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M - Cardiovascular Integrity

Autonomic Dysfunction Related to CVD Management of AD varies and is often site dependent (Figure 4.0). The Paralyzed Veterans of America (PVA) Consumer Guide Autonomic Dysreflexia: What You Should Know (www.pva.org) has been used for patient education at most E-Scan sites (10 of 12). Within the sites, six reported using PVA guidelines routinely, and four sites report using them when deemed appropriate. Individuals with SCI are routinely provided with AD wallet-sized information cards summarizing the signs, symptoms and management of AD, to serve as a medical alert in an emergency room setting, after discharge from inpatient rehabilitation. Nurses, physiatrists, physiotherapists and/or urologists, at these sites, typically distribute wallet cards. GF Strong routinely distributes a customized AD card. Additionally, two sites use modified AD assessment tools, at their sites. Given the documented lack of knowledge (regarding the recognition and management of AD, among emergency service practitioners in tertiary health science centres reported in only three provinces - British Columbia, Manitoba and Ontario), the practice of carrying wallet cards is prudent and should be universal. Also, given that an ABC of AD certification course has been developed (by a collaboration of Canadian researchers and clinicians), promotion of AD training and certification among patients, family members, rehabilitation team members and emergency room personnel should be a key focus of continuing professional development, in rehabilitation and rehabilitation-related care settings. Unfortunately, no sites report routine assessment of OH. OH can be assessed via sympathetic skin responses (SSR) and/or the Sit Up Test, a key element of the autonomic standards, and a recent addition to the International Standards for the Neurological Classification of Spinal Cord Injury (reference in Table 4.0). Only one of 12 sites reports conduct of the SSR, by a nurse or physical therapist. Assessment and management using testing of postural blood pressure, autonomic testing, bedside blood pressure monitoring, orthostatic blood pressure monitoring and/or 24-hour blood pressure monitoring are conducted. However, these approaches were reported to occur at only one site. This could be related to an error in reporting by individuals responsible for the E-Scan data collection, at each site or, alternatively, there are no formalized protocols established. Of concern is that, no matter the approach, basic blood pressure monitoring is not being internalized in SCI rehabilitation environments, with the likely consequence that the relationship of blood pressure to OH may not be readily recognized - unless the patient reports presyncope or syncope symptoms. Approaches to Management of Autonomic Dysreflexia Managing AD requires a consistent approach to ensure that the individual receives the appropriate management, in a timely manner. Figure 5.0 demonstrates a protocol that has been established, for when the patient presents with the signs and symptoms, which can be used for non-drug management. Rehabilitation programs routinely utilize these approaches. Figure 4.0 PARALYZED VETERANS OF AMERICA Guideline and AD Walet Card Utilization , acros E-Scan Sites 0 2 4 6 8 10 12 Paralyzed Veterans of American AD Guideline AD Information Wallet Cards Number of Sites Used as appropriate Routine Use Figure 5.0 Figure 5.0 Non-Drug and Pharmacotherap y of Autonomic Dysreflexia Suspect AD 1. Check heart rate and blood pressure for five minutes AD-Acute Non-Drug Management 2. Sit patient up! (to induce orthostatic blood pressure for five minutes 3. Loosen constrictive clothing / devices (leg bag, pressure stockings, cast, tight shoelace) 4. Check urinary drainage a. Foley • Kinks? • Irrigation • Replace if necessary b. No Foley • 2% lidocaine instillation • intermittant catheterization infill 6. When blood pressure < 150 mmHG • Check for fecal impaction blood pressure and heart rate still present 5. If blood pressure > 150 mmHG • Consider Rx 7. Find the cause Check urine R&M / C&S Abdominal US Doppler US – DVT X-ray – fracture / dislocation Check skin – pressure sore, rash ingrown toenails Once stable: • Monitor for two hours • Educate patient/family:  Suspect triggers  How to prevent/treat CARDIOVASCULAR INTEGRITY | BODY STRUCTURE AND FNUCTION 131


M - Cardiovascular Integrity
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