A patient with traumatic paraplegia due to injury of the thoracic cord of 'T3 level' is observed to have a blood pressure of 210/120. What should be the initial management?
Answer is C (Nifedipine): Presence of accelerated hypeension with blood pressures in excess of 200/100 mm Hg in a patient with high thoracic spinal cord injury (above T6) suggests a diagnosis of Autonomic Dysreflexia. Urgent management of the hypeensive crisis is paramount to prevent complications such as retinal haemorrhage, seizures, hypeensive encephalopathy or an intracerebral haemorrhage. Oral Clonidine and/or Nifedipine are the most commonly used pharmacological agents to control hypeensive crisis in patients with autonomic dysreflexia Autonomic Dysreflexia (AD) (Hypeensive Crisis following Spinal Cord injury above T6) What is Autonomic Dysreflexia Autonomic Dysretlexia (AD) is a syndrome of sympathetic overactivity that typically affects patient with spinal cord injury above or proximal to the upper thoracic level (T6 or above) due to unopposed sympathetic nervous system impulses. This is an acute medical emergency that occurs in patients whose spinal cord injury lies above the greater splanchnic outflow from thoracolumbar preganglionic sympathetic neurons (T6 or above). This results from interruption of normal feedback mechanism in the sympathetic pathway. Patients with spinal cord injury below T8 are rarely affected by this condition . When does Autonomic Dysreflexia occur Autonomic Dysreflexia is traditionally/historically believed to occur 4-6 months after the spinal cord injury (After the phase of spinal shock resolves) However recently AD has also been repoed in early phases after SCI How does Autonomic Dysreflexia Present The most characteristic presentation of AD is sudden increase in Blood Pressure (Accelerated Hypeension) often in excess 200mm Hg systolic and 100 mm Hg diastolic. It is impoant to note that normal resting Blood Pressure in patients with spinal cord injury is often 80 to 90 mmHg, and a systolic blood pressure of 130 mm Kg may he an early sign of autonomic dysreflexia Bradvcardia in association with hypeension is another typical feature of AD and this results primarily from vagal compensation. Bradvcardia is however present in only 50% of the cases. What are the Triggering factors for AD Autonomic Dysreflexia can be triggered by any painful/noxious stimulus in the clermatomes (skin), muscles or viscera below the level of cord injury. Bladder Distension is the single most common inciting stimuli Trigger Stimuli / Inciting stimuli for AD * Distension of Bladder (Due to obstructed urine outflow from spasm/kinked Foley's catheter) * Bowel impaction (Constipation) * Irritation from skin lesions (Dermatomes) Insect bites, pressure sores, constrictive clothing, localized wounds or ingrowing toe nails * Labour and pregnancy * Gynecological instrumentation and/or patients with SCI undergoing surgery What is the treatment of AD Treatment of Autonomic Dysreflexia Prevention of Trigger Factors Prevention of Trigger Factors Avoid Bladder Distension (leading cause) (prompt catheterization) Avoid Fecal Impaction (Second leading cause) (Manual evacuation, anal sphincter block, bowel programs) Anti-cholinergic Medicines are recommended Management of Hypeensive crisis Management of Hypeensive crisis Patient should be brought in a sitting position with legs dangling to take advantage of natural ohostosis. Pharmacological management with oral/transdermal medicine should be initiated - Transdermal Nitroglycerine - Oral Clonidine - Oral Nifedipine - Oral Phenoxybenzamine - Oral Prazocin Pharmacological management with intravenous medicines may be considered in cases of hypeensive crises or encephalopathy or intraoperative hypeension - Nitroprusside - Diazoxide - Trimethaphan - Fenoldopam
Subcutaneous LMWH
Steroids
Nifedipine
Normal saline/Dextrose