Prevention and management of early complications of spinal cord injury
There are many complications of spinal cord injury, mainly including: the motor system, respiratory system, cardiovascular system, pressure sores and urinary system in five aspects.
I. Complications of the locomotor system
The most common complication of the locomotor system is joint contracture. Since the spinal cord injury has to be bedridden for a considerable period of time, if no attention is paid to the training of joint movement, severe joint contracture may occur, which affects the ability to take care of oneself afterwards.
Therefore, the following issues should be noted to avoid joint contracture: pay attention to active/passive joint activities during bed rest, at least five times a day for the whole range of active/passive joint activities; pay attention to body position, lying down should pay attention to shoulder joint abduction and elbow joint extension, apply splint or posture pad to keep the joint in functional position, pay special attention to wrist and ankle joints; for joint contracture that affects life, surgical treatment can be considered.
II. Respiratory complications
Respiratory complications are common complications of early spinal cord injury. What are the mechanisms, clinical manifestations and treatment measures?
1.The mechanism of respiratory complications of spinal cord injury
The most important respiratory complications related to spinal cord injury are pulmonary infection, pulmonary atelectasis and respiratory failure. The respiratory complications are related to the loss of innervation of the respiratory muscles after spinal cord injury. The primary respiratory muscles include the intercostal muscles and diaphragm, and the secondary respiratory muscles include the abdominal and cervical muscles.
The loss of innervation of respiratory muscles after spinal cord injury causes serious impairment of respiratory function, and also causes obstruction of sputum or obstruction of the respiratory tract because the patient’s ability to cough up sputum in bed is affected, and spinal cord injury can also be accompanied by joint injury to the chest and abdomen or severe abdominal distension, which all lead to respiratory complications in patients with spinal cord injury.
2, the impact of spinal cord injury level on respiratory function
According to the spinal cord anatomy, the nerves innervating the respiratory muscles are normal when the spinal cord is injured below thoracic 12, so the respiratory muscles function normally; while in cervical spinal cord injury, the intercostal muscles and abdominal muscles are completely paralyzed, while the nerves mainly innervating the diaphragm mainly originate from the cervical 3-5 segment, so the function of the diaphragm can be partially preserved in spinal cord injury at the level of cervical 4 and below; all respiratory muscle functions are lost in spinal cord injury at the level of cervical 4 or above, and artificial ventilation.
3, the clinical manifestations of respiratory complications of spinal cord injury
Pulmonary complications of spinal cord injury patients mainly include shortness of breath, increased pulse rate, significant anxiety, increased body temperature, changes in respiratory rate, increased volume and viscosity of secretions, decreased lung capacity, etc.
4.Prevention and treatment of respiratory complications of spinal cord injury
Prevention of pulmonary complications is more important than treatment. While the patient is bedridden, encourage active respiratory function training; regularly turn, pat the back, and assist in sputum removal by placing both hands on the lower edge of the rib arch and pushing the thorax backward and upward during coughing (attention should be paid to combined rib fractures), and when combined with respiratory obstruction it is best to jointly apply postural drainage. For the management of pulmonary atelectasis, the early stage can be used to assist in sputum removal and regular turning and patting of the back; if pulmonary atelectasis still cannot be improved, the application of fiberoptic bronchoscopy can be considered to release pulmonary atelectasis. At the same time, early and reasonable application of antibiotics should be emphasized to control pulmonary infections; for patients with spinal cord injury in the upper cervical segment, viscous sputum and combined with serious pulmonary complications, early tracheotomy is of great significance.
Third, the cardiovascular system complications
What countermeasures should be used to deal with the cardiovascular system complications in the early stage of spinal cord injury: low heart rate, postural hypotension, and autonomic hyperreflexia? How to prevent and treat deep vein thrombosis in patients with spinal cord injury? The cardiovascular complications associated with spinal cord injury include: low heart rate, postural hypotension, and autonomic hyperreflexia. Their occurrence is related to sympathetic and parasympathetic dysfunctions after spinal cord injury.
1.Mechanism and treatment of low heart rate
Low heart rate: The sympathetic nerves innervating the heart originate from T1-4 spinal cord segments. spinal cord injury above T6 affects the sympathetic nerves innervating the heart, but the vagus nerve function is normal, so it is easy to have a low heart rate after spinal cord injury. Atropine may be used if the heart rate is below 50 beats/min; if it is still below 40 beats/min consider a temporary pacemaker. It is important to emphasize that any stimulation of the vagus nerve can cause changes in the cardiovascular system, and severe cardiac arrest can occur, such as endotracheal stimulation (aspiration) may cause cardiac arrest, and atropine can be applied prophylactically if necessary. Generally, this condition will resolve on its own 2-3 weeks after spinal cord injury.
