A noxious stimulus below a T6-or-above lesion fires a sympathetic surge the brain cannot call off, because the inhibitory signal cannot cross the injured segment. The body splits in two: flushed and sweating above, cold and goose-fleshed below, with a bradycardia that gives it away. This is the one hypertensive patient you sit up. Act, and the monitor will answer you.
Mr Okafor, 41 · C5 spinal cord injury, ASIA A, 8 months post
Called you in with a pounding headache. Face and neck are flushed and sweating; his legs are pale, cold and covered in goosebumps. He has an indwelling catheter and an abdominal binder and compression stockings on. There has been no urine in the bag for four hours.
Baseline 96/60Spinal shock resolvedCurrently lying flat
Position and first moves
Hunt the trigger
Drugs
Afterwards
Bladder programme — intermittent catheterisation
Bowel programme — which cord lesion?
Build the programme
196/108mmHg46beats/min
Baseline 96/60. This is a rise of 100 mmHg systolic above his own baseline.
Nothing has been done yetThe blood pressure is the whole monitor here. Choose an action on the left and this log will tell you what it bought him — or cost him. Baseline systolic in a person with a high cord injury is often only 90 to 110 mmHg, so a rise of 20 to 40 mmHg above their own baseline is already significant even when the number would look unremarkable in another patient.
SBAR while it is happening
“Dr Vega, this is Priya on 4 West. S: Mr Okafor, C5 ASIA A, is in autonomic dysreflexia — blood pressure 196 over 108, baseline 96 over 60, heart rate 46, pounding headache, face and neck flushed and sweating above his injury level, goosebumps and cold pale skin below. B: Indwelling catheter, no output for four hours. A: I have him sitting upright, binder and stockings off, and I am replacing the blocked catheter now. R: I need an order for nitroglycerin paste or immediate-release nifedipine, and I need you at the bedside. He has not taken a PDE-5 inhibitor.”
Silent dysreflexia is real. Some patients have no headache at all, so any unexplained bradycardia, sweating or blood pressure jump in a T6-or-above patient is dysreflexia until you have excluded it.
Why the programme is the treatment
Delegation boundaryWhere the state practice act and facility policy allow, and after RN teaching and return demonstration, trained assistive personnel may carry out an established, unchanged bowel programme including digital stimulation and suppository insertion on a stable patient. Intermittent catheterisation is not a UAP task in most states — it goes to the LPN/LVN or the RN. What never transfers is the judgement: the RN assesses, teaches the technique, evaluates the result, and owns any patient who is unstable, newly injured, or having an episode of autonomic dysreflexia.
Do not treat asymptomatic bacteriuriaIt is nearly universal in people who catheterise, and treating it breeds resistance without helping the patient. Treat when there are symptoms — and in spinal cord injury the symptoms are atypical: fever, cloudy or foul urine, new or worsening spasticity, new incontinence between catheterisations, malaise, flank or suprapubic discomfort, or an episode of autonomic dysreflexia. Annual follow-up watches for hydronephrosis and reflux, stones, and — after decades of indwelling catheterisation — bladder cancer.