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The Sub Acute Stage: From four to 21 days post injury
A secondary condition is any medical, social, emotional, mental, family or community problem that a person with a primary condition, such as a spinal cord injury (SCI), may experience. For all intents and purposes of the Sub Acute Stage, this discussion will focus on the secondary medical conditions of spinal cord injuries.
Immediate Secondary Conditions
There are secondary conditions that must be addressed immediately to avoid severe complications. They could potentially inhibit beginning physical rehabilitation in a timely manner and could have negative consequences for years to come. The best way to combat many of these secondary conditions is to prevent them!
Deep vein thrombosis (DVT) or pulmonary embolism is a potentially severe complication of spinal cord injury. Changes in the normal neurologic control of the blood vessels can result in stasis or "sludging". DVT in the lower leg is almost universal during the early phases of recovery and rehabilitation. Thromboses in the thigh, however, are a great concern, as they are at risk for becoming dislodged and passing through the vascular tree to the lungs. A major obstruction of the arteries leading to the lung can potentially be fatal.
Therapeutic measures to reduce or eliminate the risk for deep vein thrombosis include Ace wrapping of the legs and the use of pneumatic compression stockings. Medications administered subcutaneously, such as Heparin, are useful in reducing blood viscosity and improving flow. In the event a thrombosis develops, treatment typically begins with intravenous Heparin. Once adequate anticoagulation is provided, the patient is switched to an oral medication, such as Coumadin.
Possible signs and symptoms of DVT include swelling of the leg, dilation of the veins, increased skin temperature, pain and tenderness, and, rarely, a bluish discoloration of the lower leg. Sometimes, there are no signs or symptoms of DVT. There are also no characteristic signs or symptoms of lung clots, meaning the signs and symptoms are very nonspecific, such as fever, chest pain, cough, or changes in heart beat.
When the injury involves the upper thorax, the normal breathing pattern is permanently altered. The diaphragm does most of the work in quiet breathing. The chest wall muscles (intercostals) are used primarily for deep breathing or coughing. The abdominal muscles also participate in coughing. When the intercostal and abdominal muscles are paralyzed, the entire load is taken by the diaphragm. This results in poor coughing and a high risk of pneumonia.
Pneumonia is one of the most common complications of acute spinal cord injury. Preventive measures are very important to reduce the risk of pneumonia. These include: percussion and drainage using gravity to assist; assisted coughing (also termed "quad" coughing); abdominal binders (to increase the resistance against which the diaphragm works); and early mobilization (i.e.; getting the patient out of bed as soon as possible).
You may need to learn new ways to change your position to prevent too much pressure. Pressure sores can occur, for example, when you sit or lie in one position too long. Shearing is also a kind of pressure injury. It happens when the skin moves one way and the bone underneath it moves another way. An example of this is if you slouch when you sit.
Pressure sores will also be referred to as pressure ulcers or decubitus ulcers. Damage from a pressure sore will range from slight discoloration of the skin (stage I) to open sores that go all the way to the bone (stage IV). The affected area may feel warmer than the surrounding tissue. In light-skinned people, the discoloration may appear as dark purple or red. In darker-skinned people, the discoloration will appear darker than the surrounding tissue.
A pressure sore is any redness or break in the skin caused by too much pressure on your skin for too long a period of time. The pressure prevents blood from getting to your skin so the skin dies. Normally, the nerves send messages of pain or feelings of discomfort to your brain to let you know that you need to change position, but damage to your spinal cord keeps these messages from reaching your brain.
The best defense against pressure sores is PREVENTION!
Autonomic dysreflexia, also known as hyperreflexia or AD, means an over-activity of the Autonomic Nervous System causing an abrupt onset of excessively high blood pressure. Persons at risk for this problem generally have injury levels above T-5. Autonomic dysreflexia can develop suddenly and is potentially life threatening and is considered a medical emergency. If not treated promptly and correctly, it may lead to seizures, stroke, and even death.