2.The mechanism of postural hypotension and its treatment
Sympathetic nerve imbalance after spinal cord injury, peripheral and venous vasodilatation, reduction of cardiac return blood volume caused. Postural hypotension can be judged when the systolic blood pressure drops more than 20 mmHg and/or the diastolic blood pressure drops more than 10 mmHg after changing from a lying position to an upright position. Patients may experience dizziness, nausea, sweating and other symptoms. Treatment: apply elastic bandage, girth to increase the amount of blood return and perform postural exercises; apply blood pressure-raising drugs (dobutamine) if necessary. Generally speaking, it can be relieved by itself 2-6 weeks after the injury.
3.Autonomic hyperreflexia mechanism and treatment
Autonomic hyperreflexia is also a frequent problem in the rehabilitation after spinal cord injury. The mechanism is: visceral filling under the plane of injury stimulates sympathetic nerves causing neurotransmitter release resulting in increased blood pressure; parasympathetic nerves (vagus nerve) reflex excitation, but the impulses caused by it is difficult to conduct through the injured spinal cord to the plane of injury below, can not counteract the increase in blood pressure, but cause bradycardia, vasodilation above the plane of injury (headache, skin redness) and a lot of sweating.
Common causes of autonomic hyperreflexia include bladder dilatation, urinary tract infection, cystoscopy and urodynamics, dystocia, epididymitis or scrotal compression, rectal dilatation, stones, acute surgical abdomen, hemorrhoids, DVT and PE, pressure sores, skin breaks or fractures, insect bites, clothing snags, heterotopic ossification, and pain.
Treatment procedure: Ask the patient to sit up quickly, loosen any clothing or instrumentation that may cause a snag, check blood pressure pulse every 2-3 minutes; check for anything that may cause vegetative hyperreflexia, starting with the urinary system.
If there is no urinary catheter, insert and retain a urinary catheter for the patient quickly; if there is a urinary catheter, check whether it is patent; if the blood pressure is still high, rectal problems should be considered, and if necessary, apply a glycerin enema to defecate; the patient can be given oral anti-hypertensive drugs with rapid onset and short duration of action, commonly used nifedipine, 10 mg, orally, sublingual is not recommended; if the patient’s symptoms are not significantly relieved after the above treatment, he should be sent to The patient should be sent to the monitoring room to apply drugs to control blood pressure and continue to look for other possible causes.
4. Management of deep vein thrombosis (DVT)
The incidence of DVT is very high in patients with spinal cord injury. If no preventive measures are taken, 40% of spinal cord injury patients will develop DVT formation; even if measures are taken, 15% of acute spinal cord injury patients still have DVT and 5% of acute spinal cord injury patients have pulmonary embolism clinically. the peak of DVT is 7-10 days after spinal cord injury.
1.The treatment of DVT
The treatment of DVT also emphasizes prevention over treatment.
(1) Mechanical prevention
Start as early as possible after injury; commonly used methods are elastic stockings and extracorporeal pneumatic compression devices; DVT is less likely to occur within 72 hours of injury, and mechanical methods can be applied alone, while combined application of mechanical and pharmacological methods of anticoagulation is recommended after 72 hours of injury.
(2) Drug method
Active bleeding should be excluded before use; start 72 hours after injury; commonly used subcutaneous injection of low-molecular heparin; last 8-12 weeks; for those who need surgical treatment, stop using low-molecular heparin on the day of surgery, while mechanical anticoagulation method can be continuously applied.
2.Diagnosis of DVT
Patients presenting with DVT show unilateral lower limb swelling, erythema, lower limb pain, pressure, heaviness, sudden onset of dyspnea, chest pain, hypoxemia, tachycardia, and unexplained fever. the most important method of DVT diagnosis is ultrasound and/or lung perfusion scan examination. Venography, pulmonary spiral CT and/or pulmonary angiography are performed for those with significant clinical symptoms but negative results on these tests. Among them, venography is known as the gold standard for the diagnosis of DVT.
3.Treatment of DVT and PE
Combined heparin and vitamin K antagonist (warfarin) anticoagulation therapy should be applied when the diagnosis is clear; adjust the dosage of warfarin according to INR and stop heparin after INR>2.0 and last 24 hours; vitamin K antagonist should be taken for at least 3 months and maintain INR between 2-3 during the period of taking the drug; for those who have contraindication to anticoagulation, inferior vena cava filter placement can be considered.
