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An engg student from Venezuela; Was living with her father .  Then she moved to Texas.
Car of Jacqueline.Hit by a 17yrold boy driving in a drunkenstate.
She was in the burning car for 45seconds.
Following accident,she required 40surgeries
Without a left eyelid,she needseyedrops to retain her vision
Reginald Stephey was convicted on two counts ofintoxicated manslaughter. He completed twoconcurrent seven-year prison sent...
Doctors are still working on her.
.Outline• How to preserve what we have got  and how to get the best out of it?• System wise intensive care Rx
SPINAL CORDPROTECTIVE STRATEGIESSURGICALPHARMACOLOGICAL
SURGICAL THERAPIES  NEUROLOGIC DETERIORATION ? RADIOLOGY?  CLOSED REDUCTION—SUCCESSFUL?. SPINAL STABILITY---LOST?Accepted ...
Early Surgical TherapyExperimental studies…. Go for it!Clinical studies………..favourable outcomeMust occur <24 hrs, especial...
SURGICAL APPROACHESANTERIOR APPROACH   Your Text herefor removal of disk material, bone, or ligamentous tissue compressin...
PHARMACOLOGICAL      STRATEGIESCORTICOSTEROIDSHYPOTHERMIAHYPERTENSION
CORTICOSTEROIDS    stabilize membranes    • prevent the release of lysosomes and.     excessive Ca2+ ionic fluxes into cel...
NASCIS Your Text here• R  Ref :trauma.org
NASCISNASCIS-I  No neurologic benefit; ? Inadequatedose?NASCIS-II patients treated within 8 hours ofinjury showed signif...
NASCIS-IIITreatment group 2 :especially among patientswhose therapy was initiated 3 to 8 hours afterinjury ‘showed’ greate...
REAL STORYNASCIS II flaws in study design and statisticalanalysis, NASCIS III concerns regarding thetiming of surgery, t...
HYPOTHERMIAEfficacy in mild to moderate traumatic SCI; not insevereCirculatory, pulmonary, metabolic, andimmunologic side ...
HypertensionIn patients with hypo-perfusionMAP above 85 mm Hg for the first 7 days afterinjury is recommended to preserve ...
CONCLUSIONno clear benefit from any pharmacologictherapy has yet emerged
MEDICAL THERAPYPULMONARY SYSTEMCARDIOVASCULAR SYSTEMGITGENITO URINARYTEMPERATURE CONTROLCOAGULATION
PULMONARYSYSTEM• The main key which we need to  keep the engine revving …. Never  loose it in SCI
PULMONARY SYSTEMLEVEL   VENT       COUGH COMMENTS        FUN        0=no        0=no fun   fun        +++= N/L   +++=     ...
Anatomy        »Diaphragm– Phrenic nerve– C3-C4-C5– Contributes to 65% of Vital Capacity-- injury >C3 = cough tidal breath...
Anatomy        »Intercostal muscles– Intercostal nerves– T1-T11  • Both layers act as inspirators at low    volumes, and e...
Lungs get drowned!Pulmonary complications -- leading causes ofmorbidity and early mortality -- seen in as many as75% of pa...
↑WOB ALSO TROUBLESVital capacity improve in supine position! [↓RV]*↓ed lung compliance, ↑ed WOBGastric atony ↔ pulmonary m...
Other pulmonary         complicationsVentilatory failure and aspiration were the earliestto occur: at 4.5 days [Jackson an...
. Protocol For Reduction ofPulmonary Complicationsin Patients with SCI
Aggressive pulmonary               hygiene  .Frequent nasotracheal suctioning • to remove secretionsPositional changes eve...
PROTOCOL…continued    .Bronchodilator therapy for assisting secretion clearance and bronchodilatoreffects [relative parasy...
Anticipation is important.                       • significant declines in    first 1 to 3 days     pulmonary reserve     ...
