脊髓损伤SCI课件

脊髓损伤（SCI）1编辑版pptLeadingcauses&Locationof

SpinalcordinjuryMotorvehicleaccidents(47%)Falls(21%)Sports(14%)Actofviolence(14%)LocationofSCI:cervical(53%),thoracic(35%),lumbarandsacral(10%)2编辑版pptPatternsofspinalcordinjuryCompletesyndromesNomotororsensoryfunctionIncompletesyndromesBrown-SequardSyndromeCentralCordSyndromeAnteriorCordSyndrome3编辑版pptEffectscont.Cervical:AboveC4:VentillatorC5-C7:Littlehand/armcontrolThoracic:Paraplegic:wrist/handokT1-T8:PoortorsocontrolT9-T12:Bettertorsocontrol4编辑版pptAutonomicdysreflexiaSpinalcordlesionaboveT6Hypertensionandincreasedsympatheticoutflow,flushing,sweatingabovedermatomeduringincreasedvisceralinput(bladderover-distension,urination,rectaldistension,surgery,UTI)RiskofheartfailureandstrokeBladderneckcontractionduringvoiding5编辑版pptCardiovascularComplicationsinSpinalCordInjury6编辑版pptSpinalcordinjurycanresultinsignificantcompromiseofcardiovascularcontrol

duetoanimpairedautonomicnervoussystem

andskeletalmuscleparalysis7编辑版pptAcuteCardiovascularComplicationsfromtheNSCID20058编辑版pptChronicCardiovascularComplicationsfromtheNSCID20059编辑版pptSpinalCordandAutonomicNervousSystemAnatomy10编辑版pptCardiovascularAnatomy11编辑版pptEvolutionofthecontrolofthecardiovascularsystemCourseofEventsImmediatelyafterSCIoccurs,bloodpressurerisesduetoreleaseofnorepinephrinefromtheadrenalglandsandbyapressorresponsefrommechanicaldisruptionofvasoactiveneuronsandtractsinthespinalcord.Thisisfollowedbyaperiodofspinalshock(decreasedcorticalspinalandsympatheticactivityandunopposedvagaltone).

Overtimereflexesandspasticity

returnduetocompensatorychangesoccurinthevascularbeds,skeletalmuscle,andrennin-angiotensinaldosteronesystem.12编辑版pptShort-andlong-termconsequences.HypotensionCardiacarrhythmiasAutonomicdysreflexiaPoikylothermiaDeepveinthrombosisCoronaryheartdiseaseExerciseresponse13编辑版ppt

Hypotension

DecreasedcompensatoryvasoconstrictionVenouspooling(skeletalmuscleandsplanchnicregions),venouspoolingintheextravasculartissueslowerextremities(legswelling)reducedvenousbloodreturnresultinginreducedstrokevolume,andbloodpressure.Hypotension,andespeciallyorthostasis,usuallyimproveswithindaystoweeksascompensatorychangesoccurinthevascularbeds,skeletalmuscle,andrennin-angiotensinaldosteronesystem.14编辑版pptHypotensionManagementLegelevation,AbdBinder,Acewraps,TedHose,TiltinspaceW/C,Tilttable,EasystandSalttablets.Pseudoephedrine(ActifedandPseudofed)Fludrocortisone(Florinef)Midodrine(ProAmitine)Desmopressin(DDAVP)ErythropoietinOctreotide15编辑版ppt

Cardiacarrhythmias

TheANSmodulatescardiacelectrophysiologyandautonomicdysfunctioncanleadtoventriculararrhythmias.BradycardiaTachycardia16编辑版pptBradycardiaUnopposedVagalStimulationseenwithSCIaboveT117编辑版pptBradycardia100%ofpatientswithmotorcompletecervicalinjuriesdevelopbradycardia,68%arehypotensive,35%requirepressors16%haveprimarycardiacarrest.35-71%developbradycardiawithmotorincompletecervicalinjuriesandfewhavehypotensionorrequirepressors.Patientsinthisgrouprarelyhaveprimarycardiacarrest.13-35%havebradycardiawiththoracolumbarinjuries.Thisproblemusuallyresolvesoverthefirst2-6weeksafterSCI.