AD occurs when an irritating stimulus is introduced to the body below the level of spinal cord injury, such as an overfull bladder. The stimulus sends nerve impulses to the spinal cord, where they travel upward until they are blocked by the lesion at the level of injury. Since the impulses cannot reach the brain a reflex is activated that increases activity of the sympathetic portion of autonomic nervous system. This results in spasms and a narrowing of the blood vessels, which causes a rise in the blood pressure.
Postural hypotension, also known as orthostatic hypotension, is a condition which results in a decrease in blood pressure when you sit or stand. This can cause "light-headedness" or "fainting." It occurs more commonly when you are first injured, when you are fatigued or after an illness.
There is an increased tendency for postural hypotension if the level of injury is at T-6 or above, but it can occur in all spinal cord injured individuals.
Postural hypotension after a SCI occurs since the blood vessels do not decrease in size, in response to lowered blood pressure, due to the altered function of the autonomic nervous system. Because of this, blood pools in the pelvic region or legs while you are sitting or standing. Postural hypotension usually occurs when you are initially placed in your wheelchair or on the tilt table.
Wear elastic hose and an abdominal support and come to sitting or standing positions gradually. If postural hypotension occurs tilt or lay backward until you are nearly horizontal to the floor. This increases blood pressure and the "fainting" will quickly disappear. Medication is available if it interferes with daily living.
When bacteria gets into your bladder or kidneys and causes you to have symptoms, you have a urinary tract infection (UTI).
• Increased spasms of legs, abdomen, or bladder
• Feeling the need to catheterize more often (frequency) (Intermittent)
• Feeling the need to catheterize immediately (urgency) (Intermittent)
• Burning of the urethra, penis, or pubic area
• Mild low back pain or other aches
• Feeling "lousy" or tired
• Sediment (gritty particles) or mucus in the urine or cloudy urine
• Bad smelling urine (foul odor)
• Blood in urine (pink or red urine)
Note: The appearance and smell of your urine may change because of changes in your diet or fluid intake. If you have changes in the urine but no symptoms (see list above) you do not need to seek treatment for a UTI.
People who empty their bladders by self-catheterization may occasionally see small blood clots or red blood visible on their catheters because of trauma (bumping against the bladder or urethra or forcing the catheter past the sphincter). This is not cause for worry unless it happens frequently. Larger amounts of blood, or urine that is red from blood, should always be reported to your health care provider.
Future Secondary Conditions
In addition to the immediate secondary conditions, which you must continue to be vigilant about for the rest of the injured person’s life, there are other secondary conditions that can occur over time. Again, awareness and prevention of these conditions is the best defense.
Bowel and bladder function is almost always disrupted after a SCI, regardless of level, because the nerves controlling these organs attach to the base of the spine (S2-S4) and therefore are unable to receive messages from the brain. However, there are various techniques and surgical options to manage both bowel and bladder care.
SCI survivors and caregivers will be instructed on different methods for bowel programs during the hospital stay and rehabilitation. Bowel programs vary from person to person according to their individual needs. It is important to try to establish a routine for bowel programs to avoid accidents. Most people perform their bowel program at a time of day that fits in with their prior bowel habits and current lifestyle.
The program usually begins with insertion of either a suppository or a mini-enema, followed by a waiting period of approximately 15-20 minutes to allow the stimulant to work. If possible, this is best done while on a shower chair or toilet seat. After the waiting period, digital stimulation is done every 10-15 minutes until the rectum is empty. In order to avoid damage to the rectal tissue, no more than four digital stimulations should be performed during a single bowel program. Those with a flaccid bowel frequently omit the suppository or mini-enema and start their bowel programs with digital stimulation or manual removal. Most bowel programs require 30-60 minutes to complete.
When messages can no longer be passed from the bladder muscles to the brain, the bladder is affected in one of two ways:
The bladder muscles lose muscle tone and instead of emptying, urine backs up into the kidneys. This type of bladder is also at risk for becoming overly stretched. Flaccid bladder usually occurs with injuries below the T-12 level.