Start seeing through a          binocular into the long term          plans……cervical SCI below C4 when spinal shockresol...
Suggested settingsACMV / SIMVVentilator settings should be selected that limit theoccurrence of ventilator-associated lung...
Shift gears accordingly…Chest trauma is associated with SCIpulmonary contusions, rib fractures,pneumothorax, hemothorax, a...
Fluid plays… Don’t SLIPNeurogenic Pulmonary oedema : Neurogenicincreases in extravascular water  pulmonaryedema [both in ...
CARDIOVASCULARSYSTEM• Body systems also crash like a  vehicle after the impact
Spinal cord…. Does it belong to CNS or         CVS!!!!complete cervical SCI has the most pronouncedphysiologic effects, co...
The Sympathetic BOMB         BLASTA transient severe increase in blood pressurecaused by an extensive sympathetic discharg...
Aftermath…..After this HYPOTENSION predominates [ in allpatients with complete cervical SCI ]Due to vasodilatation 20 to ...
‘Shock’ing consequencesautonomic imbalance leads to….
SPINAL SHOCKseen with physiologic or anatomic transection, ornear transection, of the spinal cordconsists of the loss of s...
SPINAL SHOCK continuedThe more severe the functional spinal cordtransection and the higher the level of injury, thegreater...
Lack of speed kills….Beware of the bradycardia in SCIcomplete cervical SCI +++; thoracic and lumbarinjuries +/-interruptio...
What has fallen there…?SBP < 90 mm of Hg / 30% below baselinegoal : ? MAP > 85 mm of Hg for first 7 dayscorrection of hypo...
DON’T ‘PRESS’ TOO MUCH         vasopressor Vs inotropic         agentspotent ά-agonist substantial increases inafterload ...
ArrhythmiasExperimental models & clinical reports shown --Cardiac dysrhythmias [suppressed by atropine]tachycardia, and ST...
Arrhythmias continued ..TYPE                  persistent bradycardia   Primary cardiac arrestsevere cervical SCI   31/31  ...
GASTROINTESTINAL               SYSTEMIssues                     Comments  .Gastric distention         Increased risk of as...
GENITO URINARYSYSTEM• .
GENITO URINARY SYSTEM.                        INITIAL PHASE       FLACCID BLADDER                        CATHETERISE      ...
TEMPERATURECONTROL• .
TEMPERATURE CONTROLThe body temperatures of patients with completeSCI tend to approach that of the environmentNo regulator...
COAGULATION• .
DEEP VEIN THROMBOSIS  40-100%  ↑ed age, a concomitant lower extremity fracture,  and lack of or delay in thromboprophylaxi...
Diagnosis and TreatmentDiagnosis CLINICAL SUSPICION D-DIMER LEVELS, VENOGRAPHY, COLOR FLOW DUPLEX IMAGING CT ANGIOGRAPHY, ...
AUTONOMICHYPERREFLEXIA• .
AUTONOMIC         HYPERREFLEXIAoccurs in 85% of patients with spinal cordtransections above T5is secondary to autonomic va...
AUTONOMIC             HYPERREFLEXIAVasoconstriction occurs below the lesion;reflex activity of carotid and aortic barorece...
OTHER ISSUES• .
Infectionsleading cause of deathpneumonia, urosepsis
HYPERREFLEXIC SYNDROMESmuscle spasms caused by hyper-active spinalreflexes without the tempering effect of modulatingcorti...
PRESSURE ULCERSdirect pressure effects, reduced tissue perfusion,and limited mobility.The use of rotational beds, frequent...
LONG-TERM IMMOBILIZATIONaltered calcium metabolismpainful heterotopic ossificationcalcification of musclesjoint immobility...
THANK YOU• LET’S TRY TO MAKE OUR ROLES  MORE AND MORE JUSTIFIABLE IN  THIS WORLD
Intensive fcare for spinal cord injury
Intensive fcare for spinal cord injury
Intensive fcare for spinal cord injury
Intensive fcare for spinal cord injury
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Intensive fcare for spinal cord injury

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Transcript of "Intensive fcare for spinal cord injury"

  1. 1. ..
