Chapter 07: Sci - Medical Complications #1

Front 1

Above what level are SCI patients are risk for orthostatic hypotension & AD?

Back 1

T6

Front 2

Above what level is an SCI patient unable to regulate his/her own BODY TEMPERATURE?

Back 2

T8

Front 3

Sympathetic chain runs from what spinal cord levels?

Back 3

T1-L2

Front 4

What are the 3 symptoms of ORTHOSTATIC HYPOTENSION?

Back 4

1. Hypotension
2. TACHYcardia
3. Syncope

Front 5

Name 3 pharmacologic treatments for ORTHOSTATIC HYPOTENSION

Back 5

1. Na tablets (1g QID)
2. Midodrine (alpha 1 adernergic agonist) 2.5-10mg TID
3. Florinef (mineralocorticoid) 0.05-0.1 mg QD

Front 6

What are the 2 classic symptoms of AUTONOMIC DYSREFLEXIA?

Back 6

1. BRADYcardia
2. HYPERtension

- sweating above level (vasodilitation), flushing below level (vasocontriction), headache, sinus congestion

Front 7

How soon should you expect to see AD if it develops?

Back 7

As early as 2-4 wks postinjury (after recovery from spinal shock)

Front 8

How do you manage AD?

Back 8

1. Sit upright & loosen clothing
2. Check bladder -cath if necessary
3. Meds
4. Fecal disimpaction
5. BP q2-5 minutes, monitor for at least 2 hrs after resolution

Front 9

What medications can you use to manage AD?

Back 9

- Nitropaste 0.5-2 in
- Clonidine 0.3-0.4mg

Prevention: alpha, beta blockers can be used

Front 10

AD prediposes patients to what cardiac abnormality?

Back 10

ATRIAL FIBRILLATION & reentrant-type arrhythmias

Front 11

Loss of which central pathway causes DETRUSOR SPHINCTER DYSSYNERGIA (DSD)?

Back 11

PONTINE mesencephalic nuclei -pontine micturition center

Front 12

Which nerve carries voluntary control of the external sphincter from the cerebral cortex?

Back 12

PUDENDAL (S2-S4)

Front 13

PARASYMPATHETIC control of the detrusor muscles of the bladder is achieved via what nerve roots?

Back 13

S2-S4

Front 14

Alpha-1 or Beta-2 adrenergic receptors?
Stimulation causes contraction muscle around prostatic urethra & base of bladder (urine storage)

Back 14

ALPHA-1

Front 15

Alpha-1 or Beta-2 adrenergic receptors?
Stimulation causes RELAXATION of BLADDER itself

Back 15

BETA-2
"B" for bladder

Front 16

Reflexive voiding (d/t stretch of detrusor muscles) is carried through what type of fibers?

Back 16

A-DELTA (myelinated)

-Stretch is detected by CHOLINERGIC MUSCARINIC receptors in bladder wall - parasympathetic

Front 17

INTERNAL sphincter is controlled by what nerve roots?

Back 17

SYMPATHETIC
T11-L2

Front 18

EXTERNAL sphincter is controlled by what nerve roots?

Back 18

S2-S4 (pudendal nerve)

Front 19

ALPHA-1 adrenergic receptors respond to NE how?

Back 19

CONTRACT
- base of bladder/prostatic urethra - URINE STORAGE

Front 20

BETA-2 adrenergic receptors respond to NE how?

Back 20

RELAX
- bladder wall - URINE STORAGE

Front 21

What 3 things does cystometry measure?

Back 21

1. Sensation
2. Capacity
3. Presence of involuntary detrusor activity

Front 22

What is the accepted normal bladder capacity?

Back 22

300-600 mL

Front 23

An AREFLEXIC bladder will store or leak urine?

Back 23

STORE - this is the case during period of spinal shock
- there is no spinal reflex to trigger urination
- parasympathetic tone goes unchecked (keeps bladder relaxed and sphincters contracted)
- reason for initial indwelling catheter in SCI

Front 24

What 3 things do urodynamic studies study?

Back 24

Function of
1. Bladder Neck
2. External sphincter
3. Detrusor

Front 25

During NORMAL voiding what changes should you see on a urodynamic study?

Back 25

NONE

Front 26

At what volume is the FIRST sensation of bladder filling in a normal bladder?

Back 26

100-200cc

Front 27

During a NORMAL FILLING stage of a urodynamic study what happens to intravesicular pressure?

Back 27

only a SLIGHT increase due to the high viscoelasticity of a normal bladder wall

Front 28

Intermittent cath can reduce the risk of malignancy compared to indwelling catheters in patients that use it for how much long?

