Morning Report: 3/25/2014

Thanks to Dr. Ting for today’s Morning Report!

Chronic SCI

Complications of chronic SCI

– DVT/PE

– Decubitus ulcers

– Pneumonia (even down to thoracic levels although only C3-5 controls the diaphragm due to impaired cough reflex)

– Increased prevalence of CAD

– UTI/renal stones due to bladder dysfunction and indwelling foley or intermittent self-catheterization

– With lesions above T6, disrupted splanchnic sympathetic output decreases vasoconstrictive response to positional changes. This and less LE muscular squeeze lead to more venous pooling and decreased cardiac filling/output. This causes baseline hypotension and orthostatic hypotension. Also likely more rapid decompensation in hypovolemic and distributive shock

– Atypical presentations: no chest pain in cardiac conditions with lesions above T5. Abdominal emergencies may present with vague complaints only – nausea /anorexia or …

Autonomic dysreflexia

– Occurs in patients with injury above T6

– Triggered by stimulus (eg bladder distension, fecal impaction, UTI, tight clothing, sexual arousal, abdominal emergencies) below level of injury which triggers intact spinal sympathetic reflex arcs and leads to splanchnic and peripheral vasoconstriction.

– Functioning baroreceptors (carotid sinus) signal brain that hypertension is occurring

– Vagus response slows HR and causes vasodilatation but inhibitory signal is disrupted by lesion

– Classically:

elevated BP
flushing, nasal congestion above lesion level, diaphoresis
piloerection below lesion level
flushing above lesion level
nasal congestion,
usually bradycardia sometimes tachycardia

– Can progress to true HTNsive emergency – complications include retinal hemorrhage, ICH, MI, APE, seizure

– Rx: simple things first – loosen tight clothing, sit upright, decompress bladder, disimpact rectum

If syndrome persists, continue search for inciting stimulus
BP mgmt with nitrates* or nifedipine. Also hydralazine, labetalol
*many pts will be on Viagra

– Dispo: low threshold to admit if unresolved or treated with meds but source not identified

Sources

Stephenson, R., Berliner, J. (Oct 17, 2013). Autonomic dysreflexia in spinal cord injury. Retried from: http://emedicine.medscape.com/article/322809-overview#showall
Claydon, V, Steeves J. & Krassioukov, A. Orthostatic hypotension following spinal cord injury: understanding clinical pathophysiology. Spinal Cord (2006) 44, 341-351
McKinley WO, Gittler MS, Kirshblum SC, et al. Spinal cord injury medicine. 2. Medical complications after spinal cord injury: Identification and management. Arch Phys Med Rehabil 2002; 83:S58.