Severe pounding headache with sudden hypertension in a T6-or-above SCI patient is an emergency, act immediately.
Before you read
Test yourself first: 3 questions
Question 1 of 3
A client with a spinal cord injury at T6 suddenly develops a severe pounding headache and blood pressure of 200/110. The nurse FIRST:
Answer: B. This is autonomic dysreflexia (injuries at/above T6). First raise the head of the bed/sit the client upright to lower BP, then find and remove the trigger (usually a full bladder or impacted stool). It is a hypertensive emergency.
Question 2 of 3
A client with a T3 spinal cord injury suddenly reports a pounding headache, and the nurse notes blood pressure 210/110, bradycardia, flushing above the injury, and sweating. What is the nurse's FIRST action?
Answer: A. These findings indicate autonomic dysreflexia, a medical emergency in clients with injuries at T6 or above. The FIRST action is to raise the head of the bed (sit the client upright) to lower blood pressure, then quickly find and remove the noxious stimulus (often a full bladder or impacted stool). Lying the client flat or delaying worsens the dangerous hypertension.
Question 3 of 3
A client with a spinal cord injury suddenly has a pounding headache, flushing above the injury, and severe hypertension. The nurse FIRST:
Answer: B. This is autonomic dysreflexia. First, sit the client upright (high-Fowler's) to lower blood pressure, then find and remove the trigger (often a full bladder or impacted stool). It's a hypertensive emergency.
Keep the streak going with more questions like these, each with a full rationale.
What is autonomic dysreflexia?
The stimulus causes massive uncontrolled sympathetic discharge leading to severe, sudden hypertension. If not relieved quickly it can cause seizures, stroke, or death. The first action is to sit the patient upright and find and remove the trigger.
Key points to remember
- Occurs in spinal cord injuries at or above T6 from a stimulus below the injury level.
- The most common trigger is a distended bladder (blocked or kinked catheter); fecal impaction is the next most common.
- Hallmark is a sudden, severe pounding headache with dangerously high blood pressure.
- Above the injury: flushing, sweating, and nasal congestion; below the injury: pale, cool skin with goosebumps.
- Bradycardia and blurred vision often accompany the hypertensive episode.
Signs & symptoms
- Sudden severe HTN, pounding HA
- Bradycardia, flushing above injury
- Sweating, nasal congestion
Nursing priorities
- Raise the head of the bed/sit the patient upright immediately to lower blood pressure by orthostasis.
- Identify and remove the noxious stimulus: first check the bladder/catheter for kinks and ensure drainage.
- Check for and relieve fecal impaction (use anesthetic ointment first) and remove tight clothing or pressure.
- Monitor blood pressure frequently (every few minutes) throughout the episode.
- Administer prescribed rapid-acting antihypertensive if blood pressure remains dangerously high after removing the trigger.
Patient teaching
- Prevent triggers by keeping a regular bladder and bowel routine and ensuring the catheter drains freely.
- Recognize early signs (pounding headache, sweating, flushing) and sit upright and remove the cause immediately.
- Wear a medical alert bracelet and seek emergency care if blood pressure cannot be controlled.
Red flags: report now
- Severe pounding headache with sudden hypertension in a T6-or-above SCI patient is an emergency, act immediately.
- Persistently elevated blood pressure despite removing the trigger can cause stroke or seizure, give antihypertensive and notify the provider.
- Never leave the patient flat; lowering the head worsens the hypertension.
References
Clinical references for this topic
