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Autonomic Dysrefexia Interrupted brain communications can put spinal cord-injury patients at risk I t's a brisk afternoon in Your Town, and you're called to a 36-year-old male with "high blood pressure." You arrive to fnd a single-level house with a wheelchair ramp out front. At the door you're greeted by a visiting nurse who guides you to a young-appearing man in a hospital bed. "I'm not sure what's wrong with him," she tells you. "I took over from the night nurse and he was fne, but then he woke up late this morning with a headache. Now the headache is worse, he has blurred vision, and he's not acting right." She explains that your patient has had T1 quadriplegia, also known as tetraplegia (see sidebar), since a rollover car accident several years ago. Today is her frst day caring for him, so she is unable to give you a detailed history, but she does supply you with his vital signs. His heart rate is 100, blood pressure is 226/114, respira- tions are 20, SpO 2 is 100% on room air, and temperature is 98.9ºF. You talk to the patient and fnd that he opens his eyes to verbal stimuli and is oriented to name only. Your physical exam fnds that heart sounds are loud, but there are no extra sounds or murmurs. His lung sounds are clear. His abdomen is soft and non-tender. His upper extremities have some shoulder shrug and elbow extension to your commands, but his fngers are weak and clumsy. His lower extremities are atrophied and faccid. He has strong peripheral pulses. His skin is intact and warm and dry. He has a Foley catheter in place, but there is not much urine in the bag. "Did you just empty the catheter bag recently?" you ask. "No" she tells you. "It's the same one from last night." "Are you qualifed to change his Foley catheter?" She says she is and agrees to change it before you transport the patient to the hospital. While she does, you place an IV and think about your options for treating hypertensive emergency, just in case your hunch does not play out. The visiting nurse swiftly replaces the catheter, and the patient immediately puts out nearly 1,500 ml of urine. You smile hopefully and take his blood pressure again: 170/90—already trending down. Several minutes later the patient's confusion begins to clear. You smile about your better-than-average start to the day, pull out your phone and call your medical control physician to discuss whether you should transport to the ED or make arrangements for the patient to see his own physician later in the day. The Storm After the Storm Many of the spinal cord injury patients we care for as EMS providers were injured minutes to hours before we treat them, but others were injured years before inter- secting with our care. The patients in this subset have often endured long admis- sions and extensive courses of rehabilita- tion therapy and have been sent home to try to live as normally as they can. This is obviously not an easy road. Paralysis presents constant logistical and mental obstacles but also stresses the body in more subtle, insidious ways. In this article we will talk about autonomic dysrefexia, one of the most dangerous syndromes that challenge patients with spinal cord damage. Autonomic dysrefexia can cause hypertensive crisis and stroke. It most commonly affects patients with severe spinal injuries at T6 or above and is the result of interruption of communication between the brain and sympathetic nerves. The Sympathetic Nervous System The sympathetic nerves start in the brain and proceed down the spinal cord. They exit the spinal cord just below each vertebra from T1 to L2 and go out into the body to innervate the heart, blood vessels, bronchi, skin and other organs. The sympa- thetic nerves go to work when the brain senses a stimulus or stressor acting upon the body that is interpreted as fear, anger or pain. Examples of these stressors are increased oxygen demand from exercise, injury or infection; decreased blood pres- sure from trauma or sepsis; and irritating stimuli from sources such as a urinary tract infection, an overfull bladder, a full rectum, an unrelenting itch or an object exerting | By Tiffany Bombard, NREMT-P, MD Neurotrauma Review Series PART 4: We usually think of our spinal neurotrauma patients as presenting to us immediately after their injuries, still positioned in the environment of their accident. In this, the last in a series of articles on neurological injuries, we will consider our other kind of spinal trauma patient, the one we see long after the day of their injury. 52 APRIL 2014 | EMSWORLD.com EMS_52-55_NeuroP40414.indd 52 3/17/14 7:37 AM