What are medical emergencies?
Medical Emergencies are a few conditions affecting spinal cord injured people that require urgent treatment. They can happen anytime irrespective of the numbers of years that have passed after your injury. You should be aware of them and the first aid that is required just incase you are faced with them at home They are as follows:

1. Autonomic Dysreflexia
2. Pressure sore
3. Bladder blockage or infection
4. Kidney infection
5. Chest infection
6. Sudden lowering of Blood Pressure

What Is Autonomic Dysreflxia?
This is a warning system to let you know that something is wrong; and that your body is experiencing pain or discomfort. This is an acute emergency and if not treated quickly may lead to bleeding in the brain with serious consequences. It consists of a rapid increase in blood pressure caused by pain, irritation or over-stimulation in a paralyzed part of the body. Only if you have a spinal cord lesion above T6 are you prone to autonomic dysreflexia or hyper-reflexia. Your family members should also be aware of Autonomic Dysreflexia so that they can help you when needed.

How will I know that I have autonomic dysreflexia?
The Symptoms for autonomic dysreflexia are

• pounding headache
• goose pimples
• profuse sweating
• flushed and blotched skin on face and upper trunk Those with a spinal cord lesion above T6 must be aware of autonomic dysreflexia or hyper-reflexia and so should their family and careers.
• high blood pressure

Note: You may already have a lower normal blood pressure (e.g. 90/60) after injury, therefore 120/80 may represent a rise.

What are the main causes for autonomic dysreflxia?
The symptoms of autonomic dysreflxia can be any one of the following or combination of the follows:

• over-full bladder - caused by a blocked catheter
• bladder stones
• Urinary tract infection
• constipation
• anal fissure
• wind
• ingrown toenail
• burns or scalds
• pressure sore
• labor pain
• ejaculation during sexual intercourse menstrual cramps

What is the immediate action to be taken?

• remove the cause (if possible) you may have to contact your doctor to help you remove the cause.
• Sit up either yourself or with help
• if symptoms persist, give drugs to lower the blood pressure and contact your doctor

Autonomic Dysreflexia is a serious condition and if immediate relief is not achieved you must call a doctor.

What are the other emergencies that can arise?
Pressure Sores could also become a medical emergency if timely care is not taken. It can be life threatening as can lead to

• infection spreading to blood, heart and bone.
• Amputation
• Prolonged bed rest
• Autonomic dysreflexia

Other emergencies that can arise are Pressure sores and problems related to the Bladder like Kidney infection and kidney stones. These are discussed at length in chapters given before. Apart from these you may be prone to Chest infections and low blood pressure.

Tell me more about Chest infections
If your spinal lesion is above T6 you have to take extra care to avoid chest infections.The potential problems that may occur in the are

• Decreased Lung Volume
• Congestion and/or Pneumonia

What is Decreased Lung Volume?
Decreased lung volume is caused be either change in the function of the respiratory muscles or thick secretions in the lungs. You can identify this by shortness of breath.

How can I prevent this?
Decreased lung volume can be prevented by regularly:

• Doing deep breathing regularly
• Sitting in wheelchair daily
• maintaining regular turning schedule in bed
• Doing regular assisted coughing as needed to bring up secretions
• Do respiratory treatment as prescribed by the doctor

What is assisted coughing?
Why Congestion and/or Pneumonia happen?

Assisted coughing is when someone else assists you in coughing out your secretions

which you may be unable to do yourself. Coughing assists in cleaning thickened secretions from the respiratory system. If your spinal lesion is T6 and above then ask your physiotherapist to teach assisted coughing procedure to your family members, who can assist you at home.

They occur when there is thickened secretions in the lungs that is not being coughed up and out. The symptoms of them are

• Decreased lung volume
• Excess secretion in the lungs
• Heavy feeling in the chest
• Elevated temperature (above normal)

How can I prevent it in the first place?