There are several different bladder management methods:
Involves draining the bladder several times a day by inserting a small rubber or plastic tube called a catheter. The catheter does not stay in the bladder between catheterizations. Several different discrete types of intermittent catheter are available and this is one of the preferred methods.
External Bladder Control Methods
reduces pressure on the valve and allows urine flow out of the bladder easier. There is a chance that the operation will affect a man’s ability to obtain a reflex erection. This operation is not normally carried out on women.
Choosing a rehabilitation facility is one of the most important decisions to be made in this entire process. Each rehabilitation facility has varying admission policies and depending on where in the country it is located transportation will need to be secured. These decisions need to be made during the Sub Acute Stage so as soon as the SCI survivor is medically stabilized they can begin therapy.
There are many factors to consider when choosing a rehabilitation facility, but at the very least the facility should meet the following criteria to handle the needs of a spinal cord injury patient:
• Have accreditation from the Rehabilitation Accreditation Commission (CARF) for spinal cord injury
• A physician in charge who specializes in physical medicine and rehabilitation
• Physician coverage seven days a week, 24 hours a day
• A support staff that is specifically trained in spinal cord injuries
• The availability of rehabilitation nursing and respiratory care on a 24 hour basis
• Therapy sessions for a minimum of three hours per day
• Specialties offered such as driver education, therapeutic recreation, etc.
• A full roster of weekend and evening activities for residents
• Programs that include family and loved ones in the care and rehabilitation of the survivor
It is common for families of survivors to contact, or if possible visit, at least three rehabilitation facilities before choosing a program. Other factors to consider are:
• The availability of continuum of care programs to offer support post-rehab
• Education, research and clinical trials being conducted
• High patient satisfaction
• The availability of affordable housing for family member/caregiver
• The availability of patient transfer/transportation
The Injury Co-op has developed a Printable PDF for Choosing a Qualified SCI Rehab Facility for your convenience.
The first step is to contact a caseworker at the hospital to begin the process of gathering the necessary paperwork to apply for government programs, such as Medicare/Medicaid, Social Security and the Department of Rehabilitation.
Also, there are state health insurance programs in place for patients under the age of 18. It varies state by state, but pediatric patients may also qualify for Supplemental Security Income.
There are also private foundations dedicated to providing assistance to qualified applicants for housing, medical equipment, transportation, etc.
According to The University of Alabama National Spinal Cord Injury Statistical Center and the Centers for Disease Control and Prevention, the costs of living with SCI can be considerable, and vary greatly due to the severity of injury.
Spinal cord injuries are devastating to almost every aspect of one’s life and grieving the loss of how life was “before” is completely natural and healthy. Often, SCI survivors go through a period of disbelief or struggle with self-blame. Questions like ‘Why me?’ and ‘Why didn’t I just die?’ are common in the early stages post-injury. Some survivors struggle with acceptance or experience a lot of anger about their injury and take it out on those they love the most. Like with most grief cycles, fortunately, these feelings will subside and be replaced with new, more positive thoughts.
Typically, the hospital will involve a counselor to help the survivor reach acceptance, but family and friends can play an important role by being supportive and involved in the rehabilitation process. However, there is a difference between normal feelings of loss and grief after a SCI and the overwhelming sadness and despair that are signs of clinical depression.
Depression can cause some or all of the following physical and psychological symptoms:
• Changes in sleep pattern
• Feeling down or hopeless
• Loss of interest or pleasure in activities
• Changes in appetite
• Diminished energy or activity
• Difficulty concentrating or making decisions
• Feelings of worthlessness or self-blame
• Thoughts of death or suicide
If you or a loved one is showing some or all of these symptoms please notify your primary care physician. Depression is treatable and should be addressed to avoid it further complicating rehabilitation. Also, it is important to note that caregivers of persons with SCI also often struggle with depression and should watch for symptoms in their selves and if needed seek medical advice.