Page 485 - ACCCN's Critical Care Nursing

462 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

abnormalities, specific radiological procedures such as ● Hyperglycaemia is associated with increased inflam-
cervical myelography, high-resolution CT scan or mag- mation and must be controlled to less than 10 mmol/
netic resonance imaging will identify fractures, disloca- Hg, avoiding hypoglycaemia. 84
82
tion of bony fragments, and spinal cord contusion. ● The concept of pain relief and sedation in patients
In patients with a dislocated cervical fracture, decom- with spinal cord injury is based on the maintenance
pression and anatomical bony realignment may be of coupling between metabolism and spinal cord
achieved with traction forces applied manually, or with blood flow while achieving hypnosis, analgesia and a
halo or Gardner–Wells systems under radiological control. ‘relaxed cord’. This concept includes maintenance of
If the anatomical bony alignment procedures and trac- normal to high systemic perfusion pressures, nor-
tion forces fail to decompress the cord, surgical inter- moxia and normocapnia.
vention to remove the lesion is required. The timing ● Psychological and empathetic support is essential and
of surgical intervention remains controversial. While appropriate referral for grieving and stress is para-
urgent surgical decompression or internal stabilisation mount. Rehabilitation counselling and planning starts
should be performed in all patients with deteriorating at the acute stage in order to give the family unit some
neurological status, some centres tend to defer surgical future focus and hope.
treatment in patients with spinal cord injury but stable
neurological deficit. See the Online resources for specific protocols related to
spinal injury.
Concepts of Neuroprotection CEREBROVASCULAR DISORDERS
and Regeneration
Cerebral vascular disorders include cerebrovascular
There have been many negative SCI clinical trials in disease and cerebral vascular accidents (stroke). A stroke
regard to neuroprotection with the exception of methyl- (acute brain injury of vascular origin) may be either isch-
prednisolone within 8 hours after SCI, which has shown aemic or haemorrhagic and is defined as an interruption
77
some beneficial effect. The failure of these neuroprotec- of the blood supply to any part of the brain, resulting in
tive agents has been attributed to the attempt of blocking damaged brain tissue.
only one molecular pathway of a complex range of SCI
molecular mechanisms. However, there has been renewed
interest in regeneration which involves stem cell trans- Stroke
plantation or similar restorative approaches designed to Stroke is the primary cerebrovascular disorder in Australia
optimise spontaneous axonal growth and myelination and New Zealand and is still the third-leading cause of
but is still in its infancy in Australia and NZ due to limit- death. Every year approximately 40,000 people in Austra-
ing legislation in regard to stem cell research. lia are admitted to hospital with a diagnosis of stroke;
approximately 6000 New Zealanders suffer from a stroke
every year and approximately 2000 deaths each year are
Collaborative Management attributable to stroke. 85,86 The prevalence of stroke is
Patients with acute cervical spinal cord injury require ICU higher among men than women (1.4% versus 1.0%).
monitoring, observation and support of ventilation, Almost 60% of people who have had a stroke are aged
a nasogastric tube to reduce abdominal distension 65 years and over, while 18% are under the age of 55
and risk of aspiration, a urinary catheter and thermal years. Indigenous Australians have higher rates of death
maintenance. and illness from heart, stroke and vascular diseases than
other Australians. In 2007–08, death rates were 2.6 times
● Tracheostomy is indicated in high cervical spine injury as high and hospitalisation rates 1.4 times as high as for
and ischaemia, sometimes only while the early other Australians. Stroke is currently the biggest single
85
oedema is resolving. cause of adult disability in Australasia. Strokes can be
● Spinal alignment and immobilisation requires careful divided into two major categories: ischaemic (85%), in
positioning with dedicated neck support by experi- which vascular occlusion and significant hypoperfusion
enced clinicians. occur; and haemorrhagic (15%), in which there is extra-
● Shoulder and lumbar support pillows are often pre- vasation of blood into the brain. Although there are some
scribed. Pressure-relief mattresses must be suitably similarities between the two broad types of stroke, the
designed for spine immobilisation and when pre- aetiology, pathophysiology, medical management, surgi-
scribed can be tilted to facilitate ventilation. cal management and nursing care differ.
● Meticulous integument and bowel care are indicated
with daily protocols for regular stool softeners and
peristaltic stimulants essential for the prevention Aetiology
of autonomic dysreflexia and autonomic nerve Hypertension is the leading risk factor for stroke. Other
dysfunction. risk factors include diabetes, cardiac disease, previous
● Early nutritious feeding is essential, whether oral or cerebrovascular disease (transient ischaemic attack
enteric; however, aspiration must be prevented. The or stroke or myocardial infarction), age, sex, lipid disor-
supplementation of feeding with high-energy protein ders, excessive ethanol ingestion, elevated hematocrit,
fluids to match the catabolic state assists with recovery elevated fibrinogen and cigarette smoking. Cerebral arte-
(see Chapter 19). riosclerosis predisposes indiuiduals to both ischaemic