  2. 2. An engg student from Venezuela; Was living with her father . Then she moved to Texas.
  3. 3. Car of Jacqueline.Hit by a 17yrold boy driving in a drunkenstate.
  4. 4. She was in the burning car for 45seconds.
  5. 5. Following accident,she required 40surgeries
  6. 6. Without a left eyelid,she needseyedrops to retain her vision
  7. 7. Reginald Stephey was convicted on two counts ofintoxicated manslaughter. He completed twoconcurrent seven-year prison sentences . On May20, 2011 Saburido again appeared on the 4th tolast episode of The Oprah Winfrey Show
  8. 8. Doctors are still working on her.
  9. 9. .Outline• How to preserve what we have got and how to get the best out of it?• System wise intensive care Rx
  10. 10. SPINAL CORDPROTECTIVE STRATEGIESSURGICALPHARMACOLOGICAL
  11. 11. SURGICAL THERAPIES NEUROLOGIC DETERIORATION ? RADIOLOGY? CLOSED REDUCTION—SUCCESSFUL?. SPINAL STABILITY---LOST?Accepted Indications for SurgeryProgressive neurologic deterioration in an unstable spine,especially with spinal canal compromiseFailure of closed reduction and stabilization of dislocation withresidual canal narrowing of > 50%Unstable spine with dislocated bilateral "locked" facetsUnstable spine where nonunion is likelyUncooperative patient with unstable spine risking furtherneurologic injuryCompression of conus medullaris or cauda equina
  12. 12. Early Surgical TherapyExperimental studies…. Go for it!Clinical studies………..favourable outcomeMust occur <24 hrs, especially in incompleteinjuriesLate (>48hrs) only stabilizes spinal column andhelps rehabilitation
  13. 13. SURGICAL APPROACHESANTERIOR APPROACH Your Text herefor removal of disk material, bone, or ligamentous tissue compressingthe spinal cord anteriorlyto treat unstable compression-flexion and distractive-flexion injuries,often in conjunction with a decompressive corpectomy (removal ofvertebral body) if the cord is compressedPOSTERIOR APPROACHfor significant disruption of the posterior bony or ligamentous structuresof the cervical spine, particularly with minimal or no involvement of thevertebral bodyto treat occipitocervical and atlantoaxial instability and for spinalinstability causing flexion injuriesCOMBINED APPROACH [BOTH ANT & POST STRUCTURES]flexion teardrop fractures, vertical compression burst fractures withsignificant posterior ligamentous injury, and bilateral facet dislocation withdisk compression of the spinal cord.
