ABCD: Circulation – Nursing Care for Acute Spinal Cord Injury

00:01 So that's airway and breathing.

00:02 You know what you should assess for, you know the lab test that we would do, know what we are watching for.

00:08 Now, we're gonna go to circulation.

00:10 Now, we're talking about what's moving that oxygenated blood around the patient's body.

00:16 Now, often times, patients with a spinal cord injury have low blood pressure or hypotension.

00:23 The reason it could happen is because the patient might have blood loss coming from other injuries if they are in a trauma or they have this blood pooling because the sympathetic nervous system isn't functioning as effectively.

00:36 Remember the central spinal cord, right, central nervous system -- you got the brain and spinal cord as our central nervous system -- spinal cord is the information highway that brings information from the body to the brain and takes commands from the brain down to the body.

00:55 When you have a spinal cord injury that ain't working so well anymore so that's why you end up with vessels vasodilating and it's hard for the patient to maintain their blood pressure, so your job is to assess perfusion.

01:09 You want to keep an eye out on the patient's heart rate, their blood pressure.

01:12 Look at their capillary refill in their extremities and watch their cardiac rhythm on the monitor.

01:18 So you already know before you go in, somebody with a spinal cord injury you're gonna be watching for problems with their blood pressure likely it could be low but you always have to ask yourself, okay, what are the reasons this could be low? Might be because of the injury but also could be because the patient has blood loss from the other wounds or both; so your job is to keep an eye on the early signs so it would let you know someone with a spinal cord injury is getting into problem in circulation.

01:47 Okay, we just covered a whole lot of information.

01:50 I want you to pause the video for just a moment and think through -- A, B and C, is airway, breathing and circulation.

01:58 Don't look at your notes, see how much you could recall on what you would actually assess as a nurse and monitor in a spinal cord injury patient, in the categories of airway, breathing and circulation? Okay, now I wanna go a little further in circulation.

02:18 If you stopped and did that review, let's lay the last layer on.

02:21 You wanna maintain a systolic blood pressure at least above 85 to 90.

02:27 Now remember, a stroke patient will like to keep that blood pressure up a lot of time.

02:31 This is different. We're gonna tolerate a little bit lower blood pressure -- 90 is gonna be okay.

02:36 Now each health care provider in each situation may give you a little bit different number, this is just a frame of reference for you.

02:44 Also looking at the mean arterial pressure above 85 -- remember, a mean arterial pressure is an average pressure in the entire system.

02:52 So think about vasoactive medications to help us maintain the blood pressure.

02:58 You might have to give them a medication that will help elevate that blood pressure because people with a spinal cord injury are at risk for low blood pressure whether it's due to volume loss or problems with pooling blood not returning back up to the heart.

03:13 Also, you might want to think about IV fluids if the intravascular volume is depleted or they might consider blood replacement.

03:20 So we're thinking about circulation.

03:22 We know why the patient might be in a problem.

03:25 We know our target is we want to keep it at least a 90, 85-90 mmHg for their systolic blood pressure or a mean arterial pressure over 85.

03:36 We might have to hang some IV vasoactive medications to help bring that blood pressure up and we might also replace volume -- give them IV fluids or blood replacement, but be careful; it's really a tricky balance.

03:50 You want them to be hydrated, you want them to be intravascularly volume -- we want that volume to be normal, but we don't want them to be overloaded.

04:00 So, fluid volume management is another important piece of circulation.

04:05 People or patients with multiple injuries often get large amounts of IV fluids for lots of reasons -- we're trying to keep their pressure up, they lost a lot of blood, the quickest thing we could get into them; but that can be a problem because excess fluids can cause further cord swelling and increase damage so you're really walking a very fine line with trying to keep a normal blood pressure and adding volume but not adding too much volume that could cause edema and further damage to that patient's spinal cord, so your job is to be right on top of it.

04:41 Monitor the fluid intake, know how much food that patient is getting in, watch their urine output and their electrolyte levels extremely closely -- this is your job.

04:51 You are the one who's with the patient the most so you're looking at all the orders coming in and all the treatments going to that patient making sure you're right on top of what their I and O is.

05:03 You do not want to wait until the end of the shift, you want to keep watching this on a very frequent basis particularly in the acute phase of the spinal cord injury.

05:12 Okay, now, we've got some more in circulation cuz we're gonna talk about shock, okay? Now shock, whatever the cause is, is not getting enough oxygenated blood to the cells to meet their metabolic needs -- that's shock, right, no matter what the cause is.

05:30 Now the word in front of shock is the cause.

05:33 So we're gonna talk about spinal shock and we're gonna talk about neurogenic shock.

05:38 Let's unpack spinal shock first.

05:40 Okay, this is usually temporary.

05:43 It could last for a hours maybe even up to weeks, okay, so the first thing you want you to know this one should resolve but you're gonna see decrease reflexes, they're not gonna be able to have the same sensation.

05:55 They may not feel things when you touch them, they might have a hard time controlling their body temperature.

06:02 So, as a nurse, you're gonna end up putting blankets on, taking blankets off; putting blankets on, taking blankets off because they have a really hard time with their body temperature if they're in spinal shock.

06:14 Now, lastly, they'll have this flaccid paralysis below the level of injury and flaccid means just there's nothing they can do about moving those.

06:25 So let's focus in on spinal shock -- temporary, hopefully its hours but it could be up to weeks.

06:31 They're gonna have decreased reflexes, loss of sensation, hard time controlling their body temperature and flaccid paralysis below the level of injury.

06:42 Now, neurogenic shock can get a little crazier.

06:46 Usually this is patient who had a cervical or a really high thoracic injury.

06:51 Now you don't want either one of these types of shock but this one can be even more complicated to manage.

06:57 So its high cervical, it's cervical or high thoracic; you're gonna have a loss of vasomotor tone caused by the injury.

07:04 Now when we say loss of vasomotor tone, your vessels -- your arteries and veins constrict when we need to raise your blood pressure, they dilate when we need to lower your blood pressure.

07:15 If someone's lost that vasomotor tone, the spinal cord injury says, now things aren't working the way they're supposed to so that's gonna give us some real problems and usually the cause of shock.

07:27 Watch for low blood pressure and low heart rate.

07:32 Hey, that's a bad combo because you know if I wanna raise your blood pressure, we kinda constrict those vessels and speed up the heart rate -- that's what happens in your sympathetic nervous system, but somebody, in neurogenic shock, that signal pathway is just not working.

07:48 Things aren't getting back and forth between the brain and the spinal cord so that's why you have low blood pressure, hypotension and slow heart rate.

08:00 Remember, sometimes, a heart rate that's slow would be enough to throw you into shock depending on how fragile the patient was.

08:05 Put those two together -- low blood pressure and low heart rate, we've really got a problem.

08:12 You've lost that sympathetic nervous system response, so you end up with this peripheral vasodilation and the venous pooling and you have lower cardiac output -- kiss of death, right? How the sympathetic nervous usually works is it cause everything to constrict and work harder when you need extra volume, but because of the spinal cord injury, your patient is at risk for neurogenic shock.

08:37 So, I'm not a fan of spinal shock, but neurogenic shock can even be a worst-case scenario.