18编辑版pptBradycardia

duetounopposedvagalstimulation19编辑版pptBradycardiaItisoftenprecipitatedbytrachealorrectalstimulation(eg,duringsuctioningorbowelprogram)andhypoxia.Atropinemaybeneeded,andtemporary(sometimespermanent)cardiacpacemakershavebeenused.Thisproblemusuallyresolvesoverthefirst2-6weeksafterSCI.20编辑版pptTachycardiaPSVTSinusetachycardiaAtrialFlutterAtrialFibrillation21编辑版ppt

Autonomicdysreflexia

DuetolossofsupraspinalcontrolofhyperreflexicSympatheticNervousSystemactivity,causedbynoxiousstimulibelowthelevelofinjuryinindividualswithSCI.Thiscanleadtodangerouslyhighbloodpressuresthatcanresultincerebralhemorrhage.22编辑版pptAutonomicDysreflexia

Autonomicdysreflexia(AD)istheimbalanceofexcessivereflexsympatheticdischargeoccurringinpatientswithspinalcordinjury(SCI)abovethesplanchnicsympatheticoutflow(T5-T6)duetonociceptiveinput..23编辑版pptSignsandSymptomsofADHeadacheNasalstuffynessFacialflushIncreasedspasticityElevatedbloodpressureSeizureStroke24编辑版pptTreatmentofADSitupChecktheBloodPressureApplyNitropasteSeekoutthecause90%ofthetimeitisrelatedtothebladdersoreplacethefoleyBowel,skin,fracture,DVT,Infection,ingrowntoenail,legbagstrap25编辑版pptPoikylothermiaPoikylothermia:PatientswithlesionsaboveT6arepoikilothermicandcannotregulatetheirbodytemperature.ThelackofvasoconstrictorsandabilityshiftbloodflowtowarmorcoolthebodyTheinabilitytosweatbelowthelevelofthelesion.26编辑版pptTreatmentofPoikylothermiaAvoidexcessivewarmorcoolenvironmentsDressappropriatelyAddorremoveblanketsWearahatifitiscoolWaterspraybottleifitiswarmIntravenousfluidsshouldbewarmed.27编辑版pptDeepveinthrombosis(DVT)Overallincidencewithoutprophylaxisisestimatedtobe40%basedonmeta-analysisofDVTinpatientswithacuteSCI.PowellM,KirshblumS,O'ConnorKC.ArchPhysMedRehabil.1999Sep;80(9):1044-6BloodFlow28编辑版pptDVT:PathophysiologyPredisposingriskfactorsforthedevelopmentofDVTfollowingSCIcanbeclassifiedwiththeVirchowtriadVenousstasisresultsfromlossofpumpingfunctionprovidedbycontractingmuscles.Hypercoagulability

canoccurasaresultofstimulationofthrombogenicfactorsfollowinginjury,withresultantincreaseinplateletaggregationandadhesion(reducedfibrinolyticactivityalongwithhigherlevelsofvonWillebrandfactorantigenandFactorVIII-relatedantigenandresultinginhyperactiveplateletaggregationIntimalinjurymayresultdirectlyfromthereleaseofvasoactiveamineswithtraumaorsurgery,orindirectlyfromexternalpressureontheparalyzedleg.

29编辑版pptDeepVenousThrombosisSwellingFeverofunknownoriginIncreasedspasticityandADClinicallyapparentDVToccursinapproximately15%to50%.DVTcanleadtopulmonaryembolism(5-10%)anddeath.30编辑版pptDVTTreatmentAnticoagulationwithLovenox,Heparin,andorcoumadinIfclinicallycontraindicatedplacevenacavalfilterContinueactivityandcompressiongarments31编辑版pptDVT/PEPreventionGuidelinesAllpatientswillbeonLovenoxorHeparintopreventbloodclot:Non-complicatedspinalcordinjury(noco-morbidity)willhave8weeksoftreatmentComplicatedspinalcordinjury(havingatleastoneco-morbidity)willhave12weeksoftreatmentStandardofcaretopreventDVT:AnticoagulationTherapyattherapeuticdoses(Lovenox30mgSQBIDorHeparin5000unitsSQBID/TID),SCD’swhileinbed,andTedhoseand/orAceWrapswhenoutofbed.32编辑版pptPearlsDVToccursin40-90%ofpatientsdependingonthedegreeofprophylaxis.Riskfactorsdeclinein8-12weeks.ProximalprogressionofDVTandpulmonaryembolismoccurin20-50%.HistoricalyclinicalfactorsbelievedtobeassociatedwithDVTincludemotorcompleteinjuries,paraplegia,andmalegender.InarecentstudybyPowelletal,therewasnostatisticaldifferenceinincidenceofDVTbetweenmotorcompleteversusmotorincompleteinjuries,tetraplegicversusparaplegic,ortraumaticversusnontraumaticcauses.Thus,allSCIpatientsareatriskofdevelopingaDVT.PowellM,KirshblumS,O'ConnorKC.ArchPMedRehabil.1999Sep;80(9):1044-633编辑版pptPulmon