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Thread: Dr.young ...need help from you AD & HIGH BP

  1. #1

    Dr.young ...need help from you AD & HIGH BP

    Hi Sir,
    My Brother in law lives in India had c5-c6 injury in April 09 & is quad.He is in Rehab center from the past 8months.
    He had an episode of Autonomic dysreflexia in Sept.& during that time he had seizures & high BP..He spent 5 days in ICU.& now he is taking antiseizure medicine& high Bp medicine .Doctors r saying AD is under control but still his BP is not under control .
    He went for Urodyanimic test but during that time his BP shoots up so they cancelled it.
    He is using catheter now instead of CIC .In the morning before he passes stool his Bp is in the range if 160/100 but soon after passing stool his BP is in the range of130/80 or 120/70.

    Do you think he has some bowel problem.
    Which tests we shud perform to rule out the problem?
    Which is better catheter or CIC in the long run.
    He wants to go back to his home but still in the rehab center as his BP is not under control.
    Please Dr.Wise help us..
    preety

  2. #2
    Something is causing his AD. Someone with a tetraplegic injury should have a blood pressure of around 90-100 systolic, and 50-60 diastolic. Does he have symptoms when his AD is active? Generally any systolic blood pressure rise of 40 mm. Hg. or more over resting baseline should be treated as AD. What was his blood pressure prior to his SCI? Has he had tests to rule out other causes of high blood pressure such as an adrenal tumor?

    Does he have pressure ulcers? HO? Fractures? Has he had abdominal ultrasound to rule out abdominal pathology? It is common to have mild to moderate AD during bowel care. Is he using an anesthetic ointment or gel with his bowel care to try to prevent this? Is he taking any medication to control his AD? It is critical to find the cause if it is AD, as the cause itself can be life threatening.

    I hope your brother's doctors have this document. If not, insist that they get it: http://www.pva.org/site/News2?page=NewsArticle&id=7657

    You and he should read this one: http://www.pva.org/site/News2?page=NewsArticle&id=7747


    (KLD)

  3. #3
    YES he had high BP before SCI .After the injury his BP was in the range of 130/80 & 110/70 for 7months post SCIafter that he had an episode of AD& now his BP is flutuating very high& low.
    He is taking medicine for his seizures,BP medicine,antimuscarinic drug (ROLITEN),Baclofen,Urimax.
    Is there any medicine for AD?We have no idea about it..
    They apply jelly before Bowel movement but before Bowel movement he gets high BP ( very early in the morning).

  4. #4
    Quote Originally Posted by dinpooja View Post
    Hi Sir,
    My Brother in law lives in India had c5-c6 injury in April 09 & is quad.He is in Rehab center from the past 8months.
    He had an episode of Autonomic dysreflexia in Sept.& during that time he had seizures & high BP..He spent 5 days in ICU.& now he is taking antiseizure medicine& high Bp medicine .Doctors r saying AD is under control but still his BP is not under control .
    He went for Urodyanimic test but during that time his BP shoots up so they cancelled it.
    He is using catheter now instead of CIC .In the morning before he passes stool his Bp is in the range if 160/100 but soon after passing stool his BP is in the range of130/80 or 120/70.

    Do you think he has some bowel problem.
    Which tests we shud perform to rule out the problem?
    Which is better catheter or CIC in the long run.
    He wants to go back to his home but still in the rehab center as his BP is not under control.
    Please Dr.Wise help us..
    preety
    Preety,

    I agree with what KLD (SCI-Nurse) is saying. It is likely that something is causing the autonomic dysreflexia (AD). The two most common sources of sensory input that cause AD are the gut and the bladder. As you mention, it may be related to his bowel movement. Bowel movements often cause AD. It would be useful to try anesthetic ointment (i.e. ointment with lidocaine) to numb the rectal areas to see if it reduces the AD. Another possibiity is that he has a kidney or bladder stone. This can be ruled out with an x-ray of the kidney and urinary tract.

    Let me explain what AD and, once the mechanisms are clear, it is easier to explain the medications for AD. AD usually occurs in people who have spinal cord injury above T5. A strong sensation (painful or not, coming from below the injury site) stimulates the spinal cord to increase sympathetic activity. This causes blood vessels in the lower body to constrict, raising blood pressure. You can see pilo-erection (goose bumps) in the skin below the injury site. The heart rate may initially increases because of the catecholamines (adrenalin and noradrenalin) released by the sympathetic nervous system.