  14. 14. PHARMACOLOGICAL STRATEGIESCORTICOSTEROIDSHYPOTHERMIAHYPERTENSION
  15. 15. CORTICOSTEROIDS stabilize membranes • prevent the release of lysosomes and. excessive Ca2+ ionic fluxes into cells Improvement in blood flow • Reduction in tissue edema, • direct vasodilative effects of steroids • antioxidant properties alter ionic-clearing mechanisms enhance Na+ K+-ATPase activity inhibit lipid peroxidation formation
  16. 16. NASCIS Your Text here• R Ref :trauma.org
  17. 17. NASCISNASCIS-I  No neurologic benefit; ? Inadequatedose?NASCIS-II patients treated within 8 hours ofinjury showed significant improvement in motorand sensory function Vs30 mg/kg, followed by 5.4 mg/kg/hr Treatment 1:methylprednisolone, placebo…..PRACTICEfor 23 hoursTreatment 2:naloxone, 5.4 mg/kg fol-lowed by 4 mg/kg/hr for 23 hoursTreatment 3:placeboNASCIS-III MP 30 mg/kg within 824 hours Treatment 1: Methyprednisolone 5.4 mg/kg/hr for hrs f/b Treatment 2: Methyprednisolone 5.4 mg/kg/hr for 48 hours Treatment 3: Tirilizad mesylate 2.5 mg/kg every 6 hours for 48 hours
  18. 18. NASCIS-IIITreatment group 2 :especially among patientswhose therapy was initiated 3 to 8 hours afterinjury ‘showed’ greater motor recovery at 6 weeksand 6 months after injury than patients treated withthe same agent for 24 hours. [ post-hoc analysis;NOT Level 1/Level 2/Level 3 ]No functional benefit was demonstrated for the useof steroid therapy in the treatment of penetrating
  19. 19. REAL STORYNASCIS II flaws in study design and statisticalanalysis, NASCIS III concerns regarding thetiming of surgery, the process of neurologicassessment, and the fact that differences in motorscores and functional outcome were clinicallynegligible…no difference in the level of disabilityMP-48-hour infusionhigher incidence ofinfectionsSo STEROIDS ARE NOT STANDARD Rx IN A/CSCI; JUST A TREATMENT OPTION
  20. 20. HYPOTHERMIAEfficacy in mild to moderate traumatic SCI; not insevereCirculatory, pulmonary, metabolic, andimmunologic side effectsOnly experimental; no clinical evidenceHence this also is an option; not a standard Rx
  21. 21. HypertensionIn patients with hypo-perfusionMAP above 85 mm Hg for the first 7 days afterinjury is recommended to preserve neurologicfunction because autoregulation is impaired… [Nodefinitive data]more aggressive hypertensive therapy may haveadvantages, but risk of hemorrhage and edema.
  22. 22. CONCLUSIONno clear benefit from any pharmacologictherapy has yet emerged
  23. 23. MEDICAL THERAPYPULMONARY SYSTEMCARDIOVASCULAR SYSTEMGITGENITO URINARYTEMPERATURE CONTROLCOAGULATION
  24. 24. PULMONARYSYSTEM• The main key which we need to keep the engine revving …. Never loose it in SCI
  25. 25. PULMONARY SYSTEMLEVEL VENT COUGH COMMENTS FUN 0=no 0=no fun fun +++= N/L +++= N/LABOVE 0 0 Paralysis of diaphragm and accessory muscles,C3 resulting in apnea; lifelong ventilator dependenceC3-C5 0 to + 0 Partial to complete diaphragmatic paralysis; paralysis of accessory muscles-marked reduction in lung volumes with hypoxemia; recurrent atelectasis and pneumonia; prolonged mechanical ventilator dependence; probabl° tracheostomy; most patients will be weaned from mechanical ventilationC5-C7 + to ++ +to ++ Paralysis of accessory muscles; marked reduction in volumes with hypoxemia-recurrent atelectasis and pneumonia; many patients need mechanical ventilation; possible tracheostomyHIGH ++ ++ Partial paralysis of accessory muscles; reduction inTx lung volumes with ateiectasis1 increased incidence of pneumonia; possible need for mechanical
  26. 26. Anatomy »Diaphragm– Phrenic nerve– C3-C4-C5– Contributes to 65% of Vital Capacity-- injury >C3 = cough tidal breath-- ↓in all lung volumes except RV in Cx spine injury improve over next 4-5 ms
  27. 27. Anatomy »Intercostal muscles– Intercostal nerves– T1-T11 • Both layers act as inspirators at low volumes, and expirators at large volumes • Below C3 ↑ing function of diaphragm;but cough is extremely limited, since expiratory assistance of i.c. muscles are not there
  28. 28. Lungs get drowned!Pulmonary complications -- leading causes ofmorbidity and early mortality -- seen in as many as75% of patients.The reduction of lung volumes and the inability togenerate an effective cough  progressiveretention of pulmonary secretions  gradualmicroatelectasis and lobar atelectasis incremental hypoxemia and CO2 retention.