Back 28

10 years or more

Front 29

What two things put a patient as greater risk for developing vesicoureteral reflux?

Back 29

- Bladder wall hypertrophy
- loss of vesicoureteral angle (where ureters enter into trigone of bladder obliquely normally)

Front 30

LOWER motor neuron or UPPER motor neuron bladder?
Failure to EMPTY

Back 30

LOWER -flaccid

Front 31

LOWER motor neuron or UPPER motor neuron bladder?
Failure to STORE

Back 31

UPPER -spastic

Front 32

LOWER motor neuron or UPPER motor neuron bladder?
MS

Back 32

UPPER -detrusor hyperreflexia

Front 33

LOWER motor neuron or UPPER motor neuron bladder?
Conus & Cauda equina

Back 33

LOWER

Front 34

LOWER motor neuron or UPPER motor neuron bladder?
lesion AT the SACRAL MICTURITION CENTER

Back 34

LOWER (S2-S4 or lower)

Front 35

LOWER motor neuron or UPPER motor neuron bladder?
Crede maneuver

Back 35

Suprapubic pressure for LOWER MOTOR NEURON (large flaccid bladder)

Front 36

LOWER motor neuron or UPPER motor neuron bladder?
BETHANACOL

Back 36

LOWER
-Stimulates ACh receptors
-Causes contraction of detrusor muscles

Front 37

LOWER motor neuron or UPPER motor neuron bladder?
MINPRESS

Back 37

LOWER
-Blocks ALPHA adrenergics
-Causes relaxation of base of bladder & prostatic urethra

Front 38

LOWER motor neuron or UPPER motor neuron bladder?
HYTRIN

Back 38

LOWER
-Blocks ALPHA adrenergics
-Causes relaxation of base of bladder & prostatic urethra

Front 39

LOWER motor neuron or UPPER motor neuron bladder?
CARDURA

Back 39

LOWER
-Blocks ALPHA adrenergics
-Causes relaxation of base of bladder & prostatic urethra

Front 40

LOWER motor neuron or UPPER motor neuron bladder?
DETROL

Back 40

UPPER
-ANTI-ACh
-Causes relaxation of detrusor muscles

Front 41

LOWER motor neuron or UPPER motor neuron bladder?
DITROPAN

Back 41

UPPER
- relaxes smooth muscle directly

Front 42

LOWER motor neuron or UPPER motor neuron bladder?
PRO-BANTHINE

Back 42

UPPER
-ANTI-ACh
-Causes relaxation of detrusor muscles

Front 43

What % of AIS A patients will progress to AIS D after one year?

Back 43

2-3%

Front 44

In complete tetraplegia, what % of key muscle groups in the zone of partial preservation w/ grade 1 or 2 at one month post-SCI will progress to grade 3 in one year?

Back 44

>95%

Front 45

Most upper limb recovery in complete SCI happens in what time period?

Back 45

first 6 months, greatest rate of change in the first THREE months

Front 46

What % of complete paraplegics eventually achieve community ambulation?

Back 46

only 5%

Front 47

What % of INCOMPLETE tetraplegics recover sufficient motor fxn to ambulate at 1 year?

Back 47

46%

-partial or complete preservation of PINPRICK seems to the best predictor of functional return

Front 48

What is a COMBINATION type bladder?

Back 48

DSD
- D/t injury bewtween sacral (S2-4) & pontine micturition center
- Small, overactive, spastic bladder
- Tight, spastic internal sphincter (hyperactive)
- overall failure to empty

Front 49

How do you treat detrusor sphincter dyssnergia?

Back 49

1. ANTI-ACh meds
- relax detrusor
2. Intermittent cath
3. ANTI-Alpha meds
- relax base of bladder & prostatic urethra
4. Sphincterotomy

Front 50

When is it appropriate to prophylax an SCI patient for UTIs?

Back 50

- before invasive procedure (cystoscopy/urodynamics)
- evidence of vesicoureteral REFLUX
- growth of UREASE producing organisms (proteus, psuedomonas, klebsiella, providentia, E. Coli, epidermidis)

Front 51

What is the particular risk of having a UREA splitting organism causing bacteriuria?

Back 51

They produce STRUVITE CALCULI (ammonium & Mg phosphate)

Front 52

Clean catch sample how many organisms/mL should be present before you initiate treatment?
For catheterization sample?

Back 52

>100,000/mL

>100/mL for cath samples

Front 53

UTI related complications can sometimes be avoided by draining the bladder at pressure below ___cm H2O.

