When caring for a patient with a spinal cord injury at the T4 level, the nurse notes the patient has a blood pressure of 210/110 mmHg, a pounding headache, and bradycardia. What is the most likely cause?

1. A

   Hypovolemic shock

2. B

   Autonomic dysreflexia

3. C

   Spinal shock

4. D

   Neurogenic shock

Appeared in: DSSSB 6 September 2024

Explanation

• The patient's symptoms constitute the classic triad of Autonomic Dysreflexia (AD): severe, paroxysmal hypertension, a pounding headache, and reflex bradycardia.
• This condition is a life-threatening emergency that occurs in patients with spinal cord injuries at or above the T6 level.
• It is triggered by a noxious stimulus (like a full bladder or bowel) below the level of the injury.
• The stimulus causes an unopposed sympathetic nervous system surge, leading to vasoconstriction and extreme hypertension below the injury.
• The body's attempt to compensate for the high blood pressure by activating the parasympathetic system (vagus nerve) causes the heart rate to slow down (bradycardia).

Why Other Options Were Wrong

• Option A: Hypovolemic shock is characterized by hypotension (low blood pressure) and tachycardia (fast heart rate) due to fluid or blood loss. The patient presents with severe hypertension and bradycardia, which are opposite signs.
• Option C: Spinal shock is a temporary condition immediately following SCI, characterized by the loss of all reflex activity, flaccid paralysis, and sensory loss below the injury level. It does not cause severe hypertension.
• Option D: Neurogenic shock involves hypotension and bradycardia. While it shares bradycardia with the patient's symptoms, the defining feature is low blood pressure due to widespread vasodilation from a loss of sympathetic tone. The patient has severe hypertension.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Recognition and management of Autonomic Dysreflexia in patients with Spinal Cord Injury to guide bedside assessment, documentation, and the next nursing action.
• Autonomic Dysreflexia is a medical emergency. The nurse's first action is to place the patient in a sitting position to lower blood pressure, followed immediately by a search for and removal of the triggering stimulus.
• Failure to treat AD promptly can lead to seizures, retinal hemorrhage, stroke, myocardial infarction, or even death.
• Patient and family education is crucial for long-term management, as AD can occur years after the initial injury. They must know the signs and the immediate actions to take.

How to Approach the Question

• First, identify the patient's primary diagnosis: a spinal cord injury at the T4 level.
• Next, carefully analyze the cluster of acute symptoms presented: extremely high blood pressure (hypertensive crisis), a pounding headache, and a slow heart rate (bradycardia).
• Recall the major acute complications associated with spinal cord injuries, particularly those above the T6 level.
• Systematically compare the patient's symptom triad with the classic presentations of the four options provided.
• Recognize that severe hypertension combined with bradycardia is the hallmark sign of Autonomic Dysreflexia, distinguishing it from the various forms of shock which typically involve hypotension.

Concept Tested & Keywords

• Concept Tested: Recognition and management of Autonomic Dysreflexia in patients with Spinal Cord Injury.
• Stem keywords: spinal cord injury, T4 level, blood pressure of 210/110 mmHg, pounding headache, bradycardia
• Lead-in keywords: most likely cause
• Clinical cues: The combination of a high-level spinal cord injury (T4 is above T6) with the triad of severe hypertension, headache, and bradycardia is a classic presentation.

Question ID

Q_kmu39Pjqcgg4Mh9_7CW7

Copy ID

Reference Book

E6 Nursing Brunner Adult Health 3SA Vol 2 Part 2 p. 102-104

E6 Physiology Guyton 4SAE Part 2A p. 30-32