    Normally, the brain regulates sympathetic activity by sending inhibitory signals from the brainstem through the spinal cord to the sympathetic neurons in the lower spinal cord. The sympathetic neurons activate neurons in the sympathetic ganglia. However, because of the spinal cord injury, these inhibitory signals don't get down into the spinal cord. So, the sympathetic activity continues. The other part of the parasympathetic system is the vagus nerve (the tenth cranial nerve) that does not go through the spinal cord. The vagus releases acetylcholine that affect muscarinic receptors to slow down the heart. So, paradoxically, during an AD attack, the heart slows down and can even become abnormally slow, i.e. bradycardia. The parasympathetic system will also activate profuse sweating and vasodilation above the injury site, as well as a pounding headache from the vasodilation.

    As you can see, treatment of AD will not be simple. If one gives catecholamine blockers, it may reduces some of the sympathetic effects of the AD episodes but this may aggravate the other symptoms above the injury site, such as bradycardia, vasodilation above the injury site, and headaches. If one gave muscarinic blockers, it may reduce some of the parasympathetic response to the AD but this may make the hypertension worse. Ganglionic blockers may work but would not stop the vagal effects. For this reasons, many doctors use drugs just to get the AD under control and then focus on eliminating the cause. For example, doctors often use a calcium channel blocker, such as nifedipine, to block vasoconstrictive effects of catecholamines. A direct vasodilator, such as nitric paste, can also be used.

    In an emergency room, when a person with AD is encountered, doctors typically take the following steps in the following order to control the AD:
    1. They put a foley catheter in to make sure that the bladder is draining. A full bladder is one of the most common causes of AD.
    2. Using lidocaine jelly to anesthetize the anus and rectum, the rectum would be digitally examined to rule out fecal impaction.
    3. Drug Therapies
      1. Calcium channel blocker nifedipine (10 mg po)
      2. Vasodilator nitroglycerine spray (0.4 mg) or ointment (2%) to chest
      3. Alpha-adrenergic blocker phenoxybenzamine (10 mg po bid) will help reduce long term vasoconstriction, continue as necessary (20-40 mg/day).
      4. Ganglionic blocker Mecamylamine (2.5 mg po) should rapidly reduce blood pressure.
      5. Anti-hypertensive Diazoxide (1-3 mg/kg up to 150 mg) injections until mean blood pressure is <100 mm Hg.


    The drugs are obviously to lower blood pressure so that they do not cause a devastating brain hemorrhage or other problems. Once blood pressure is down, the cause of the AD must be identified and removed. A list of some causes are given in this article http://emedicine.medscape.com/article/322809-overview

    Wise.
    Last edited by Wise Young; 11-29-2009 at 03:11 PM.

  5. #5
    Thankyou Dr.wise & SCI Nurse....
    Dr. Wise is there any specific medicine for AD .
    Actually my BIL is taking antiseizure& antihypertensive medicine, antimuscarinic drug ...Are those r AD prevention drugs?
    Which tests shud be done to rule out what is causing AD apart from kidney xray...
    do u think my BIL shud have urodyanmic test ?
    thanx again
    preety
    Last edited by dinpooja; 11-30-2009 at 12:10 AM.

  6. #6
    Anticholenergic medications will reduce some AD symptoms due to bladder pressure, but do not prevent AD. They may only mask symptoms. There are no medications that will prevent AD, and again, the AD is only a SYMPTOM of something else seriously wrong. If you mask the symptoms, you may miss a life threatening condition that is causing the AD.

    When looking for AD, since 90% of the causes are urinary, the main culprits are overdistended bladder, high bladder pressures, clogged indwelling catheters, urinary tract infections and stones. Conditions such as epididymitis can also cause it, as can sitting on the testicles.

    8% of the time it is gastrointestinal, usually constipation or impaction, or doing bowel care with digital stimulation. Using lidocaine gel 2-4% will usually help with the latter (not just regular lubricant). It can also be caused by gall stones, gastritis or a gastric ulcer, appendicitis, or any other abominal pathology.

    It can also be broken bones, pressure ulcers, tight fitting braces, shoes or clothing, or anything else below the level of injury that is causing the body pain.

    Medications that are used IN AN EMERGENCY to keep the blood pressure down to prevent a stroke include nifedipine or any other fast acting ganglionic blocker (ace inhibitor, calcium channel blocker). Sometimes IV Apresoline or Nitroglycerine paste is used. Medication should NOT be the only action taken. It should be used only to prevent a stroke while the cause is looked for and eliminated/treated.

    If your brother is considering doing intermittent cath, then urodynamics should be done 3-6 months post injury and then annually thereafter. It is not necessary or helpful if he is going to use a long-term indwelling catheter. We do not recommend the latter for young people who are able to cath themselves if at all possible, as there are less complications if intermittent cath is done properly.

    (KLD)

  7. #7
    I know it's probably a stupid question, but what's 'AD'?

  8. #8
    AD = Autonomic Dysreflexia, a very dangerous condition that can occur in those with injuries at T7 or above. As above: http://www.pva.org/site/News2?page=NewsArticle&id=7747

    (KLD)

  9. #9
    Thanks

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