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 spinal cord impairment below the level of injury, including paralysis, loss of reflexes, anal sphincter tone, bowel and bladder control, as well as persistent penile erection (priapism) that can occur following a spinal cord trauma. 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 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 cause of spinal shock is accidental high-impact, direct spinal cord trauma, with motor vehicle collisions causing half of all spinal cord injuries. The most commonly involved area of spinal cord injury is the cervical spine. Decreased blood flow to the spinal cord can also produce spinal shock. For instance, a hypotensive patient in the medical intensive care unit (ICU) or a postangiography patient with an occlusion of the spinal cord arteries 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 ages 20 to 29 years 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 collisions, 34% are due to domestic injuries such as falls, 15% are due to sporting injuries, and 6% are secondary to self-harm injuries. 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; often, the initial neurological exam is not accurate due to intoxication. The cost of care for these patients is extraordinarily high since they require long-term care, which most families can not afford.

Assessment

Healthcare practitioners should obtain a detailed history of the accident as factors such as a rollover crash, ejection outside the car, or seat belt usage can give significant information on the severity and nature of spinal cord injury. The presence of intoxication is essential information as it may confuse the physical exam findings on presentation. Because the energy necessary to produce a spinal cord injury during a traumatic event is very high, patients should be thoroughly examined for other tissue and organ injuries. A complete spinal examination should include a motor and a sensory exam, with findings including decreased motor activity, muscle strength, and organ dysfunction (eg, constipation and urinary retention) being common findings with spinal shock. Recording an American Spinal Injury Association (ASIA) score is essential for prognosis; long-term expectations can be made relatively accurately before discussing with the family and the patient. While evaluating the patient, clinicians should assume spinal instability, taking all necessary precautions to keep the spine 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 assessed in a timely fashion to minimize poor outcomes. Preferably, these patients should be evaluated at a level 1 trauma center due to the extent of injuries. Spinal immobilization, airway, breathing, and hemodynamic stability evaluation should be established first. Clinicians should utilize the basic airway, breathing, and circulation approach to the trauma patient for the initial review. In-line cervical spine immobilization should be maintained during the assessment, ensuring the spine does not sustain extra movement.[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 sandbags or foam wedges to prevent unintentional movement.[7] 

After this initial assessment, further evaluation is necessary to determine the location of the injury, if possible. A complete neurological examination should be carried out 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] 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 may be helpful but should not be the initial imaging modality.

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 spinal column injuries (ie, 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 used for 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; therefore, prophylaxis should be initiated immediately. Because approximately 60% of these patients will require spine stabilization with surgical intervention, neurosurgery or orthopedic clinicians 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

• Promptly treat circulatory collapse and shock; immediately establish large-bore (ie, 14-gauge or 16-gauge) IV lines.
• Immediately start a crystalloid fluid bolus upon the patient's arrival.
• If there is no response to fluid bolus, inotropic therapy is required; however, repetitive fluid boluses should not be given in established spinal shock as this may lead to fluid overload.
• Use atropine for isolated and clinically significant bradycardia, which is a common feature of spinal shock.
• Monitor the patient's 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 (ie, oral or tracheal suctioning) can exacerbate bradycardia in these patients; therefore, hyperoxygenation with the administration of 100% oxygen for 2 minutes before nursing procedures is recommended.
• Due to autonomic nervous system dysfunction, patients with spinal cord injuries may lose the ability to self-regulate body temperature; therefore, temperature regulation and monitoring with invasive devices to obtain accurate core body temperature are essential.
• Due to expected urinary retention, a urinary catheter should be maintained and discontinued after 72 hours of injury. Intermittent catheterization should be used to minimize the risk of urinary tract infections. 
• Constipation is common in patients with spinal cord injury; to prevent complications, patients with spinal shock should be maintained on a laxative bowel regimen.
• Patients with spinal shock will require enteral nutrition; therefore, a nasogastric tube capable of suction should be maintained because, in the initial phase of the injury, patients often develop paralytic ileus requiring suctioning to decompress the stomach and bowel.
• Patients should be frequently assessed and treated for 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, which can occur within hours in immobilized patients.[11]
  • Skincare with protocol-based turning and positioning (ie, 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. Initially, a standard mattress or full-support mattress is recommended.[5]
• Prevent catheter-associated urinary tract infections and central line-associated bloodstream infections by following sterile placement techniques 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 the alignment of the whole spine.
• Standard venous thromboembolism (VTE) prophylaxis is indicated in all patients with spinal cord injury because VTE and pulmonary embolism can occur within 72 hours of admission in these patients who do not receive appropriate prophylaxis.[12]
• 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 the patient's pain.
• Provide DVT and gastric ulcer prophylaxis.
• Prevent pressure ulcers.
• Ensure adequate oxygenation and ventilation.
• Educate the patient about the disorder.
• Elevate the head of the bed to avoid aspiration.
• Encourage the patient to cough and use the incentive spirometer.
• Optimize interventions for neurogenic bowel and bladder.
• Consult with a 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 fecal retention
• Unstable hemodynamics resulting 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, and rehabilitation services, as well as anticipatory guidance from case managers, social workers, and spiritual care. The registered nurse is important in the care and education of the patient and 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, and 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 (eg, ramps, assistive devices)
• Mental health resources
• Assistance with activities of daily living (eg, ADL) 

Evidence-Based Issues

Current guidelines on managing spinal cord injury:

1. Immobilize with an appropriate collar.
2. Resuscitate and evaluate at a level 1 trauma facility.
3. Perform imaging studies.
4. Prevent hypoxemia and hypotension.
5. Perform DVT prophylaxis.
6. Perform neurogenic bladder and bowel management.
7. Initiate pain management.
8. Implement nutrition management.