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Autonomic Dysreflexia in Spinal Cord Injury

Definition: Autonomic dysreflexia (AD) is a potentially life-threatening condition that can occur in anyone with a spinal cord injury at or above T6.

• Sudden and significant increase in blood pressure, pounding headache, bradycardia.
• Profuse sweating and flushing of the skin at or above the level of injury especially face, neck and shoulders.
• Piloerection or goose bumps at or above the level of injury.
• Cardiac arrhythmia, atrial fibrillation, premature ventricular beats and atrioventricular conduction abnormalities.

Note: If AD is not recognized and treated promptly the hypertension may escalate to dangerous levels resulting in intracranial haemorrhage, seizures, cardiac arrhythmia or death. This is a medical emergency.

Management

• Recognize the signs and symptoms of autonomic dysreflexia (AD).
• Check the patient's blood pressure (BP).

  Note: A patient with a spinal cord injury above the T6 level often has a normal systolic BP in the 90-110 mm Hg range. Therefore an elevation of 20-40 mm Hg above baseline may be a sign of AD.

• If signs and symptoms of AD are present but BP not raised and the cause has not been identified, seek Consultant advice.
• If BP is elevated, immediately sit the patient up if the patient is supine (as their condition allows).
• Loosen any clothing or constrictive devices.
• Monitor the BP and pulse frequently (every 2-5 minutes).
• Quickly survey the patient for the instigating cause, beginning with the urinary system.
• If an indwelling urinary catheter is not in place, catheterize the patient.
• If patient has an indwelling urethral or supra-pubic catheter, check the system along its entire length for kinks, folds, constrictions, obstructions and for correct placement. If a problem is found correct it immediately.
  • If the catheter is draining and the BP remains elevated, suspect faecal impaction.
  • If the catheter is not draining and the BP remains elevated, remove and replace catheter in conjunction with reference to the above.

    Important: If there is difficulty passing a catheter please contact the on-call Urology Service or Burwood Spinal Unit medical staff on call.

    Note: Monitor the patient's BP during bladder drainage. Sudden large fluid loss can cause hypotension if the patient has been given drugs to lower BP.

• If acute symptoms of AD persist, including elevated BP, suspect faecal impaction.
• If BP is ≥150 mm Hg systolic, consider administering glyceryl trinitrate (GTN) spray x 2 sublingually.

  Note: Monitor patient for signs of hypotension.

Important: If no cause can be identified and hypertension persists, seek further medical assistance IMMEDIATELY. This is now an acute medical emergency. Burwood Spinal Unit: discuss with the Acute General Medical Consultant and transfer the patient to the Emergency Department at Christchurch Hospital.

Topic Code: 17664