DFIB Posted October 3, 2012 Author Posted October 3, 2012 (edited) Well hell. Foley? Removed? Sweating? High pressure? Autonomic dysreflexia. Sit his ass upright! Wendy CO EMT-B RN-ADN Student You are just way too good Wendy! Actually it is not any patient I have personally attended. I just thought Autonomic Dysreflexia was an interesting case study in the prehospital setting so I set up the obvious path to a relatively straightforward discover. It interested me that sex could trigger this condition and bladder distention is the number one cause so u decided to use them both. I pitched in a couple of drugs to to cover the scent and had a lot of fun with the assumptions I thought participants would make. All the added drama was just for fun. I am curious, would you try to medicate this patient's hypertension or just fix the origin of the stimuli? Anyone care to mention the second most common cause of this condition? Edited October 3, 2012 by DFIB
island emt Posted October 3, 2012 Posted October 3, 2012 I was overlooking all the widow dressing such as barking dog ,newly mowed lawn hedges need trimming, etc. The weapons out in plain view are still a red flag to me. You don't forget the sound of high velocity lead hitting the walls a foot over your head , EVER. The redneck riviera scenario re-enforced the perception of possible dangers on entering the scene. It wasn't until the end that you gave the thoracic spinal injury and cause. Good on you Wendy!
Arctickat Posted October 3, 2012 Posted October 3, 2012 I was too busy gawking at the hot wife in her skimpy robe and lingerie...she really should have put on her bulky USMC? sweats and sweatshirt. She had enough time to do that whilst waiting for us to arrive. Sigh...sometimes I just with I had a head cam.
DFIB Posted October 3, 2012 Author Posted October 3, 2012 I was overlooking all the widow dressing such as barking dog ,newly mowed lawn hedges need trimming, etc. The weapons out in plain view are still a red flag to me. You don't forget the sound of high velocity lead hitting the walls a foot over your head , EVER. The redneck riviera scenario re-enforced the perception of possible dangers on entering the scene. It wasn't until the end that you gave the thoracic spinal injury and cause. Good on you Wendy! It did go kinda fast after that! All of you guys are great! I love bouncing ideas around with all of you.
island emt Posted October 3, 2012 Posted October 3, 2012 OK Wendy here's a challenge for you. Why don't you give a short lecture /training on Autonomic dysreflexia. Defib that was a pretty good scenario to make folks think.
DFIB Posted October 4, 2012 Author Posted October 4, 2012 (edited) OK Wendy here's a challenge for you. Why don't you give a short lecture /training on Autonomic dysreflexia. Defib that was a pretty good scenario to make folks think. I am already on it. To follow shortly but if Wendy wants to beat me to it she is welcome. AUTONOMIC DYSREFLEXIA Autonomic Dysreflexia is an important imbalanced reflex sympathetic discharge that is common in patients with spinal cord injury above T-6 vertebrae. Statistically Autonomic Dysreflexia can occur in 49%-90% of all persons with spinal cord injury above the splanchnic sympathetic outflow[1] although there are reports of patients presenting Autonomic Dysreflexia with spinal cord injuries as low as T-10. The rate of occurrence can vary greatly from several incidents per day in some patients to an occasional presentation or none in others. The first presentation is usually 4-6 months after injury but can present as early as two months or even after years, Since males are 4 times more likely to suffer spinal cord injury, Autonomic Dysreflexia is almost an exclusive male condition although approximately 66% of pregnant women develop Autonomic Dysreflexia during labor.[2] Since Autonomic Dysreflexia seems to be a condition that is exclusive to patients with spinal cord injury above the T-6 vertebrae, and generally occurs in an out-of-hospital setting many physicians have never seen this condition and would not recognize it when presented. This scenario also amplifies the importance that pre-hospital providers be familiar with the presentation and treatment of Autonomic Dysreflexia in the field.[3] More to follow. [1] Medscape Reference, Autonomic Dysreflexia in Spinal Cord Injury http://emedicine.med...rview#aw2aab6b4 [2] Medscape Reference, Autonomic Dysreflexia in Spinal Cord Injury, IBID [3] Spinal Cord Injury Information Network, Autonomic Dysreflexia, Fact sheet # 25, http://www.spinalcor...asp?durki=21542 Edited October 4, 2012 by DFIB
DFIB Posted October 4, 2012 Author Posted October 4, 2012 Autonomic Dysreflexia is the nervous system reaction to overstimulation of the autonomic nervous system when there is an interrupted flow of stimulation at the level of the injury. The mechanism of this condition begins in patients that have a spinal cord injury above the splanchnic outflow, generally above the 6th thoracic vertebrae. The development of this mechanism is described below. 1) Below the injury, the intact peripheral nerves transmit strong nervous stimuli into the spinal cord and stimulate the sympathetic neurons located in the intermediolateral gray matter of the spinal cord. This stimuli does not have to be a painful stimuli as even pleasurable stimuli such as sexual intercourse can trigger this condition. 2) The sensory input or stimuli travels up the spinal cord and provokes a huge sympathetic surge from the thoracolumbar sympathetic nerves, resulting in peripheral hypertension, caused by widespread vasoconstriction primarily in the subdiagfragmatic vasculature. 3) The surge in the sympathetic reaction releases an entire gamma of neurotransmitters , norepinephrine, dopamine-b-hydroxylase, dopamine, that result in vasodilation above the level of injury but that is blocked from traveling to the subdiagfragmatic vessels. This explains symptoms such as piloerection, skin parlor and sudation above the injury. 