Q. I just got back from a check-up with my physician. During the exam he discovered a small pressure sore. He explained how important it was to prevent them, but I’d like more information.
A: If you have dark skin, it might be difficult to observe reactive hyperemia. You will need to watch your skin to learn its color changes. For example, a subtle purplish color may be your sign of reduced blood supply. You may also need to rely more on feeling for lumps, unusual swelling or temperature changes in the soft tissue.
You can test the blood supply to your skin by doing the “blanching test.” If you have a reddened area, press it with your finger. If the area remains red, the blood supply is not adequate and a sore may be starting. If it turns white when you press it and then turns pink when you release the pressure, the blood supply is good.
To prevent pressure sores you must relieve or reduce the pressure. • Shift your weight frequently: you must not rely solely on your cushion for protection • • Spread your weight over a larger area: use arm rests on your wheelchair to help take pressure off your bottom, use a proper cushion (never use a donut or ring shaped cushion, folded blanket, towel or bed pillow) over an extended period of time, sleep on a proper mattress. • Do complete skin checks before dressing in the morning and the last thing at night before going to bed. Look for redness, darkened areas, cracks, bruises, blisters. Use a mirror to check places you cannot see. • Feel for lumps, soft areas or warmth (use back of hand). • Keep skin clean and dry at all times.
Additional signs that a pressure sore may be starting include an increase in spasms (twitching or jumping of legs, arms or stomach muscles), unusual sweating and elevated body temperature.
Daily living guidelines for the prevention of pressure sores are: • Wear shoes when you are in your wheelchair. • Wear clothes that fit properly. Clothes that are too tight or have thick seams cause pressure on your skin. If your clothing is too loose, it may wrinkle under you. • Protect your skin from injury. Use padding when necessary. • Avoid extreme temperatures such as hot pipes, cigarettes, car heaters blowing hot air on feet or legs, hot liquids, food or hot bath water. Temperature of bath water should not be above 120 degrees Fahrenheit.. • Avoid sunburns. • Eat a nutritionally balanced diet including 2 to 3 quarts of fluid each day to prevent dehydration o Avoid getting cuts and bumps o Don’t store objects under your wheelchair cushion – use a bag or back pack on the rear of your wheelchair. • Use only equipment (braces, splints, wheelchair, etc.) that is fitted to you and kept in good repair. • Do not sit on a car seat belt, wear it.
Remember, prevention of a pressure sore is always easier than the cure.
Q: I am a T-4 paraplegic. I recently felt quite dizzy and had a pounding headache which made me go to the emergency room. After quite a while, it was determined I was showing symptoms of autonomic dysreflexia due to a small sore on my bottom. I had a little understanding of this condition and thought it might be the cause of my discomfort, but the emergency room staff did not seem familiar with it. Do you have some information on it that I could carry on me in case this happens again.
A: Autonomic dysreflexia, also called autonomic hyperreflexia, is a term used to identify a set of reflex responses or symptoms. These symptoms are a warning signal from your body that there is something wrong below your level of injury. This is an emergency situation which requires immediate attention. You may experience autonomic dysreflexia if your spinal cord injury occurred at or above the level of the sixth thoracic vertebra (T-6 or above). It is more common with persons having a spinal cord injury in the cervical (neck) area.
Because the symptoms and causes of autonomic dysreflexia vary from one individual to the next and from one episode to the next, emergency room staff unfamiliar with spinal cord injuries may have difficulty diagnosing and treating this condition. Symptoms may include some or all of the following:
• sweating and warm, red or blotching skin above the level of injury
• pounding headache
• goose bumps, chills and pale skin below the level of injury
• unusually fast or slow heart beat
• nasal congestion or runny nose
• blurred vision
• upset stomach (nausea)
• difficulty breathing
• confusion; loss of alertness; in extreme episodes, loss of consciousness
The severity of your symptoms may change during one episode, and from one episode to the next. At the first sign of any of these symptoms, you need to take action to eliminate the cause. If the cause of autonomic dysreflexia in not relieved, your blood pressure will continue to rise and may cause seizures, strokes, or death.
How Autonomic Dysreflexia Occurs
Your brain, spinal cord, and nerves act as a communication system for your body. Before your injury, messages from your body were able to travel along your nerves and spinal cord to and from your brain. Your spinal cord produces reflex responses to certain messages it received. Your brain was able to sense and understand messages, to control movement and other body functions, and to monitor and regulate reflex responses produced by the spinal cord.
Now the messages between the lower part of your body and your brain are blocked at the damaged part of your spinal cord. Your spinal cord is still able to produce reflex responses, but now the brain cannot send messages to regulate responses below the damaged part of your spinal cord.
When there is an irritating stimulus from the lower part of your body, your spinal cord receives the message and produces reflex responses. The responses in the lower part of your body are out of control because your brain cannot monitor and regulate them. As a result, you may experience the set of symptoms known as autonomic dysreflexia.
How to Control Autonomic Dysreflexia
If you are lying down, the first action is to sit up. This will lower your blood pressure temporarily while you look for the cause. The best way to control autonomic dysreflexia is to find and eliminate the cause. Some of the common causes are: full bladder, constipation, skin irritation, urinary tract complications, sexual stimulation primarily of the genitals, or any painful stimulus below the level of injury.
To assist persons with spinal cord injuries in receiving correct diagnosis and treatment, Sister Kenny Institute has prepared a medical alert card for autonomic dysreflexia. The card is a plastic “credit card” containing information on the symptoms, causes and treatment of autonomic dysreflexia, and lists medical journal references. Call Medformation at 874-4444 to obtain a card.
Spinal Cord Injury
Special thanks to the Arkansas Spinal Cord Commission for information used in preparing this column.
To submit questions on medical or rehabilitative issues for future columns, write: Medical Issues and Disability, Sister Kenny Institute, Dept. 16601, 800 E. 28th St., Minneapolis, MN 55407