  29. 29. ↑WOB ALSO TROUBLESVital capacity improve in supine position! [↓RV]*↓ed lung compliance, ↑ed WOBGastric atony ↔ pulmonary mechanicsIn 2-5 wks , spinal shock state resolvesprogressive spasticity of chest wall + abdomenimprove pulmonary function
  30. 30. Other pulmonary complicationsVentilatory failure and aspiration were the earliestto occur: at 4.5 days [Jackson and Groomes et al]
  31. 31. . Protocol For Reduction ofPulmonary Complicationsin Patients with SCI
  32. 32. Aggressive pulmonary hygiene .Frequent nasotracheal suctioning • to remove secretionsPositional changes every 2 hours [KINETIC Rx- Start early] • best achieved with rotational or circle beds • effectively ↓es complications & Ventilator duration- ICU stayChest percussion every 4 hoursAssisted coughing exercises every 4 hours rsDeep breathing exercises every 4 hoursIncentive spirometry every 4 hours
  33. 33. PROTOCOL…continued .Bronchodilator therapy for assisting secretion clearance and bronchodilatoreffects [relative parasympathetic overactivity in tetraplegics-↑secretions]Early use FOB in cases of lobar atelectasis secondary to retainedsecretionsEarly institution of mechanical ventilation • in those with progressive labored breathing, • increasing respiratory failure (hypoxia or hypercapnia) • and vital capacities <1000 mlClose monitoring of respiratory mechanics in patients receiving mechanicalventilation • with optimal use PEEP therapy and • limitation of plateau pressure to <30 cm Hg
  34. 34. Anticipation is important. • significant declines in first 1 to 3 days pulmonary reserve • progressive cord edema first 2 days • Ascending neurologic injuryso what will happen? @admission- diaphragm •VC check Q6H if <2L;functioning  then If <1L & respiratory failure symptomaticintubate
  35. 35. Start seeing through a binocular into the long term plans……cervical SCI below C4 when spinal shockresolves (2-3 weeks)  muscles develop spasticity improvement in lung volumes and overallventilatory ability eventual weaning frommechanical ventilationNearly all patients with complete cervical SCIabove C6 will require a tracheostomy because ofthe length of time on the ventilator and the difficulty
  36. 36. Suggested settingsACMV / SIMVVentilator settings should be selected that limit theoccurrence of ventilator-associated lung injuryPEEP is added to recruit collapsed alveoli andprevent further atelectasis
  37. 37. Shift gears accordingly…Chest trauma is associated with SCIpulmonary contusions, rib fractures,pneumothorax, hemothorax, and ARDS.May result in prolonged mechanical ventilation withdifficult weaning and delayed operative spinalintervention.
  38. 38. Fluid plays… Don’t SLIPNeurogenic Pulmonary oedema : Neurogenicincreases in extravascular water  pulmonaryedema [both in head injury and in SCI; ?related tothe initial sympathetic discharge]Cardiogenic pulmonary edema : reducedmyocardial inotropy [in high SCI] , overzealousfluid administration.Because of the hemodynamic alterations observedin SCI (hypotension, bradycardia), the usual
  39. 39. CARDIOVASCULARSYSTEM• Body systems also crash like a vehicle after the impact
  40. 40. Spinal cord…. Does it belong to CNS or CVS!!!!complete cervical SCI has the most pronouncedphysiologic effects, consisting of cardiovascularinstability, cardiac dysrhythmias, and ventriculardysfunctionSCI below T5 results in varying degrees ofhypotension caused by the functionalsympathectomy below the level of injuryDISTINCTLY DIFFERENT MECHANISMS…
  41. 41. The Sympathetic BOMB BLASTA transient severe increase in blood pressurecaused by an extensive sympathetic discharge atthe time of injuryThe systolic blood pressure may be as high as 300mm Hg, lasting 2 to 5 minutes, with a gradualdecline to values less than baselinemay be responsible for the noncardiogenicpulmonary edema
  42. 42. Aftermath…..After this HYPOTENSION predominates [ in allpatients with complete cervical SCI ]Due to vasodilatation 20 to withdrawal ofsympathetic neural outflowIts a functional sympathetic blockade [sympatheticreceptors lose their normal input and regulation]Parasympathetic system remains intact since… thevagus nerve exits from the brainstem.