Back 53

below 40 cm H2O

Front 54

Afferent reflex arc is carried by what nerve?
Efferent?

Back 54

afferent - Pudendal

efferent - PSNS fibers from S2-S4 nerve roots

Front 55

Ejaculation is rare with UPPER or LOWER motor neuron lesions?

Back 55

UPPER, especially if COMPLETE

Front 56

Complete or incomplete SCI lesions below what level generally results in poor erection quality/duration

Back 56

T11

Front 57

What parameters need to met in order for vibratory ejaculation to take place?

Back 57

- >6 mos post injury
- L2-S1 must be intact

Front 58

Penile injections of what can aid with erections in SCI patients

Back 58

1. Prostaglandin E1
2. Alpha blockers
3. Vasodilators

Front 59

What % of men with COMPLETE UMN SCI lesions can ejaculate?

Complete LMN?

Back 59

5%

18%

Front 60

How long after SCI does it typically take for menses to return in females?

Back 60

6-12 months

- fertility is not affected once menses returns

Front 61

Why are oral contraceptives probably not a good idea in a woman with an SCI?

Back 61

Increased risk of THROMBOEMBOLISM

Front 62

Innervation of the uterus is from what levels?

Back 62

T10-T12

*Those with lesions above T10 may not be able to perceive contractions

Front 63

Motor or sensory?
Auerbach's plexus

Back 63

aka MYENTERIC = MOTOR

Front 64

Motor or sensory?
Meissner's plexus

Back 64

aka SUBMUCOSAL = SENSORY

Front 65

What nerve carries SYMPATHETIC innervation to the GI system?

Back 65

HYPOGASTRIC

Front 66

What never carries PARSYMPATHETIC innervation to the GI system?

Back 66

- VAGUS
- Pelvic splanchnics (S2-S4)

Front 67

Innervation of the EXTERNAL anal sphincter?

Internal?

Back 67

Pudendal nerve (voluntary)

Internal is under SYMPATHETIC control T11-L2

Front 68

Reflexive stool propulsion (d/t Auerbach's plexus) can still occur in a LOWER motor neuron or UPPER motor neuron lesion?

Back 68

UPPER

Front 69

In a LOWER motor neuron bowel the lesion is below what level?

Back 69

Conus medullaris
- ARRLEXIVE

Front 70

Upper motor neuron or lower motor neuron?
constipation & fecal impaction

Back 70

Upper motor neuron
- d/t decreased fecal movement

Front 71

Upper motor neuron or lower motor neuron?
constipation & incontinence

Back 71

Lower motor neuron
- d/t decreased fecal movement (arreflexive)
- constipation from flaccid external sphincter

Front 72

When should surgical decompression or colonoscopy be considered in regards to colonic distention?

Back 72

If cecum dilated >12cm

Front 73

Name 4 types of medication that can worsen/cause GERD

Back 73

CCB
Benzos
Nitrates
Anti-ACh

Front 74

What is the most common cause of EMERGENCY ABDOMINAL SURGERY in those with SCI?

Back 74

Cholecystitis

*Have 3x higher risk of developing it

Front 75

When does pancreatitis most commonly develop in SCI patients?

Back 75

FIRST MONTH POST INJURY

Front 76

What are some symptoms that would cause you suspect SMA Syndrome as the diagnosis?

Back 76

- Postprandial N&V
- Pain
- Bloating

Front 77

What are some predisposing factors that SCI patients have that make them more prone to developing SMA syndrome?

Back 77

1. Weight loss - loss of fatty padding to insulate 3rd part or duodenum
2. Prolonged period of time in SUPINE position
3. Flaccid abdominal musculature causing hyperEXTENSION
4. Possible spinal orthosis (halo)

Front 78

If you suspect SMA syndrome what test should you order?

Back 78

Upper GI series - demonstrates abrupt duodenal obstruction to barium flow
- angle between SMA & aorta is decreased and clamps duodenum, "nutcracker effect"

Front 79

How do you treat SMA syndrome?

Back 79

1. small freq meals
2. lie in left lateral decubitis position
3. REGLAN - stimulate gastric motility
4. Rarely surgery - duodenojejunostomy

Front 80

What demographic (age/sex) is most likely to develop HYPERCALCEMIA after SCI?

Back 80

Adolescent & young males - tetraplegia>paraplegia

Front 81

If an SCI patient develops hypercalcemia how long after injury does it typically develop?

Back 81

4-8 weeks post injury

Front 82

What are the symptoms of hypercalcemia?

