Prehospital Reflection:
You are responding to a 40 year old male, conscious, breathing, not alert. BP is excessively high. History: Quadriplegic.
On arrival, you find a 40 year-old wheelchair bound male with a pulse rate of 70, blood pressure of 200/110, flushed to the face, neck and arms with a pounding headache. The patients’ partner had administered 4 sprays of their own glyceryl trinitrate (GTN) before our arrival and reported that catheter bag was filling, he had opened his bowels today and all tight fitting clothing had been removed. The partner advises that this patient has been hospitalized with autonomic dysreflexia in the past.
What is Autonomic Dysreflexia?
Autonomic Dysreflexia (AD) is a potentially lethal fact of life for those living with, or those caring for persons with spinal cord injuries (SCI). Up to 80% of spinal injury patients will experience an episode of AD in their first year post SCI, and recurring episodes are considered common. The condition is characterised by a sudden rise in blood pressure, often in excess of 200mmHg systolic, with an associated throbbing headache, bradycardia and flushing above the level of injury.1 The symptoms begin when a stimulus, usually an undetectable painful stimuli below the SCI. This provokes a sympathetic reflex resulting in wide spread vasoconstriction to the areas below the injury, increasing systemic BP. The parasympathetic nervous system attempts to compensate by decreasing heart rate, vasodilation and flushing in the areas above the SCI. Once these compensatory mechanisms are overwhelmed, BP will continue to rise along with the risk of hemorrhagic stroke, seizure and death.2
Management
Pre-hospital treatment focuses on treating the symptoms with the goal of reducing the risk of these adverse outcomes. Available literature recommends first line treatment (both pre and inter-hospital) with the use of anti-hypertensives such as GTN spray/paste whilst reversible causes are investigated.3 Those of us not familiar with the complication may find ourselves perplexed with the range of presenting symptoms and even more so when devising a treatment plan for these patients. In this case, a call to the CSP in SOC resulted in an ASMA consult to approve the use of continued GTN every 5 minutes. By the time we arrived to hospital, the patients’ blood pressure had dropped to 109/65 and the headache had become bearable. Whilst the outcome for the patient was favorable in this instance, it highlighted that whilst this condition is commonplace among a select population group, many first responders are unaware of the dangers associated with AD and the requirement for rapid pharmacological intervention. Thus, if presenting to a symptomatic SCI patient with a suspected or confirmed diagnosis of autonomic dysreflexia, strongly consider an early ASMA consult for pharmacological management outside of our current guidelines.
References
1.Ginis, K.A., Tomasone, J. R., Welsford, M., Ethans, K., Sinden, A. R., Longeway, M., & Krassioukov, A. (2017). Online training improves paramedics' knowledge of autonomic dysreflexia management guidelines. Spinal Cord, 55(2), 216-222. http://dx.doi./10.1038/sc.2016.116
2.Solinsky, R., Kirshblum, S.C, & Burns, S.P. (2017, August). Exploring detailed characteristics of autonomic dysreflexi. The Journal of Spinal Cord Medicine, 1-8. http://dx.doi./10.1080/10790268.2017.1360434
3.NSW State Spinal Cord Injury Service. (2014). Treatment of Autonomic Dysreflexia for Adults & Adolescents with Spinal Cord Injuries. Agency for Clinical Innovation (Health service series number 13-136). Retrieved from https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0007/155149/Autonomic-Dysreflexia-Treatment.pdf
Page contributors:
Rob Curtis, AP23619
Ambulance Paramedic, Metropolitan Ambulance Service
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