Spinal Cord Injury Medical Issues

Deep vein thrombosis (DVT) occurs in more than 50% of patients who do not receive prophylactic measures. The first-line preventive measure are mechanical compression devices on the lower extremities, but studies have shown that although this minimizes venous stasis, it is relatively ineffective in preventing DVT when used alone. Thus, unless contraindicated, compression devices should be supplemented with lowmolecular-weight heparin, such as enoxaparin, or with unfractionated heparin.

Bladder dysfunction from SCI requires a variety of interventions. In acute cases, an indwelling Foley catheter is appropriate and should be used until the patient is hemodynamically stable. However, because of the risk of infection, the catheter should be removed as soon as medically possible and intermittent catheterization substituted. The prophylactic use of antibiotics acutely or chronically does not reduce infection rates.

SCI has been shown to be an independent risk factor for gastrointestinal (GI) ulcers and upper GI bleeding. There are two forms of pharmacologic prophylaxis: histamine H2 receptor antagonists and proton pump inhibitors. Based on present evidence, both are equally safe and effective in preventing stress ulceration in SCI patients.

Loss of lower GI motility is universal in SCI patients and requires early attention. Once enteral nutrition is instituted, bowel movements should be facilitated. This requires the use of oral medications, suppositories, and digital stimulation.

EARLY SPINAL CORD INJURY REHABILITATION

It is important that rehabilitation specialists are involved early in the care of the SCI patient. In acute cases, this is intended to maintain range of motion and to begin strengthening exercises as well as to initiate mobilization, thereby minimizing the risk of joint contracture. In SCI patients with pulmonary problems, respiratory therapists can enhance pulmonary hygiene. Pulmonary interventions, such as suctioning, percussion, vibration, and training of accessory respiratory muscles, reduce the incidence of pneumonia and shorten time in acute care.

One of the primary obstacles to early mobilization is orthostatic hypotension, which limits tolerance to being upright. Nonpharmacologic therapeutic measures include leg-compression stockings, abdominal binders, and a tilt table to gradually elevate the patient as tolerated. Pharmacologic treatments typically include adrenergic agents to enhance vascular tone.

Attention to skin integrity is important during the process of mobilization. SCI creates a number of psychologic, psychosocial, and family issues. These may include grief and denial reactions, major depression, and, in the most severe cases, decisions to remove life support. It is thus important to provide psychologic and social services support to the patient and family.

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