• Drink 2 to 3 litres of water daily
• Do daily deep breathing exercising
• Sit in wheelchair daily
• Maintain regular turning schedule in bed
• Stop smoking in case you do

How can low Blood Pressure be an emergency?
Low blood pressure in the range of 90/60 is quite a common feature after Spinal Cord Injury, specifically if you have a cervical lesion. But at times such as after bowel movement the BP start lowering down and should be checked.

What are the Symptoms of Low blood pressure?
Most common symptoms are

• feeling sleepy
• blurring of speech
• feeling very hungry

What immediate action I need to take if I feel like that?
You just need to eat something preferably salty and rest. If it still persists then contact your doctor.

Complications

It is important for persons with SCI to know what complications may lie ahead

In this article, we will discuss several of the common complications for patients with SCI. These include skin breakdown, osteoporosis and fractures, pneumonia, atelectasis, aspiration, heterotopic ossification, spasticity, autonomic dysreflexia, deep vein thrombosis, cardiovascular disease, syringomyelia and neuropathic/spinal cord pain.

Osteoporosis and Fractures

The majority of people with SCI develop osteoporosis. In people without SCI, the bones are kept strong through regular muscle activity or by bearing weight. When muscle activity is decreased or eliminated and the legs no longer bear the body's weight, they begin to lose calcium and phosphorus and become weak and brittle. It generally takes some time for osteoporosis to occur. In people who use standing frames or braces, osteoporosis is less of a problem. Generally, it takes 2 years following SCI for some degree of bone loss to occur.

Using the legs to provide support in transferring is helpful in increasing the load on the bones, which may reduce or slow down the osteoporotic process. Standing using a standing frame or a standing table also helps prevent weakening of the bones and so does using braces for functional or parallel bar walking. Newer techniques, such as electrical stimulation of the leg muscles, may decrease osteoporosis as well.

Unfortunately, at the present time, there is no way to reverse osteoporosis once it has occurred. The main risk associated with osteoporosis is fracture. Once the bones become brittle, they fracture easily. An osteoporotic bone takes much longer to heal.

Pneumonia, Atelectasis, Aspiration

Patients with spinal cord injuries above the T4 level of injury are at risk to develop restriction in respiratory function, termed restrictive lung disease. This occurs five to 10 years following spinal cord injury and can be progressive in nature. The quadriplegic individual as part of a health care maintenance routine should have pulmonary function studies at yearly or every-other-year intervals between five and 10 years post injury. As the medical treatment of spinal cord-injured individuals continues to improve, respiratory complications of SCI are becoming more prominent. Adequate health maintenance and protection from this complication are appropriate and necessary as part of the long-term care of the spinal cord-injured individual.

Heterotopic Ossification

Heterotopic ossification is a condition, not well understood, that occurs in acute spinal cord injury and consists of the laying down of bone outside the normal skeleton. This occurs generally at large joints such as the hips or knees. The primary problem with heterotopic ossification, or HO, is the risk for joint stiffening and fusion. Should the hip or knee become fused in a certain position, a surgical release is necessary to allow range of motion to occur. Unfortunately, it takes between 12 and 18 months for heterotopic bone to mature once it has developed. Activities that are used to prevent the development of HO include range of motion programs and other functional activities that move the joints within a functional range. Currently treatment is limited with the exception of preventing the joint fusion (termed ankylosis).

Spasticity

After spinal cord injury the nerve cells below the level of injury become disconnected from the brain. Following the period of spinal shock, changes occur in the nerve cells that control muscle activity. Spasticity is an exaggeration of the normal reflexes that occur when the body is stimulated in certain ways. After spinal cord injury, when nerves below the injury become disconnected from those above, these responses become exaggerated.

Muscle spasms, or spasticity, can occur any time the body is stimulated below the injury. This is particularly noticeable when muscles are stretched or when there is something irritating the body below the injury. Pain, stretch, or other sensations from the body are transmitted to the spinal cord. Because of the disconnection, these sensations will cause the muscles to contract or spasm.

