As a trial lawyer in Atlanta, Georiga, working with clients who have suffered spinal cord injuries, including both paraplegia and quadriplegia, I have found a wide array of effects of such injury about which most people know nothing. One of those is autonomic dysreflexia. Of course, this incomplete and over-simplified post cannot constitute medical advice, only an expression of awareness of the problem and the types of things that must be communicated to a jury at trial to help them understand.
On one occasion, a very independent young client who became paraplegic due to an injury was stopped speeding in a small town in New Mexico en route to California. The client had a tough time explaining to an officer why, due to autonomic dysreflexia, it was a matter of life and death to a handicapped equipped restroom as quickly as possible. It took letter from a physician at Shepherd Spinal Center explaining the condition to get the ticket dropped without the client having to return to New Mexico.
Autonomic dysreflexia is a problem for which spinal cord injury victims are very susceptible, especially if the injury is at or above the T-5 level. People with spinal cord injuries at T6 – T10 may also be susceptible. It is unusual with injuries at T-10 and below. The older the injury the less likely the person will experience autonomic dysreflexia.
Autonomic dysreflexia can develop suddenly, and is a possible emergency situation. If not treated promptly and correctly, it may lead to seizures, stroke, and even death.
Autonomic dysreflexia means an over-activity of the Autonomic Nervous System. It can occur when an irritating stimulus is introduced to the body below the level of spinal cord injury, such as an overfull bladder. The stimulus sends nerve impulses to the spinal cord, where they travel upward until they are blocked by the lesion at the level of injury. Since the impulses cannot reach the brain, a reflex is activated that increases activity of the sympathetic portion of autonomic nervous system. This results in spasms and a narrowing of the blood vessels, which causes a rise in the blood pressure. Nerve receptors in the heart and blood vessels detect this rise in blood pressure and send a message to the brain. The brain sends a message to the heart, causing the heartbeat to slow down and the blood vessels above the level of injury to dilate. However, the brain cannot send messages below the level of injury, due to the spinal cord lesion, and therefore the blood pressure cannot be regulated.
Symptoms of autonomic dysreflexia include pounding headache (caused by the elevation in blood pressure), goose pimples, sweating above the level of injury, nasal congestion, slow pulse, blotching of the skin and restlessness.
The most common stimuli causing an episode of autonomic dysreflexia are an overfull bladder a bowel full of excrement or gas. As spinal cord injury victims and their loved ones are painfully aware, these toileting issues are a major — and often humilitating — problem for people with spinal cord injuries. Any stimulus to the rectum, such as digital stimulation, can trigger a reaction, leading to autonomic dysreflexia. Other causes include skin irritations, wounds, pressure sores, burns, broken bones, pregnancy, ingrown toenails, appendicitis, and other medical complications.
Treatment of autonomic dysreflexia must be initiated quickly to prevent complications. Since a full bladder is the most common cause, the first thing to do is check the urinary drainage system. If a Foley or suprapubic catheter is used, check to see if the bag is full or elevated, the tube kinked, or the catheter plugged. If those obvious things do not solve the problem, change the catheter immediately. If that doesn’t work, digital stimulation to evacuate the bowel is probably the next step. If neither bladder nor bowel is stimulating autonomic dysreflexia, check for a pressure sore, ingrown toenail or fractured bone. If all those causes have been elimiated, get to the emergency room ASAP. Spinal cord injury patients should carry a card explaining autonomic dysreflexia and the treatments required.
As with most things, an ounce of prevention is worth a pound of cure. Some precautions that a spinal cord injury patient can take include:
- If using an indwelling catheter, keep the tubing free of kinks, the drainage bags empty, check daily for grits (deposits) inside of the catheter, and .catheterize yourself as often as necessary to prevent overfilling.
- If you have spontaneous voiding, make sure you have an adequate output.
- Carry spare clothes and an intermittent catheter kit when you are away from home.
- Maintain a regular bowel program.
- Perform routine skin assessments.
- Have a yearly re-evaluation.
There are many online information resources about spinal cord injury and autonomic dysreflexia It is extremely important that anyone with a spinal cord injury go to a specialized rehabitation center such as the Shepherd Center in Atlanta, which is just a mile or so down the street from us.
As I mentioned above, none of this is medical advice. But if you are going to trial to recover damages sufficient to fund a life care plan for a spinal cord injury, it is important to have a lawyer to understands this stuff well enough to communicate it effectively to a judge and jurors who never heard of autonomic dysreflexia.
The Shigley Law Firm represents plaintiffs in wrongful death and catastrophic injury (including spinal cord and brain injuries) in cases statewide in Georgia, and in other states subject to the multijurisdictional practice and pro hac vice rules in each state. Ken Shigley was designated as a "SuperLawyer" in Atlanta Magazine and one of the "Legal Elite" in Georgia Trend Magazine. He is a Certified Civil Trial Advocate of the National Board of Trial Advocacy, and has been chair of both the Southeastern Motor Carrier Liability Institute and the Georgia Insurance Law Institute. He particularly focuses on cases arising from truck and bus accidents and defectively manufactured products.