of bladder care is to prevent infections, minimise and contain incontinence and find an appropriate way to empty the bladder. This will need to be related to the child’s developmental level, lifestyle, and family needs. For the adolescent patient sexual function also needs to be considered.

Bladder dysfunction depends on the level of spinal cord injury
Some patients will have a contractile/reflex bladder which contracts when the bladder muscle (detrusor) is under a certain amount of pressure. Depending on the urethral sphincter function these patients will leak in between catheters.Some patients will have an acontractile/flaccid bladder that stretches and holds a large volume of urine but the bladder muscle (detrusor) does not contract and bladder emptying occurs usually by overflowSome patients will have a combination bladder
In the early acute phase of the SCI an indwelling urinary catheter will be used. Always use lignocaine lubricant to insert catheter.Once patient has stabilised and opioids reduced consider change to intermittent catheter 4-6/24.
Refer to Urology to enable Stomal therapy involvement to assist in establishing a routine
Long term management can include clean intermittent catheterisation (by carer or child if able); condom drainage or other options used more for adults dependant on care, such as bladder tapping or use of a suprapubic catheterOccasionally if clean intermittent catheterisation is difficult or impractical a mitrofonoff stoma might be consideredSome patients will be prescribed Oxybutin to reduce bladder spasm & thus increase holding capacity & continence between cathetersComplications:
Recurrent UTIRenal & bladder calculiVesico ureteric refluxLatex allergy development due to increased latex exposure: use latex không lấy phí catheters
Prevention of complications:
Maintain good hydration to reduce the risk of UTI & Kidney stonesGood hand hygiene by carers, and ensuring goog hygiene of the patients perineal area to reduce infection
Priaprism (erection) may occur in boys and is usually self-limiting & not a contraindication to catheterisation. Referral to urology if priaprism prolonged

Bowels

Bowel function will be affected by loss of neurological control of its function (neurogenic bowel). In addition, medications such as antibiotics and opioids, immobility, alterations is food, fibre and fluid intake may affect function. Patients are risk of constipation, impaction and diarrhoea. It is important to achieve regular bowel emptying. Constipation is not only troublesome but can also trigger major complications such as autonomic hyper-reflexia (dysreflexia).

Commence bowel management as soon as bowel sounds are present and enteral/oral feeds begin
In the acute phase of spinal shock:
Aperients should be commenced with enteral feedingRefer to Dietician early to ensure adequate nutrition, fluid & fibre in the feeds
When spinal shock has resolved (and helpful if patient able to sit)
Refer to stomal therapy for assistance in establishing a bowel routine if the ward/rehabilitation routine is not satisfactory in the early phase; or when discharge is being discussed. Routine will depend on age, bowel function, level of injury, pre injury function & family/carer support
Bowel dysfunction: 
Some patients may have a ‘reflex’ bowel. Although peristalsis will move stool through bowel, the anal sphincter may not relax. It may need stimulation to relax & allow passage of stoolSome patients may have a ‘flaccid’ bowel. Reflexes that move stool through the bowel are impaired and the anal sphincter is relaxed preventing stool being held in the rectumSome patients have a combination of bowel function problems
Constipation
Caused by: insufficient fluid & fibre intake, insufficient aperients, ineffective evacuation of stool, medications (anticholenergics, opioids), immobility Treatment: increase fluids & fibre, increase aperients
Impaction
Caused by: chronic constipation. Will often have liquid overflowTreatment: contact stimulant, movicol or osmotic laxative; Assisted evacuation only if necessary (e.g. microlax, large volume enema, manual disimpaction)
Diarrhoea
Change in diet, antibiotics, bacteria, excess aperients, high impactionTreatment: adjust diet, reduce aperients, stool specimen, abdominal x-ray if impaction suspected; possibly consider probiotics
Type of bowel management aperients:
Contact stimulants help to move faeces through the bowel (peristalsis) e.g., senokot. Bulking agents regulate bowel by increasing water content e.g. metamucilSofteners increase water penetration of stool e.g. coloxyl very good for childrenIso-osmotic laxative e.g. Movicol,Osmotic laxative e.g. lactuloseSuppositories & enemas can stimulate bowel action & lubricate faeces for easier evacuation e.g. microlax, glycerol suppositoriesOther: if above management suggestions are ineffective discuss with stomal therapy to consider peristeen bowel washout system or Malone stoma-bowel washouts

Nutrition

Insert naso/oro gastric tube early to limit risk of vomiting and aspiration as patient will often have paralytic ileus initially. NG placement also allows for enteral feeding to commenceRefer to Dietician early to ensure adequate nutrition, fluid & fibre in the feedsConsider gastric ulcer prophylaxisRe-introduce oral feeding after ensuring ability to swallow and protect airwayGastrostomy may be required 