  43. 43. ‘Shock’ing consequencesautonomic imbalance leads to….
  44. 44. SPINAL SHOCKseen with physiologic or anatomic transection, ornear transection, of the spinal cordconsists of the loss of somatic motor and sensoryfunction below the level of injury, loss of voluntaryrectal contraction, and loss of sympatheticautonomic function
  45. 45. SPINAL SHOCK continuedThe more severe the functional spinal cordtransection and the higher the level of injury, thegreater the severity and duration of spinal shock.If the loss lasts longer than 1 hour, pathologicinjuries to the spinal cord, as opposed to atransient concussive injury are assumed to exist
  46. 46. Lack of speed kills….Beware of the bradycardia in SCIcomplete cervical SCI +++; thoracic and lumbarinjuries +/-interruption of the cardiac accelerator nerves (Tl to T4)First 2 wks-most dangerous ; resolves over 3- to 5-weeksprofound degrees of bradycardia, even cardiac arrest,may occur during turning or tracheal suctioningsedation, 100% oxygen before suctioning, and limitingthe time allowed for suctioningRx: Atropine, Temporary pacemaker
  47. 47. What has fallen there…?SBP < 90 mm of Hg / 30% below baselinegoal : ? MAP > 85 mm of Hg for first 7 dayscorrection of hypotension is crucial for optimalpreservation of neurologic function and reduction of20 injuryNo autoregulation; so aggressive RxNeurogenic shock relative hypovolemia due tovasodilation  so fill, but carefully [pulmonaryedema][1]Blood : to maintain Hb>10g[2]Fluids : isotonic crystalloids / ?HYPERTONIC
  48. 48. DON’T ‘PRESS’ TOO MUCH vasopressor Vs inotropic agentspotent ά-agonist substantial increases inafterload  impair cardiac O/P can precipitateLVF inotropic agent is often the drug of choicefor maintaining spinal cord perfusionInvasive hemodynamic monitoring isrecommendedThere is evidence to support improvement inneurologic outcome in whom hemodynamics aremanaged aggressively.SC edema is maximal at 3 to 6 days after injury,blood pressure support should continue during this
  49. 49. ArrhythmiasExperimental models & clinical reports shown --Cardiac dysrhythmias [suppressed by atropine]tachycardia, and ST T wave changes [suppressedby propranolol]The initial response to spinal cord compression--sympathetic discharge  elicited a secondary,compensatory, parasympathetic dischargeautonomic imbalance responsible for the cardiacdysrhythmias
  50. 50. Arrhythmias continued ..TYPE persistent bradycardia Primary cardiac arrestsevere cervical SCI 31/31 5/31mild cervical SCI 6/17 -thoracolumbar SCI 3/23 - frequency of brady-dysrhythmias was maximal on day 4 after injury all abnormalities resolved over a 14-day to 6-week period
  51. 51. GASTROINTESTINAL SYSTEMIssues Comments .Gastric distention Increased risk of aspirationGastric emptying delayed Adversely affect ventilation Rx : put N-G tubepeptic ulcer disease One cause- high dose steroidsgastritis, Rx: PPI, Sucralfate [continued for 4hemorrhage weeks] Enteral feedingIleusacalculous cholecystitisoccult acute abdomen patients with SCI may not demonstrate the usual signs and symptomselevated metabolic rates early nutritional supplementation
  52. 52. GENITO URINARYSYSTEM• .