Back 82

"Bones, kindey STONES, psychic overtones"
1. fatigue
2. lethargy
3. dehydration
4. constipation
5. anorexia
6. polydipsia/uria
7. psychosis

Front 83

What must you remember when checking for hypercalcemia via serum levels of calcium?

Back 83

You need to correct for albumin concentration since most of the Ca in blood is protein bound.

Labs usually show Ca level of <10.5 before correction (which is normal).

Front 84

How do you treat post SCI hypercalcemia?

Back 84

- IV normal saline
- early mobilization
- Dietary restriction, limit Vit C
- PAMIDRONATE -inhibits osteoclasts (resorption)
- FUROSEMIDE -increases urinary excretion of Ca
- Calcitonin
- Didronel

*Avoid thiazide diuretics (causes hyperCa)

Front 85

What is the average % bone loss in an SCI patient 3 mos post injury?

Back 85

22% - mostly in bones below the level of injury (osteoporosis)

Front 86

Fractures as a complication of SCI are more common in tetraplegics or paraplegics?

Back 86

PARAplegics -falls during transfers

complete>incomplete

Front 87

What are the most common fxs seen as a complication of SCI?

Back 87

1. Supracondylar femur fx
2. distal tibia
3. proximal tibia
4. femoral shaft
5. femoral neck
6. humerus

Front 88

Usually surgical correction of a fracture after SCI is not pursued except in which cases?

Back 88

1. Significant deformity
2. Vascular supply is in danger
3. femoral neck/subtrochanteric fxs

Front 89

What is the highest level of SCI that is generally able to maintain spontaneous ventilation?

Back 89

C4

Front 90

Injuries above what level have impairment of inspiration/expiration due to LOSS OF ALL ABDOMINAL & INTERCOSTAL muscles?

Back 90

Above C8

Front 91

Injuries at what level cause loss of volitional intercostal muscle activity?

Back 91

T1-T5

Front 92

What is the leading cause of death among CHRONIC SCI patients?

Back 92

PNEUMONIA

Front 93

Among hospitalized SCI patients which side of the body are respiratory complications more frrequent on?

Back 93

LEFT
-main stem bronchus on this side branches off at a more acute angle than on right, harder to suction

Front 94

With SCI lesions ABOVE C3 what is required as treatment initially for all patients? What structure is there particular concern for?

Back 94

all require VENTILATOR SUPPORT initially
- PHRENIC nerve NUCLEUS

Front 95

What does an SCI patient need to have in order to be a candidate for phrenic nerve pacing?

Back 95

- SCI injury above C3
- INTACT phrenic nerve NUCLEUS in context of an UPPER motor neuron lesion
- Need to be able to have the phrenic nerve nucleus send a signal to the diaphragm, can't do this in a LOWER motor neuron injury without an intercostal nerve graft

Front 96

What are 3 contraindications to phrenic nerve pacing?

Back 96

1. Denervated diaphragm
- it's actually better to have an injury HIGHER than C3 if the phrenic nerve nucleus is intact, AT C3 the pathway to the diaphragm is damaged
2. Less than 6 MONTHS post injury
3. Significant lung impairment

Front 97

What are the benefits of a phrenic pacer?

Back 97

1. Lengthens survival in SCI patients
2. Increased daily function
3. Increased arterial oxygenation (although decreased alveolar ventilation)

Front 98

What 3 muscles/muscle groups are responsible for INSPIRATION?

Back 98

1. Diaphragm
2. EXTERNAL intercostals
3. accessory muscles

Front 99

What 2 muscle groups are responsible for EXPIRATION

Back 99

1. INTERNAL intercostals
2. abdominal muscles

Front 100

The pattern of respiratory change in TETRAPLEGICS is restrictive or obstructive?

Back 100

RESTRICTIVE
- ALL VOLUMES SHRINK (except for residual volume)

Front 101

What parameter should you look at to determine whether a TETRAplegic should be on mechanical ventilation?

Back 101

VITAL CAPACITY
- if <1 liter, consider ventilation

Front 102

When can you usually start weaning a TETRAPLEGIC off of the ventilator?

Back 102

Vital capacity is >15-20cc/kg

Front 103

What is EXPIRATORY RESERVE VOLUME?

Back 103

The amount of air you can exhale after a normal exhale (tidal volume)

*you still can't exhale all of the air though, the remaining 15ml/kg is the RESIDUAL VOLUME

Front 104

What is VITAL CAPACITY?

