Learning Outcome

1. List the causes of spinal shock.
2. Describe the presentation of spinal shock.
3. Summarize the treatment of spinal shock.
4. Recall the nursing management role in spinal shock.

Introduction

Spinal shock is a result of severe spinal cord injury. Spinal shock refers to the muscle weakness and reflex loss seen after spinal cord injury. This "shock" can make the spinal cord appear completely functionless. Loss of reflexes below the lesion, loss of muscle use below the injury, loss of anal sphincter tone, loss of bowel and bladder control, as well as persistent penile erection (priapism) can be seen in spinal shock. Spinal cord injury can be associated with spinal fractures, dislocations, tearing of ligaments, rotational distraction, and tearing of the disc space. If the spinal shock is not associated with significant spinal column injury, the prognosis is more favorable. The overall treatment of patients with significant spinal shock and injury presents a challenge. Aggressive medical management and nursing care can reduce spinal shock effects on the overall functionality of the patient. This chapter review is designed to provide a concise introduction to the care of these patients.[1][2]

Nursing Diagnosis

• Inadequate tissue perfusion
• Inadequate breathing
• Anxiety
• Insufficient knowledge
• Imbalance in body fluids
• Inability to control bowel or bladder
• Immobility

Causes

The primary causes of spinal shock are accidental or intentional spinal cord trauma, with collisions remaining a common cause. The most common area of spinal cord injury is the cervical spine. Primary causes of spinal shock are usually a result of high-impact, direct trauma. Decreased blood flow to the spinal cord can also produce spinal shock; for example, a hypotensive patient in the medical intensive care unit (ICU) or a post-angiography patient with a clot causing occlusion of arteries that supply the spinal cord can have the same presentation. Secondary causes of spinal shock include mechanical cord compression, hypotension, hypoxia, fever, and hyperglycemia.[3] These issues are best treated in the ICU by an interprofessional team and specially trained nurses.

Risk Factors

Men in their 20s are prone to spinal cord injury and clinical diagnosis of spinal shock. According to the Centers for Disease Control fact sheet, among cases of spinal shock, 45% are due to motor vehicle accidents (MVA), 34% are due to domestic accidents such as falls, 15% are due to sporting accidents, and 6% are secondary to self-harm. A similar distribution among causes of spinal cord injury is seen in international data.[4] Intoxication due to alcohol or other drugs plays a significant role in traumatic spinal cord injury, and often the initial neurological exam is not accurate due to intoxication. The cost of care for these patients has spiraled out of control since they require long-term care, which families are often not equipped to provide.

Assessment

Healthcare providers should obtain a detailed history of the accident. Often factors such as a rollover crash, ejection outside the car, or seat belt usage can give significant information on the severity and type of spinal cord injury that should be expected. The presence of intoxication is essential information as it could confuse the physical exam findings on presentation. It is important to understand that the energy necessary to produce a spinal cord injury during a traumatic event is very high, and patients should be thoroughly examined for other tissue and organ injury. A full spinal examination should include a motor and a sensory exam. Motor activity and strength decrease in the skeletal muscles and the internal organs like the bowel and bladder. This decrease leads to constipation and urinary retention. It is of utmost importance to record an ASIA score (American Spinal Injury Association) as prognostic long-term expectations can be made with fair accuracy before discussing with the family and the patient. While evaluating the patient, assume their spine is unstable and take all the necessary precautions to keep it stable until final imaging is obtained and stability is established.

Usually, high spinal cord injuries result in transient spinal shock, with an absence of all spinal reflexes and muscle tone. In the recovery phase of the injury, however, reflexes recover and increase in amplitude, reaching a hyper-reflexive state. Other clinical features likely to be present during the assessment of patients with spinal shock include autonomic dysfunction. This autonomic dysfunction is called neurogenic shock, which is a component of spinal shock. A reduction in sympathetic tone in the blood vessels is noted with spinal shock resulting in a profound drop in blood pressure. The parasympathetic system remains functioning, leading to an unopposed parasympathetic drive which results in notable bradycardia. When the heart rate is slow enough to compromise cardiac output, intravenous atropine or glycopyrronium should be administered.[5]

Evaluation

Patients with spinal cord injury need to be evaluated in a timely fashion to minimize poor outcomes. Preferably, these patients should be evaluated at a level one trauma center due to the extent of injuries. Once the initial evaluation is completed, a complete spinal computed tomogram (CT) should be the initial imaging obtained. Magnetic resonance imaging (MRI) of the spine is very helpful but should not be the initial imaging modality.