  53. 53. GENITO URINARY SYSTEM. INITIAL PHASE FLACCID BLADDER CATHETERISE LATER BLADDER SPASTICITY PERSISTANT URINARY PROBLEMS NEPHROCALCINOSIS, RECURRENT UTI , STONES RECURRENT BOUTS OF UROSEPSIS
  54. 54. TEMPERATURECONTROL• .
  55. 55. TEMPERATURE CONTROLThe body temperatures of patients with completeSCI tend to approach that of the environmentNo regulatory mechanisms like vasoconstriction/sweatingprone to hypothermia
  56. 56. COAGULATION• .
  57. 57. DEEP VEIN THROMBOSIS 40-100% ↑ed age, a concomitant lower extremity fracture, and lack of or delay in thromboprophylaxis ↑es risk PULMONARY EMBOLISM In 0.5% to 4.6% of patients third leading cause of death moreoften with complete SCI and thoracicmiury
  58. 58. Diagnosis and TreatmentDiagnosis CLINICAL SUSPICION D-DIMER LEVELS, VENOGRAPHY, COLOR FLOW DUPLEX IMAGING CT ANGIOGRAPHY, PULMONARY ANGIOGRA-PHYTreatment PROPHYLACTIC TREATMENT AS SOON AFTER INJURY AS IS POSSIBLE (I.E., 72 HOURS) CONTINUED FOR A MINIMUM OF 3 MONTHS. EFFECTIVE TREATMENT  THE OCCURRENCE OF DVT DECREASES TO 5%.
  59. 59. AUTONOMICHYPERREFLEXIA• .
  60. 60. AUTONOMIC HYPERREFLEXIAoccurs in 85% of patients with spinal cordtransections above T5is secondary to autonomic vascular reflexes, whichusually begin to appear about 2 to 3 weeks afterinjuryAfferent impulses from bladder or bowel distention,manipulations of the urinary tract, or surgicalstimulation  the pelvic, pudendal, or hypogastricnerves to the isolated spinal cord  a massivesympathetic response from the adrenal medullaand sympathetic nervous system, which is nolonger modulated by the normal inhibitory impulses
  61. 61. AUTONOMIC HYPERREFLEXIAVasoconstriction occurs below the lesion;reflex activity of carotid and aortic baroreceptorsproduces vasodilation above the lesionoften accompanied by bradycardia, ven-triculardysrhythmias, and even heart block.Sedation or topical anesthesia does not appear toattenuate the hypertensive response, but deepgeneral, epidural, or spinal anesthesia is effectiveHypertension Rxdirect-acting vasodilators (e.g., sodium nitroprusside)beta blocking agents (e.g., esmolol),combination beta blockers (e.g., labetalol), organglionic blocking agents e.g.,trimethaphanCCBs (nicardipine),
  62. 62. OTHER ISSUES• .
  63. 63. Infectionsleading cause of deathpneumonia, urosepsis
  64. 64. HYPERREFLEXIC SYNDROMESmuscle spasms caused by hyper-active spinalreflexes without the tempering effect of modulatingcortical, brainstem, and cerebellar influences.This "mass reflex" may make the management ofthe unanesthetized patient difficult.
  65. 65. PRESSURE ULCERSdirect pressure effects, reduced tissue perfusion,and limited mobility.The use of rotational beds, frequent patient turning,good skin care, foam padding of bonyprominences, or air floatation beds can helpprevent pressure ulcers.
  66. 66. LONG-TERM IMMOBILIZATIONaltered calcium metabolismpainful heterotopic ossificationcalcification of musclesjoint immobilityosteoporosis with hypercalcemianephrocalcinosis and secondary renal failure.Late mobilization  pathologic fractures.Early institution of active physical therapy isessential
  67. 67. THANK YOU• LET’S TRY TO MAKE OUR ROLES MORE AND MORE JUSTIFIABLE IN THIS WORLD
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