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NEUROTRAUMA REVIEW For More Information Circle 27 on Reader Service Card C 3 , C 4 , C 5 Phrenic nerve roots L 2 , L 3 , L 4 Knee extensions (Quadriceps muscle) C 5 , C 6 (biceps brachii muscle) C 8 , T 1 Finger abduction T 2 - T 7 Chest and intercostal muscles T 1 - L 2 Sympathetic nerves S 1 - S 2 (gastrocnemius muscle) S 2 - S 5 Bladder and anal sphincters T 8 C 7 C 1 C 2 L 5 S 3 S 4 S 5 co C 1 C 2 C 3 C 4 C 5 C 6 C 7 T 1 T 2 T 3 T 4 T 5 T 6 T 7 T 8 T 9 T 10 T 11 T 12 L 1 L 2 L 3 L 4 L 5 S 1 S 2 S 3 S 4 S 5 Figure 1: The sympathetic nerves exit the spinal cord at T1–L2. Fran Milner, www.franimation.com fexia, the syndrome is defned by sympathetic prompting of dangerously high heart rates and blood pressures. If uninterrupted, autonomic dysrefexia occasionally moderates on its own, but it often leads to hypertensive crisis and even to vasospastic or hemorrhagic stroke. The most common stimuli that activate the sympathetic refex arc and cause autonomic dysrefexia concern the bladder. They are urinary tract infections, kidney stones and even just a full bladder. Unfortunately, because many spinal cord injury patients use urine catheters, they are particularly at risk for these problems. The second-most common dysrefexia triggers are stimuli from the rectum, such as fecal impaction or stool-flled rectum. Many spinal cord injury patients cannot have spontaneous bowel movements (caregivers must activate the rectum digitally to cause defecation), so they are espe- cially at risk for these problems as well. Other common problem stimuli are post-operative pain, 2 objects such as cushions or tightly wrapped sheets or wheelchair arms exerting prolonged pressure against the skin, tight-ftting clothing, sunburn, ingrown toenails, pregnancy, appendicitis, gallstones and any other irritating stimuli occurring below the level of injury. Autonomic dysrefexia patients look sick from the door, and they are. Along with acute onset of tachycardia and hypertension, signs and symp- toms of autonomic dysrefexia include headache, vision changes, anxiety, piloerection (goose bumps), diaphoresis and fushing above the level of injury with pallor below. 1 How Do I Fix It? First and foremost try to fnd the source of the irritation. If there is a caregiver on scene, such as a visiting nurse or home health aide or domestic partner or spouse, they can be of great help. So can your medical control physician. Consider the most common causes frst, then call medical control, if needed, for guidance on how to proceed to eliminate them. This means observing the urinary catheter if it is indwelling. Clean- looking catheter tubing and lots of clear, light-colored urine in the bag are good signs. Sparse, cloudy, dark urine is not. Ask whether the patient has had a normal amount of urine output over the last 24–48 hours and whether there has been a change in color or clarity. If there is any suspicion of catheter obstruction or infection, ask your medical control physician whether they want the patient or their care assistant (or you, if you are so trained) to remove and/or replace the catheter using sterile procedure. If the patient does not have an indwelling catheter but instead "straight catheterizes" to get urine out of their bladder, it is again to the patient's advantage to empty their bladder immediately. 3 Ask about the patient's recent bowel movements. Remember, if you think a full rectum is the source of the problem, caregivers for quadriplegic patients are usually qualifed to help the patient empty their rectum. Asking them to do so in situ might alleviate dysrefexic symptoms before they get worse. Look for skin ulcerations, burns, tight clothing and other trauma and irritants, and ask about recent surgery, illness, trauma, chills, fevers, cough, vomiting, diarrhea and the possibility of pregnancy. • UTI • Kidney stones • Full bladder • Catheter obstruction • Fecal impaction • Full rectum • Post-operative pain • Pregnancy • Prolonged pressure against the skin • Sunburn • Appendicitis • Gallstones Figure 1: Common Problematic Stimuli 54 APRIL 2014 | EMSWORLD.com EMS_52-55_NeuroP40414.indd 54 3/17/14 7:37 AM