Question 11

College answer

Syllabus topic/section:

2.1.13 Trauma Intensive Care / Spinal trauma: L1
2.1.8 Neurological Intensive Care / Spinal cord disorders: L1

Discussion:  

Candidates who had a good knowledge of longstanding tetraplegia and the corresponding pathophysiology did well. Candidates who had limited knowledge of the disorder but were able to apply general knowledge of management of spinal patients (e.g. bowel care and patency of IDC- very important in this patient population) were able to gain some marks.
The marking rubric is included to aid the candidate's future study

Discussion

• Clinical features:
  • Headache
  • Dizziness
  • Nausea
  • Shortness of breath
  • Visual disturbances
  • Palpitations
  • Facial flushing, nasal congestion and sweating above the spinal lesion (baroreceptor-mediated vasodilatation)
  • Cold clammy skin with piloerection below the lesion level 
  • "Autonomic conflict"- cardiac arrhythmias arising from competing massive sympathetic and concurrent vigorous parasympathetic activity
  • Hypertension is the dominant finding, and leads to complications, such as:
    • Myocardial ischaemia and pulmonary oedema
    • PRES and intracranial haemorrhage
    • Seizures
• Prevention strategies:
  • A - if the patient was intubated, you would extubate as soon as able, as these patients will have frequent episodes of dysreflexia in reaction to the ETT. If not intubated, they would have an NGT, and it would be a priority to remove oit.
  • B - avoid noxious airway stimuli, eg. suctioning 
  • C- Keep the circulating volume in the lower body by raising the head of the bed
  • D - even though there is no pain sensation, analgesia helps prevent noxious stimuli from triggering the episodes. 
  • E - Maintain normal electrolytes so as not to give the gut a chance to do an ileus
  • F - maintain good urine output, support good hydration, prevent urinary retention by intermittent catheterisation.
  • G - Maintain regular bowel regime with aperients and enemas (the goal is to prevent constipation)
• Management:
  • During a hypertensive crisis, 
    • Lower the legs and elevate the head (Trendelenburg position)
    • Check the usual suspects:
      • Tight binding clothes
      • Urinary catheter/bladder (retention?)
      • Bowels (constipation?)
      • Pain (give empirical analgesia)
    • Use short-acting titratable agents:
      • GTN patches or nitroglycerine paste (2%) onto the skin above the spinal level
      • Nifedipine and prazocin also sometimes used
      • Clonidine, hydralazine, labetalol, captopril, all are seen in the wild
  • Long term:
    • Botox injections
    • Intravesical capsaicin
    • Transurethral sphincterotomy
    • Sacral bladder denervation via dorsal rhizotomies 
    • Malone anterograde continence enema (MACE)