4) Baroreceptors in the neck detect the increase in pressure and respond to the hypertension by provoking bradicardia and vasodilation above the level of injury. This can be explained by Poiseuille formula that basically states the variables that affect pressure in a controlled environment taking into account viscosity, vessel lumen radius, fluid velocity and length of the pipe length of the pipe. For the purpose of our discussion Poiseuille Formila “demonstrates that pressure in a tube is affected to the fourth power by a change in radius (vasoconstriction); the pressure is affected only linearly by a change in flow rate (bradycardia).” (Wikipedia http://en.wikipedia....euille_equation ) 5) The brain attempts to shut down the sympathetic surge by sending inhibitory impulses that are blocked at the level of the spinal cord injury. At the same time there is a vagal parasympathetic stimuli that produces bradicardia that cannot compensate so the hypertension continues.( Medscape Reference, Autonomic Dysreflexia in Spinal Cord Injury) In conclusion the essence of the effects of Autonomic Dysreflexia is that the upper half of the body is under parasympathetic control and the lower half of the body is under sympathetic control where the hypertension is caused by sympathetic vasoconstriction and the headache, by parasympathetic vasodilation. The solution is to remove the stimulus so that the reflex hypertension can resolve.
DFIB Posted October 4, 2012 Author Posted October 4, 2012 (edited) The most common cause of this condition is urinary due to bladder distention and/or bladder spasms. It can also be caused by the inserting of a catheter. It was first observed in 1890 by Anthony Bowlby during the cauterization of a patient with spinal cord injury. The second most common cause is bowel related due to rectal distention. This destention can be due to constipation, edema, rectal exams, suppository insertion, impaction, enemas, or any other mechanical or physiological force that can cause distention. (Spinal Cord Injury Information Network, Autonomic Dysreflexia, Fact sheet # 25,) The immediate pre-hospital management is the elimination of the cause. Since Autonomic Dysreflexia can be caused by a host of reasons immediately begin by placing the patient in a sitting position with their feed dangling, loosen their clothing while looking for any obvious source of noxious stimuli starting with the urinary system followed by checking the bowels. An quick acting, short action antihypertensive should be administered while looking for the root cause if the blood pressure is above 150mmHg systolic. If the patient does not have a catheter in place one should be inserted immediately. If a catheter is in place check the catheter for correct placement and obstructions such as kinks, folds, or constrictions. If the catheter seems to be blocked gentle irrigation should be initiated with warm saline. Palpation or tapping of the bladder should be avoided. If the catheter is properly placed and is draining and hypertension persists, we should be suspect of fecal impaction and check the rectum for feces using Xilocaine jelly as a lubricant. This will lubricate the finger and anus while diminishing further stimuli. (Medscape Reference, Autonomic Dysreflexia in Spinal Cord Injury.) A quick acting short duration anti-hypertensive can be administered if necessary. “The most commonly used agents are nifedipine and nitrates (eg, nitroglycerine paste). Nifedipine 10mg should be in the immediate release form; bite and swallow is the preferred method of administering the drug, not sublingual administration. Other agents used are mecamylamine, diazoxide, and phenoxybenzamine. Use antihypertensives with extreme caution in older persons or in people with coronary artery disease.” (Medscape Reference, Autonomic Dysreflexia in Spinal Cord Injury) If the blood pressure remains high Nifedipine 10mg can be repeated in 30-60 minutes. Patients who suffer from Autonomic Dysreflexia should be monitored for 2 hours after the cause is resolved. If the cause of Autonomic Dysreflexia cannot be identified the patient should be admitted into the Emergency Department for observation and management. Conclusion: Autonomic Dysreflexia is a life threatening condition and it’s understanding extremely important to pre-hospital providers. A misdiagnosed or mismanaged Autonomic Dysreflexia incident can deteriorate very quickly causing permanent neurological, cardiac or vascular damage. A provider must not only understand the contradictory physiological findings but have the skills so search out and resolve the origin of the offending stimuli. Edited October 4, 2012 by DFIB
DFIB Posted October 4, 2012 Author Posted October 4, 2012 Additionally I am a little surprised at the percentages of men with spinal cord injury that are capable of sexual activity. "In 200 male paraplegics, 36.5% were unable to have erections; 42.5% were able to have erections on local stimulation; 21% were able to have erections on psychic stimulation. Of the 200 paraplegics 46 have had intercourse with intromission; 20 of these had ejaculations and 12 more reported gratification without ejaculation. Since two-thirds of these 200 patients are capable of at least a reflex erectile response, they should not be dismissed as permanently impotent. The author closes with a discussion of the relation of this response to the level and completeness of the spinal cord lesion." (A report on sexual function in paraplegics, Talbot, Herbert S., Journal of Urology (Baltimore), Vol 61, 1949, 265-270.) This scenario was a lot if fun. Thank you everyone for participating.
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