Back 104

The amount of air you can exhale after a MAXIMAL inspiration

*you still can't exhale all of the air though, the remaining 15ml/kg is the RESIDUAL VOLUME

Front 105

What is TOTAL LUNG CAPACITY?

Back 105

The TOTAL amount of air that can be held in the lungs, including the RESIDUAL VOLUME (which cannot be exhaled).

Front 106

What is INSPIRATORY RESERVE VOLUME?

Back 106

The amount of air that can be inhaled beyond the normal amount inhaled with tidal volume.

Front 107

Explain paradoxical breathing

Back 107

Normally diaphragm drops and abdominal wall move OUT when someone inhales.

In SCI diaphragm rises (dennervated) and abdominal wall moves IN when the person inhales.

Front 108

What are ABG cutoffs to initiate mechanical ventilation? Vital capacity cutoff?

Back 108

PO2 <50
PCO2 >50
VC <1 liter

Front 109

Contraindications to using insufflation/exsufflation machine for mechanical cough assist?

Back 109

H/o
- PTX
- Pneumo-mediastinum
- bullous emphysema
- recent barotrauma

Front 110

Why should you only apply suction as you are WITHDRAWING the catheter?

Back 110

Run the risk of increasing vagal tone = cardiac arrest

Front 111

What is the incidence of HO in those with SCI?

Back 111

As high as 53%
- clinically significant HO however is 10-20%

Front 112

What are the most common joints in SCI that develop HO?

Back 112

HIP
KNEE
shoulder
elbow

Front 113

How long does HO typically take to develop after SCI?

Back 113

1-4 months

Front 114

Name 6 risk factors associated with development of HO.

Back 114

1. YOUNGER age
2. Spasticity
3. Trauma/surgery to joint
4. DVT
5. Proximity to pressure ulcer
6. Complete injury

Front 115

Best imaging for EARLY detection of HO?

Back 115

BONE SCAN
- will return to normal at 6-18 mos (maturation)
- Xrays can detect 7-10 days after clinical signs

Front 116

Lab work for HO?

Back 116

Alk phos:
2 weeks - increasing
3 weeks - abnormally high
10 weeks - peak
normal before HO matures
*Not specific, CPK & ESR can also be elevated

Front 117

Treatment for HO?

Back 117

1. Gentle ROM after acute phase
2. DIDRONEL x6 months (20mg/kg/day x3 mos, 10mg/kg/day x3 mos) -20mg/kg/day x6 mos if elevated CPK
3. NSAIDs - INDOCIN SR 75mg/day x6 weeks
4. Surgery - bone only if bone is mature (12-18 mos post injury w/ normal bone scan)

Front 118

DVT is most common after SCI when?

Back 118

first 2 weeks after injury

Front 119

Gold standard for detection of DVT?

Back 119

venogram

Front 120

Leading cause of death in ACUTE SCI patients?

Back 120

PE

Front 121

Increased S2 heart sound with tachycardia in SCI patient, what should you suspect?

Back 121

PE!
- Increased S2 from pulmonary hypertension
- cor pulmonale (right sided heart failure)

Front 122

What findings on EKG are indicative of a PE?

Back 122

- RIGHT AXIS DEVIATION
- RBBB in severe cases

Front 123

What finding on ABG is indicative of a PE?

Back 123

Decrease in PO2

Front 124

Gold standard for detection of PE?

Back 124

pulmonary arteriogram

Front 125

Xray of a PE will show what?

Back 125

Wedge shaped opacity
vascularity

Front 126

Treatment for PE?

Back 126

O2, heparin, vasopressor if in shock

If surgery - embolectomy

Front 127

What two things shoulder you consider before placing SCD's on an SCI patient?

Back 127

1. Did they have SCD's on within 72 hours of their injury? If not, check for DVT first.

2. Do they have arterial insufficiency, if so, SCD's are contraindicated!

Front 128

Dosing for DVT chemoprophylaxis?

Back 128

Lovenox = 40mg SQ Qday
Low dose unfractioned heparin = 5000U SQ Q8-12 hours

*IVC if anticoag contraindicated

Front 129

Duration of DVT chemoprophyaxis for
1. INCOMPLETE
2. COMPLETE

Back 129

1. INcomplete - until discharge
2. Complete
- no other risk factors - 8 weeks
- risk factors - 12 weeks or discharge from rehab

Front 130

Treatment of DVT?

Back 130

5000 U IV bolus Heparin, then infusion of 1000 u/hr before transitioning to Coumadin (x6 months)

*target PTT = 1.5-2x normal
*5-10 days therapy prior to mobilization