Spinal immobilization, airway, breathing, and hemodynamic stability evaluation should be established first. Utilize the basic airway, breathing, circulation approach to the trauma patient for the initial evaluation, ensuring that the spine does not sustain any extra movement. Maintain in-line cervical spine immobilization during the assessment.[6] The current British National Institute for Health and Care Excellence (NICE) guidelines recommend utilizing a cervical collar, a spine board, and head immobilization between a pair of sandbags or foam wedges.[7] 

After this initial assessment, further evaluation is necessary to determine the location of the injury, if possible. A complete neurological assessment should be carried out at this time using the American Spinal Injuries Association (ASIA) grading scale. This is a universal classification tool for spinal cord injuries, which helps determine the sensory and motor level of injury for each side of the body.[8] Motor and sensory loss from an injury can either be complete or incomplete. A complete cord injury will present with motor paralysis and sensory loss below the cord injury level. Complete cord injury often results in spinal and neurogenic shock.[5]

Medical Management

Overview

Spinal shock patients should be treated in an ICU setting, as many complications can arise due to the injury. Neurogenic shock is different than spinal shock and usually occurs with higher injuries (above the T6 level). Neurogenic shock is the loss of sympathetic tone and unopposed parasympathetic signals. The blood vessels have diminished constriction, and bradycardia occurs without sympathetic signals.[3] Generally, fluids and inotropes are the initial treatment. With high cervical injuries, the diaphragmatic function will be compromised, and these patients will usually require early tracheotomy since they will likely be ventilator dependent. Deep vein thrombosis risk is high in these patients. Prophylaxis should be initiated as soon as possible. Approximately 60% of these patients will require spine stabilization with surgical intervention, and neurosurgery or orthopedic professionals should be consulted early. Since the cord is not usually completely destroyed in spinal cord injury, recovery usually occurs, although the duration and degree of recovery vary.[9][10]

Initial Treatment of Spinal Cord Injury

• Circulatory collapse and shock need to be promptly treated. This requires the immediate establishment of large-bore (14-gauge or 16-gauge) IV lines.
• Crystalloid fluid bolus should be started immediately on arrival
• If there is no response to fluid bolus, inotropic therapy will be required.
  • Repetitive fluid boluses in established spinal shock can lead to fluid overload and should not be given.
• Bradycardia is a common feature of spinal shock. For isolated and clinically significant bradycardia, atropine can be used.
• Obtain temperature as patients are frequently hypothermic.[5]

Management of Spinal Shock

• Corticosteroids are administered to decrease tissue edema and ischemia after injury in some cases. 
• Nursing procedures that cause vagal stimulation, such as oral or tracheal suctioning, can exacerbate bradycardia in these patients.
  • Hyperoxygenation with the administration of 100% oxygen for two minutes before the nursing procedure is recommended.
• Temperature regulation and monitoring with invasive devices to obtain accurate core body temperature are essential to managing these patients.
  • Due to autonomic nervous system dysfunction, patients lose the ability to self-regulate body temperature.
• Maintain a urinary catheter due to expected urinary retention.
  • After 72 hours of injury, the indwelling urinary catheter should be discontinued, and intermittent catheterization should be used to minimize the risk of urinary tract infections. 
• Constipation is expected in patients with spinal cord injury. They should be maintained on a laxative bowel regimen to prevent complications of prolonged constipation.
• Maintain a nasogastric tube as patients will require enteral nutrition.
  • In the initial phase of the injury, patients develop paralytic ileus and often require a nasogastric tube capable of suction to decompress the stomach and bowel.
• Frequently assess and treat the presence of pain.
• Occupational and physiotherapy should be started as soon as possible to optimize functional recovery, prevent contractures, and minimize muscle atrophy.[5]