Almost anything can trigger spasticity. Some things, however, can make spasticity more of a problem. A bladder infection or kidney infection will often cause spasticity to increase a great deal. A skin breakdown will also increase spasms. In a person who does not perform regular range of motion exercises, muscles and joints become less flexible and almost any minor stimulation can cause severe spasticity.

Some spasticity may always be present. The best way to manage or reduce excessive spasms is to perform a daily range of motion exercise program. Avoiding situations such as bladder infections, skin breakdowns, or injuries to the feet and legs will also reduce spasticity. There are three primary medications used to treat spasticity, baclofen, Valium, and Dantrium. All have some side effects and do not completely eliminate spasticity.

There are some benefits to spasticity. It can serve as a warning mechanism to identify pain or problems in areas where there is no sensation. Many people know when a urinary tract infection is coming on by the increase in muscle spasms. Spasticity also helps to maintain muscle size and bone strength. It does not replace walking, but it does help to some degree in preventing osteoporosis. Spasticity helps maintain circulation in the lefts. It can be used to improve certain functional activities such as performing transfers or walking with braces. For these reasons, treatment is usually started only when spasticity interferes with sleep or limits an individual's functional capacity.

Deep Vein Thrombosis

Deep vein thrombosis (DVT) or pulmonary embolism is a potentially severe complication of spinal cord injury. As mentioned above, there are changes in the normal neurologic control of the blood vessels that can result in stasis or "sludging". Deep vein thrombosis in the lower leg is almost universal during the early phases of recovery and rehabilitation. Thromboses in the thigh, however, are a great concern, as they are at risk for becoming dislodged and passing through the vascular tree to the lungs. A major obstruction of the arteries leading to the lung can potentially be fatal. Therapeutic measures to reduce or eliminate the risk for deep vein thrombosis include Ace wrapping of the legs and the use of pneumatic compression stockings. Medications administered subcutaneously, such as heparin, are useful in reducing blood viscosity and improving flow. In the event that a thrombosis develops, treatment is begun with intravenous heparin. Once adequate anticoagulation is provided, the patient is switched to an oral medication, called Coumadin.

Cardiovascular Disease

Cardiovascular disease is a major long-term risk of spinal cord injury. SCI individuals live in general rather sedentary lives and are at higher risk for cardiovascular disease than the able-bodied population. Therefore, careful assessment of cardiovascular function and the encouragement of exercise programs are appropriate and necessary long-term aspects of spinal cord injury management and care. The prescription of upper extremity exercise programs in spinal cord-injured individuals are similar to those used in other populations with the exception of the use of adaptive equipment such as racing wheelchairs or monoskis.

Syringomyelia

A post-traumatic enlargement of the central canal of the spinal cord is termed syringomyelia. It occurs in approximately 1-3% of all spinal cord-injured individuals. The primary risk of syringomyelia is a loss of function above the level of the original spinal cord injury. For example, in a patient with a thoracic4evel spinal cord injury may complain to his or her physician of numbness and weakness involving the extremities. The condition will progress with time and needs to be treated aggressively through surgical drainage. Often patients with early evidence of a syrinx will be followed to evaluate the progression of the condition. Significant syringomyelia is treated with surgical decompression and the placement of a drainage tube into the spinal cord.

Neuropathic/Spinal Cord Pain

Neuropathic (nerve-generated) pain is a significant problem in some spinal cord-injured patients. Varying types of pain are described in spinal cord injury. Damage to the spine and soft tissues surrounding the spine can cause aching at the left of the injury. Nerve root pain is described as sharp or may be described as having an electric shock-type quality. Occasionally SCI patients will describe phantom limb pain or pain that radiates from the level of the lesion in a specific pattern that is related to injury or dysfunction at the nerve root or spinal cord level. Various medications and nerve block procedures have been described and are of some use in the treatment of neuropathic pain following spinal cord injury.