Thromboprophylaxis

Refer to the Clinical Haematology Department for consideration of thrombotic risk and development of an individualised thromboprophylaxis plan Consider the use of antiembolic stockings or sequential calf compression devices (SCCD) (Link: ://www.rch.org.au/picu_intranet/guidelines/Sequential_Compression_Devices/)

Postural hypotension

Patients with SCI are risk for postural hypotension when moving from supine to sitting upright. This is due to loss of sympathetic autonomic nervous system innervation and include an inability to regulate BP normally with vasoconstriction. Do not attempt to start sitting patient up until medical approval given.
To avoid problems with postural hypotension:

Anti embolic stockings and/or SCCD’s will encourage venous return from the legsAbdominal binders encourage venous return through the IVC
Orthotics can make these to fit
Slowly increase bed angle to sitting position, rather than in one quick move. It may take weeks for the patient to tolerate sitting upright.
Involve physiotherapy team in this process

Joint contractures

Abnormal muscle tone and lack of movement can result in joint contractures. Referrals should be made to Physiotherapy, Occupational Therapy and Orthotics within 1-2 days of admission:

Physiotherapy: for range of movement exercises & positioning patient in good alignmentOrthotics: splints for ankles Occupational Therapy: splints for hands

Autonomic hyperreflexia (Dysreflexia)

Autonomic Dysreflexia is a MEDICAL EMERGENCY that needs immediate recognition and actionUsually it affects those with injuries T6 or higher and generally won’t occur until a few weeks post injury (After spinal shock has subsided).Autonomic dysreflexia is a condition where the autonomic nervous system has an abnormal excessive response to noxious stimuli below the level of the injuryCommon causes of stimuli include full bladder or bowel (ineffective emptying or constipation), pressure sores, tight clothing, fractures, surgery, painSigns & symptoms include:
Hypertension 
Sudden and severe nature which requires immediate recognition and treatmentHypertension may be the only manifestation of dysreflexia.Note: BP for children with a SCI is normally low, so a BP that is in the high end of normal range for age is actually elevated for themBradycardia
Severe pounding headacheSkin rash (flushed, blotchy, transient)Vasodilation above the level of the injury or sweating Vasoconstriction below level of injury: pale, cool skin with, goosebumps and/or piloerection Blurred vision/ pupillary dilationAnxietyNasal congestionNauseaNote: for very young children symptoms may be vague & hard to recognise due to verbal & developmental stages
Manage by: 
Remove noxious stimuli where possible 
loosen clothing, remove compression stockings, abdominal binderperform urinary catheterisation using lignocaine gel, ensure catheter not blocked bowel disimpaction using lignocaine gellook for pressure areas, ingrown toenails, evidence of fracture
Position child sitting upright or with head of bed elevatedMonitor BP & HR 5 minutelyAntihypertensive agents may be prescribed if not responding to above measures within a few minutes, or cause cannot be found

Sexual function

Sexual function can be of great concern to families even in very young children Important topic for adolescents with SCITopic needs to be discussed with family & child in age appropriate manner so that they understand implications for the child’s lifetimePuberty will occur as for other children; for females pregnancy is possible, and for males treatment may be required for erection, ejaculation & fertility

Psychological

A diagnosis of spinal cord injury is often devastating for children and their families. There are frequently preconceptions about spinal cord injury that need addressing and there may also be pre-existing issues for the child or family.

Make appropriate referrals:

Social work Clinical psychology Victorian Paediatric Rehabilitation ServiceLink to support groups or other children with similar injury

Potential complications and management

The following are the most common complications seen for these children. The prevention and management is described above under the relevant headings

Pressure soresAutonomic Hyperreflexia (Dysreflexia)Pneumonia and retained secretionsUrinary tract infectionsConstipationDeep venous thrombosisBone demineralisation/ hypercalcaemiaLatex allergySpasticity – deformities/pain

Family centred care

Incorporate child’s developmental level when planning careThe child who is unable to perform care may be able to direct it enabling a sense of controlEnable family to work with the multi disciplinary care team to develop culturally sensitive careProvide as much information as possible regarding the child’s plan of care for the next few days/weeksInvolve Nursing Care Coordinator early

Special considerations

Referral must be made to the rehabilitation team in the first 24 hoursIf long term mechanical ventilation is required, phrenic nerve/diaphragm pacing may be considered

Companion documents

Medical management of spinal cord injuryAcute traumatic spinal cord injury admission process

