Care for a patient with spinal cord injury
In the acute stages of the patient's development of paralysis of the muscles of the lower extremities (paraplegia), the prevention of secondary damage to the urinary tract is of paramount importance. Due to the areflexia of the bladder with urinary retention, the patient does not feel its filling. This can lead to damage to the muscular membrane (m. detrusor) of the bladder due to its overgrowth. To prevent this complication, urologists perform drainage of the bladder, thereby preventing the occurrence of urinary tract infections. This is best achieved by periodic catheterization of the bladder performed by qualified personnel. Alternative methods are long-term drainage of the bladder using a closed system or suprapubital (suprapubital) drainage. But this may be due to a fairly high frequency of infectious complications for a patient with paralysis.
Patients with acute lesions, especially those that cause spinal shock, often need special cardiovascular therapy in connection with attacks of high and low blood pressure (hypertension or hypotension). At the same time, they need to administer solutions to correct deviations in the volume of circulating blood. Potential medical emergencies in patients with complete transverse spinal lesions are stress ulcers of the intestine and stomach. In such situations, in the presence of gastrointestinal ulcers, therapy with cimetidine and ranitidine is effective.
Lesions of the spinal cord at a high cervical level cause the mechanical respiratory failure of varying severity due to impaired functioning of the intercostal muscles and the diaphragm. Such respiratory failure requires artificial ventilation and rehabilitation of the bronchopulmonary tract. In case of incomplete respiratory failure with indicators of forced vital capacity of the lungs of 10-20 ml/kg, it is advisable to prescribe physiotherapy (inhalation) and chest massage.
To prevent atelectasis of the lungs and fatigue, especially when a massive lesion is located below the C5 level of the spinal cord segment, a negative pressure corset can be used. In severe respiratory failure, intubation of the trachea (in case of instability of the spine, performed with an endoscope), followed by tracheostomy, ensures the availability of the trachea for ventilation and sputum suction. A promising new method is the electrical stimulation of the diaphragmatic nerve in patients with localization of the pathological process at the C5 level or higher.
As the clinical picture stabilizes, it is necessary to pay attention to the psychological state of the patient and develop a plan for his rehabilitation. A vigorous rehabilitation program often gives good results in young and middle-aged patients and makes it possible for them to return home to continue their normal lifestyle.
Some procedures for patients with paralysis of the lower extremities can be performed by the patients themselves with the help of others.
Serious problems associated with prolonged immobility of the patient create prerequisites for the occurrence of pulmonary embolism:
- violation of the integrity of the skin over the areas of compression
- urological sepsis
- vegetative instability
The patient needs to change the position of the body frequently (every 3 hours), use skin applications of emollients, and soft bed covering, the anti-bedsore mattress. Functional beds of special design facilitate the rotation of the patient's body and more uniform distribution of body weight, reducing the load on the bone protrusions.
With the preservation of the sacral segments of the spinal cord, the patient can achieve automatic emptying of the bladder. At first, patients urinate reflexively in the intervals between catheterizations, and later learn to provoke urination using various techniques. If the presence of a residual volume of urine can lead to infection of the bladder, then urological procedures or the installation of a permanent catheter are necessary.
Most patients with paralysis need to monitor bowel function and ensure that the bowel is emptied at least twice a week to prevent sprains and bowel obstruction.
Severe hypertension and bradykinesia occur in response to negative surface stimuli, distension of the bladder or bowel, or surgical manipulation, especially in patients with damage to the cervical or upper thoracic segments of the spinal cord. Hypertension may be accompanied by severe redness and profuse sweating in areas above the lesion level. The mechanism of these autonomic disorders is not clear enough. In this regard, the appointment of antihypertensive agents is required, especially during surgical operations, but it is not recommended to use beta-blockers. In some patients with spinal cord injury, acute bradycardia occurs as a result of tracheal sanitation during sputum aspiration. This can be avoided by administering small doses of atropine.
A formidable complication in the early period is a pulmonary embolism against the background of immobilization. Pulmonary embolism in patients with paralysis is noted in about 30% of cases after acute spinal cord injury.
For detailed information on physiotherapy, rehabilitation, and the technique of using orthopedic devices for severe spinal cord diseases, please contact the patient's attending physician (neurosurgeon, urologist, rehabilitologist, therapist). Orthopedic stabilization of the spine in spinal trauma is carried out exclusively for clinical indications.