Simulated Patient Scenario

Scenario Details

MDT Information

• Urgent Response - Severe Headache / Hypertension
• 48-year-old female with known spinal cord injury
• Complaining of sudden severe headache, feeling unwell
• Patient is conscious and alert
• Location: Patient's home

On Arrival

You arrive at a private residence and are met by a carer who appears concerned. The patient, a 48-year-old female, is sitting up in her wheelchair in the living room. She appears flushed in the face and neck and is sweating profusely above her chest. She is complaining loudly of a severe, pounding headache and blurred vision. She states she feels "really strange and unwell".

Initial Impression and Primary Survey

Secondary Survey and Simulation Progression

History (obtained from patient and carer)

Vital Signs/Assessment (Initial)

Physical Examination

• General Appearance: Alert, distressed, hypertensive, bradycardic, flushed and sweating above injury level.
• Head/Neck: Facial flushing, diaphoresis, nasal congestion. Complains of pounding headache, blurred vision.
• Chest: Diaphoresis above T4. Lungs clear.
• Abdomen/Pelvis: Check for abdominal distension. **Examine indwelling catheter (IDC): Check tubing for kinks, twists, or obstructions. Check catheter bag - is it filling? Is it full?** Gentle palpation for bladder distension (may be difficult to assess).
• Lower Limbs/Back: Skin cool, pale, dry below T4. Check for tight clothing, braces, or constrictive devices. Check skin integrity, looking for pressure areas or other sources of noxious stimuli. Ask about last bowel movement (check for signs of impaction if history suggests - usually deferred prehospital unless strongly suspected and easily checked).
• Neurological: GCS 15. Known T4 paraplegia. Sensation absent below T4.

Assessment and Treatment

Appropriate Management Focus

• Recognize Autonomic Dysreflexia (AD): High index of suspicion based on history (SCI T6 or above) and classic signs (sudden severe hypertension, headache, sweating/flushing above injury level, bradycardia). Treat as a medical emergency.
• Immediate Actions - Remove Stimulus:
  • Sit the patient fully upright:** This helps lower BP via orthostatic effect. Ensure legs are dependent if possible.
  • **Loosen any tight clothing, braces, or binders.**
  • **Check the urinary catheter FIRST:** Look for kinks, blockages, full bag. If blocked/kinked, straighten tubing or irrigate/replace catheter if trained and equipped per protocol (often an ED intervention). If bag is full, empty it.
  • **Check for Bowel Impaction:** If urinary cause excluded and AD persists, consider bowel impaction (ask about last BM). Digital rectal exam and disimpaction usually deferred to ED unless specifically trained/protocol directed.
  • **Check Skin:** Look for pressure sores, ingrown toenails, burns, or other painful stimuli below the level of injury.
• Oxygen Therapy: Apply oxygen only if hypoxic (SpO2 < 94%), not routine otherwise.
• Vascular Access: Establish IV access.
• Pharmacological Management (if stimulus removal ineffective & BP remains severely elevated):**
  • Administer rapid-acting antihypertensive agent per local protocol. **Glyceryl Trinitrate (GTN)** sublingual spray/tablet is often first-line prehospital (e.g., 300-600mcg SL, repeat as needed, monitoring BP closely).
  • Avoid beta-blockers initially as they can worsen bradycardia or cause unopposed alpha-stimulation.
• Monitoring: Continuous ECG and BP monitoring (every 2-5 minutes). Monitor SpO2, respiratory status, headache severity, and other symptoms.
• Transport: Transport urgently to the nearest appropriate Emergency Department. Pre-notify receiving hospital (Autonomic Dysreflexia, SCI level, BP/HR, suspected cause, treatments given).
• Teamwork & Communication: Explain actions clearly to patient and carer. Work systematically to find and remove the stimulus. Clear handover.