Autonomic Dysreflexia and Pressure Injury in Pediatric C5 SCI
A 10-year-old girl is in inpatient rehabilitation 8 weeks after a C5 AIS B spinal cord injury from a fall. Her baseline blood pressure is 90/60 mm Hg and heart rate 80. During a bowel program she develops profuse sweating, a pounding headache, heart rate 46, and blood pressure 152/94. She also has a 3-cm stage 2 pressure injury over the sacrum. She uses a manual wheelchair with a foam cushion and spends most of the day in bed because of fatigue. Her family is eager for discharge in 2 weeks. The team is debating whether to stop the bowel program, start an antihypertensive, or investigate other triggers.
1. How would you manage the acute episode and determine the likely triggers?
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This is autonomic dysreflexia until proven otherwise. Sit her upright, loosen clothing, check blood pressure and heart rate, and search for noxious stimuli: kinked catheter or urinary retention, fecal impaction, pressure injury, ingrown toenail, fracture, or tight clothing. The sacral wound and bowel program are likely triggers. Remove the trigger; if blood pressure remains dangerously elevated, use a short-acting antihypertensive per protocol and monitor for seizure or intracranial hemorrhage. Do not permanently stop bowel care; modify it with anesthetic gel, gentle technique, and premedication. Document baseline blood pressure and educate caregivers to recognize early symptoms.
2. What seating and pressure-relief plan would you implement before discharge?
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The current foam cushion and prolonged bed rest are inadequate. Obtain a pressure-relief cushion with pressure mapping, teach tilt or recline and weight shifts every 15–30 minutes while up, and schedule repositioning every 2 hours in bed. Offload the sacrum, provide wound care and nutrition support, and check the wound at every shift. Involve OT and PT for a seating assessment, transfer training, and gradual increase in upright time. Consider a power option or a lighter wheelchair if fatigue limits self-propulsion. The plan must be practical for home and school, with written skin checks and a responsible adult identified.
3. What discharge criteria and caregiver training would you require before home discharge in 2 weeks?
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Two weeks may be too soon unless the family can demonstrate recognition and management of autonomic dysreflexia, blood pressure monitoring, bowel and bladder care, skin checks, and emergency activation. Set criteria: no recent severe episode, healing wound, safe seating, trained caregivers, and a written emergency plan. Provide a home blood pressure cuff, a bowel program that avoids triggers, school nurse education, and follow-up with rehabilitation and urology. If criteria are not met, recommend a short extension or a structured home health plan rather than discharge based on calendar date.