Links

Victorian Paediatric Rehabilitation ServiceVictorian spinal cord service (Austin Hospital)The Queensland Spinal Cord Injuries Service: www.health.qld.gov.au/qscis

References

Alexander M, Matthews D (Eds). Pediatric Rehabilitation Principles and Practice 4th Edition. Chapter 11 Spinal Cord InjuriesBrown, A & Carmuciano,K. (2003). Introduction to skin management in SCI. Education handout. Victorian Spinal Cord Service Brown, A & Carmuciano,K. (2003). Introduction to the neurogenic bowel. Education handout. Victorian Spinal Cord Service Brown, A & Carmuciano,K. (2003). Introduction to autonomic dysryflexia. Education handout. Victorian Spinal Cord Service  Brown, A & Carmuciano,K. (2006). Postural hypotension. Education handout. Victorian Spinal Cord Service Burke D, & Murray D. (1992) Handbook of spinal cord medicine. Macmillan. London.Consortium for Spinal Cord Medicine.(2008) Early Acute Management in Adults with Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals. Washington DC. Parayzed Veterens of AmericaEarly acute management in adults with spinal cord injury. A clinical practice guideline for health-care professionals. J spinal Cord Med 2008; 31(4): 408-479. ://www.ncbi.nlm.nih.gov/pmc/articles/PMC2582434/Hickey, J. (2009). The clinical practice of neurological and neurosurgical Nursing. Sixth Edition. Wolter Kluwer/Lippincott Williams & Wilkins. PhiladelphiaFries,J. (2005). Critical rehabilitation of the patient with spinal cord injury. Critical Care Nurse Quarterly. 28(2):179-187.Jones, T; Ugalde, V; Franks, P; Zhou, H; White, R. (2005). Venous Thromboembolism After Spinal Cord Injury: Incidence, Time Course, and Associated Risk Factors in 16,240 Adults and Children. Archives of Physical Medicine and Rehabilitation. 86(12) Dec:2240-2247.Kirshblum S, Burns S, Biering-Sorensen F, Donovan W, Graves D, Jha A, Johansen M, Jones L, Krassioukov A, Mulcahey M, Schmidt-Read M, Waring W. (2011). International standards for Neurological classification of spinal cord injury (Revised 2011). The Journal of Spinal Cord Medicine. 34(6): 535-546The Queensland spinal cord injuries service (2013) Management of autonomic dysreflexia: Information for health professionals. The Queensland spinal cord injuries service (2012) Bowel management following spinal cord injury: Information for health professionalsThe Queensland spinal cord injuries service (2012) Bladder management following spinal cord injury: Information for health professionalsThe Queensland spinal cord injuries service (2013) Management of pressure areas following spinal cord injury: Information for health professionalsVogel, L; Hickey, K; Klaas,S; and Anderson,C. (2004). Unique issues in pediatric spinal cord injury. Orthopaedic Nursing. 23(5):300-308

Evidence table

Spinal Cord Injury (Acute Management) evidence table

 Please remember to read the disclaimer 

The development of this nursing guideline was coordinated by Janine Evans, Rosella - PICU, and approved by the Nursing Clinical Effectiveness Committee. Updated April 2015.  

How do you assess for urinary incontinence?

Here are some tests that may be done to find the type and cause of your urinary incontinence.. Urinalysis and urine culture. ... . Bladder stress test. ... . Pad test. ... . X-rays or ultrasound. ... . Urodynamic testing. ... . Electromyogram (EMG). ... . Cystoscopic exam. ... . Cystourethrogram..

What are 3 things to consider when caring for a person with functional urinary incontinence?

Management and treatment for incontinence. increased fluid intake of up to two litres a day.. high-fibre diet.. pelvic floor exercises.. bladder training.. training in good toilet habits.. medications, such as a short-term course of laxatives to treat constipation.. aids such as incontinence pads..

What is the appropriate nursing care for a patient with urinary incontinence?

Start a prompted toileting program based on the results of this program; toileting frequency may vary from every 1.5 to 2 hours, to every 4 hours. Praise the patient when toileting occurs with prompting. Refrain from any socialization when incontinent episodes occur; change the patient and make her or him comfortable.

How would you manage a patient with urinary incontinence?

Behavioral techniques. Bladder training, to delay urination after you get the urge to go. ... . Double voiding, to help you learn to empty your bladder more completely to avoid overflow incontinence. ... . Scheduled toilet trips, to urinate every two to four hours rather than waiting for the need to go.. Tải thêm tài liệu liên quan đến nội dung bài viết A client has been admitted with incontinence. what should the nurse expect to assess in this client? Factors affecting voiding Ileal conduit Retention catheter

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