IV. Pressure sores
1. Grading of pressure sores
Pressure ulcers are localized skin necrosis that occurs or is occurring due to impaired blood flow. With improper care, 80% of spinal cord injury patients have pressure sores of varying degrees; 30% of spinal cord injury patients have pressure sores in more than one area. Pressure sores are graded as follows: degree I: involving the epidermis and dermis, with localized redness that does not subside; degree II: involving the subcutaneous tissue, with localized breakage, blistering or skin collapse; degree III: involving the whole skin layer and muscle layer, with deep crater-like changes and involvement of surrounding tissues; degree IV: involving bone and joint structures, with destruction of surrounding tissues and possible formation of sinus tracts.
2. Risk factors for pressure sores
The risk factors for pressure sores are as follows: limited movement of the limb after spinal cord injury; improper care of the second stool leads to moist skin and aggravates the injury; loss of sensory impairment below the level of injury, resulting in loss of the body’s protective mechanism; improper treatment of minor trauma can rapidly aggravate the skin injury; spasm of the limb or abrasion of the skin during movement, causing injury.
3. Common sites of pressure sores
The common sites of pressure sores are the sacrococcygeal, sciatic tuberosity, greater trochanter and heel bone.
4. Prevention and treatment of pressure sores
Ninety-five percent of pressure sores can be avoided, and keeping the skin healthy is the key to preventing pressure sores. Prevention and treatment are equally important. Prevention and treatment of pressure sores: check the skin once in the morning and once in the evening during bed rest, especially the bony protrusions; change positions every 2 hours; use anti-decubitus pads; keep the skin dry and clean; use electric wheelchairs to decompress those above neck 4; decompress those at neck 5 and 6 levels with left and right lateral decompression; decompress those at neck 7 and below levels with manual support. Severe pressure sores can be healed as soon as possible by surgical transfer of skin flaps.
5.Urological complications
(1) Urinary system changes after spinal cord injury
3.5% of deaths in spinal cord injury patients are caused by urinary complications; another 5.2% of deaths in spinal cord injury patients are related to urinary diseases; the chance of death from urinary diseases in spinal cord injury patients is 10.9 times higher compared with the general population.
Urological changes after spinal cord injury: kidney and ureteral function remain normal after spinal cord injury; dysfunction of forceps and sphincter due to loss of innervation; patients with spinal cord injury cannot feel the urge to urinate and cannot urinate on their own. The urinary system changes after spinal cord injury are manifested as: hyperreflexia of the detrusor muscle (occurring in injuries above the sacral medulla, manifested as involuntary urination, high residual urine volume, and synergistic dysfunction of the detrusor extensor muscle) and absence of reflexes of the detrusor muscle (occurring in spinal cord conus or sacral nerve root injuries, manifested as bladder inability to contract and filling incontinence).
(2) Management of bladder function after spinal cord injury
There are four methods of bladder function management after spinal cord injury: indwelling urinary catheter, intermittent catheterization, external urinary collector, and suprapubic cystostomy. The purpose of treatment is to store urine at low pressure, urinate at low pressure, avoid urinary tract infection, and protect the function of the upper urinary tract.
1.Indications for the application of indwelling urinary catheter
Indications for indwelling urinary catheter application: high volume of infusion in patients in the acute stage; impaired consciousness; high pressure of the forced urinary muscle; temporary treatment of ureteral reflux; dysfunction of the patient’s hands, which prevents intermittent catheterization; other conditions in which intermittent catheterization is not available.
Indications for suprapubic fistula application
Indications for suprapubic fistula application: abnormal urethral structure; repeated ureteral obstruction; difficult ureteral insertion; perineal skin breakdown; prostatitis, urethritis, testicular/epidididymitis in male patients; other psychological problems.
Indications for intermittent catheterization
Indications for intermittent catheterization: Intermittent catheterization should be performed as soon as possible as long as the patient has normal hand function or the nursing staff is available for catheterization.
Intermittent catheterization should be avoided in the following cases: abnormal urethral structure; bladder neck obstruction; bladder volume <200 ml; unconsciousness or inability to comply due to psychological factors; time to keep catheterization; high fluid input; bladder filling can cause more serious autonomic overreflexes.
(3) Urinary tract infection and management
Improper treatment after spinal cord injury can also cause urinary tract infections. Early symptoms include: more sediment in the urine and muddy urine; obvious odor in the urine; and hematuria.
Treatment principles: drink more water; increase the frequency of catheterization; prohibit drinking coffee and other stimulating drinks. Once symptoms such as fever, chills, nausea, headache, increased cramps, abnormal pain or burning sensation, autonomic hyperreflexia, and urine routine suggesting increased white blood cells, the patient should be considered to have urinary tract infection and should be treated with antibiotics. The patient should be treated with antibiotics and the dosage should be adjusted according to the results of the drug sensitivity test; at the same time, urination should be kept open, and if necessary, a urinary catheter should be left in place, and as much water as possible should be drunk on the basis of open urination.