# A nurse is assessing a patient with a complete T6 spinal cord injury who was admitted 2 weeks ago. Which assessment finding would be most concerning and require immediate intervention?

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## 문제

A nurse is assessing a patient with a complete T6 spinal cord injury who was admitted 2 weeks ago. Which assessment finding would be most concerning and require immediate intervention?

## 보기

1. Blood pressure 90/60 mmHg with heart rate 58 bpm and dizziness
2. Absence of sensation below the nipple line with tingling
3. Blood pressure 180/110 mmHg with bradycardia and diaphoresis above the injury level **✔ 정답**
4. Flaccid paralysis of both lower extremities with absent reflexes

**정답: 3**

## 해설

Autonomic dysreflexia is a life-threatening emergency in patients with spinal cord injuries at T6 or above, characterized by severe hypertension, bradycardia, and diaphoresis above the injury level. Other findings are expected or less urgent complications of spinal cord injury.

## 심화 해설

Understanding the Priority: Why Autonomic Dysreflexia is the Most Concerning Finding

When assessing a patient with a spinal cord injury (SCI) at the T6 level or above, the nurse must be vigilant for a life-threatening emergency known as autonomic dysreflexia (AD). This condition is triggered by a noxious stimulus below the level of injury, which leads to an unmodulated reflex sympathetic hyperactivity [1,2]. The finding in option 3 represents the classic and most dangerous presentation of AD and requires immediate intervention to prevent catastrophic complications.

Breaking Down the Pathophysiology of Autonomic Dysreflexia

In a complete SCI above T6, the descending inhibitory signals from the brain cannot pass below the lesion to regulate the sympathetic nervous system. When a noxious stimulus, such as a distended bladder or bowel impaction, occurs below the injury level, it triggers a massive sympathetic reflex. This results in severe vasoconstriction below the level of injury, causing a sudden, dangerous spike in blood pressure [1,2].

The body’s intact compensatory mechanism above the injury level attempts to lower the blood pressure. The baroreceptors in the carotid arteries and aorta detect the hypertension and signal the brain to increase parasympathetic (vagal) output. This leads to bradycardia and vasodilation above the injury site, which manifests as diaphoresis (profuse sweating) and flushing of the skin on the head, neck, and upper trunk [4]. However, because the descending inhibitory pathways are blocked by the spinal lesion, the parasympathetic response cannot counteract the massive sympathetic outflow below the injury, and the severe hypertension persists. This is why a blood pressure of 180/110 mmHg with bradycardia and diaphoresis above the injury is the hallmark presentation of AD [1,2].

Clinical Significance and Immediate Risks

The severe hypertension in AD is a medical emergency because it can lead to life-threatening complications. The sudden increase in blood pressure puts the patient at high risk for cerebral hemorrhage, retinal hemorrhage, seizures, heart failure, or pulmonary edema [2]. This is why a finding of severe hypertension with reflex bradycardia and diaphoresis must be prioritized over other assessment findings. The nurse’s immediate intervention is to identify and remove the noxious stimulus, which is most often a distended bladder, and to follow emergency protocols for blood pressure management .

Why the Other Options Are Less Concerning

- Option 1: A blood pressure of 90/60 mmHg with a heart rate of 58 bpm and dizziness is consistent with neurogenic shock, which is common in the acute phase of SCI due to loss of sympathetic tone. While this requires monitoring and management, it is an expected finding in the early weeks after injury and does not carry the same immediate, life-threatening risk of cerebral hemorrhage as the severe hypertension in AD.

- Option 2: Absence of sensation below the nipple line (T4 dermatome) with tingling is an expected neurological finding for a complete T6 injury. It reflects the baseline sensory deficit and does not indicate an acute, dangerous change in condition.

- Option 4: Flaccid paralysis of both lower extremities with absent reflexes is the classic presentation during the initial spinal shock phase following a complete SCI. This is an expected finding 2 weeks post-injury and, while requiring ongoing care, is not an acute emergency like the severe hypertension in AD.

The most concerning finding is the combination of severe hypertension, bradycardia, and diaphoresis above the injury level, which is pathognomonic for autonomic dysreflexia and demands immediate nursing action to identify and remove the triggering stimulus and prevent a hypertensive crisis [1,2,3].References (research sources)

- [2]Autonomic Dysreflexia following Spinal Cord Injury.Research articleBalik V, Šulla I. (2022) · DOI: 10.1055/s-0042-1751080

- [4]Correlating autonomic physiology with symptoms of autonomic dysreflexia after spinal cord injury.Research articleDens Higano J, Burns K, Smith G, Solinsky R. (2025) · DOI: 10.1002/pmrj.13295

## 임상 시나리오

Autonomic Dysreflexia Emergency ResponseImmediate Nursing Actions for Severe Hypertension in SCI
The priority finding is a blood pressure of 180/110 mmHg with bradycardia and diaphoresis above the injury level. This is a classic presentation of autonomic dysreflexia, a life-threatening hypertensive emergency triggered by a noxious stimulus below the level of a T6 or higher spinal cord injury.

Immediately elevate the head of the bed to 90 degrees and lower the legs to orthostatically reduce blood pressure. Then, rapidly identify and remove the triggering stimulus. The most common cause is a distended bladder; check for kinked catheter tubing or perform straight catheterization. If not the bladder, assess for fecal impaction, but apply anesthetic lubricant first to avoid exacerbating the episode.

CautionNever ignore severe hypertension in a patient with high-level SCI. If symptoms persist after removing the stimulus, administer rapid-onset, short-duration antihypertensives as prescribed while continuing to monitor for a hypertensive crisis that can lead to stroke or seizure.

## 핵심 개념

- **Autonomic Dysreflexia** — A life-threatening hypertensive emergency in patients with SCI at or above T6, triggered by noxious stimuli below the injury level causing unopposed sympathetic outflow.
- **Spinal Shock** — A temporary loss of all reflexes, motor, and sensory function below the level of injury occurring shortly after SCI, often resolving within days to weeks.
- **Orthostatic Hypotension** — A drop in blood pressure upon position change, common in SCI patients due to loss of sympathetic vasoconstriction below the injury level.

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