Prevention of Complications

• Patients with spinal injury are at an extremely high risk of developing pressure ulcers as pressure ulcers can occur within hours in immobilized patients.[11]
  • Skincare with protocol-based turning and positioning (log-roll) is recommended in all patients with spinal cord injury and shock.
  • Backboards should be discontinued as soon as possible as they increase the risk of pressure ulcers. 
  • The use of airflow or dynamic alternating mattresses is contraindicated in these patients when spine stabilization has not occurred. A standard mattress or full support mattress is recommended in the initial phase.[5]
• Prevent catheter-associated urinary tract infections and central line-associated bloodstream infections by following sterile techniques for placement of these catheters and protocol-based dressing care. 
• Prevent further injury to the spine with appropriate lifting and handling of the patient. Log-rolling is recommended to maintain alignment of the whole spine.
• Prevention of venous thromboembolism (VTE) is essential in patients with spinal cord injury.
  • VTE and pulmonary embolism can occur within 72 hours of admission in patients with spinal cord injuries who do not receive appropriate prophylaxis.[12] Therefore standard  VTE prophylaxis is indicated in all patients with spinal cord injury.
• All patients with spinal shock should receive gastric stress ulcer prophylaxis for four weeks with a proton-pump inhibitor.[13]

Nursing Management

• Assess hemodynamics
• Assess sensory and motor deficits
• Assess pain
• Provide DVT and gastric ulcer prophylaxis
• Prevent pressure ulcers
• Ensure adequate oxygenation and ventilation
• Educate patient about the disorder
• Elevate the head of the bed to avoid aspiration
• Encourage patient to cough and use the incentive spirometer
• Optimize interventions for neurogenic bowel
• Optimize interventions for neurogenic bladder
• Consult with dietitian regarding nutrition
• Consult with physical therapy for early mobilization
• Provide resources for anticipated grief

When To Seek Help

• Changes in the level of consciousness
• Urinary and/or fecal retention
• Unstable hemodynamics can result from autonomic dysfunction, which may present as: 
  • Bradycardia
  • Hypotension
  • Hypertension
  • Temperature dysregulation
• Fever

Outcome Identification

The outcomes for most patients depend on the severity of neurological deficits present on admission. The prognosis is good for those who respond to initial resuscitation, but those who fail to respond usually have a protracted ICU course and prolonged recovery phase.[3][14]

Monitoring

Monitoring for the following is an essential part of nursing care for patients with spinal shock:

• Blood pressure
• Heart rate
• Temperature
• Urinary output
• Bowel movements
• Skin integrity
• Enteral feed delivery
• Neurologic examination
  • To ensure deficits are not worsening

Coordination of Care

Spinal shock carries very high morbidity. Clinical outcomes are worse if patients do not receive comprehensive care managed by an interprofessional team. An interprofessional team caring for patients with spinal shock should include emergency and trauma teams, neurosurgery, rehabilitation services, as well as anticipatory guidance from case managers, social workers, and spiritual care. The registered nurse plays an important part in the care and education of the patient as well as the family. These patients should be admitted to the ICU and closely monitored. These patients are vulnerable to complications and require deep vein thrombosis (DVT) prophylaxis, pressure sore prevention, bowel, and bladder management, safety maintenance, anticipatory guidance as well as adequate nutrition.[15][16]

Health Teaching and Health Promotion

• Neurogenic bladder
• Neurogenic bowel
• Spinal cord injury
• Accident prevention
• Nutrition
• Skin Care
• Fall precautions

Discharge Planning

• Spinal cord rehabilitation
• Alterations in a private home (ramps, assistive devices)
• Mental health resources
• Assistance with activities of daily living (ADL) 

Evidence-Based Issues

Current guidelines on managing spinal cord injury

1. Immobilization with an appropriate collar
2. Resuscitation and evaluation at a level 1 trauma facility
3. Perform imaging studies 
4. Prevent hypoxemia
5. Prevent hypotension
6. DVT prophylaxis
7. Neurogenic bladder and bowel management
8. Pain management
9. Nutrition management