4. Autonomic Dysreflexia

Actionable Nuggets for SCI (3rd ed., 2016)

The Problem:Man in power wheelchair

Autonomic Dysreflexia (AD) is a potentially life threatening condition that affects people with spinal cord injuries at or above T6. Signs and symptoms of AD include sudden hypertension (an increase in systolic BP greater than 20-40 mmHg above the patient’s usual baseline), headache, and a constellation of other symptoms, such as sweating, myosis, flushing, bradycardia or tachycardia. In affected individuals, episodes may occur as many as 20 times a day.  Long-standing AD has been shown to be associated with cognitive deficits, and may result in stroke, myocardial infarction, retinal detachment, seizure and death.

Actionable Nugget

Alert patients with SCI at T6 and above to the risks of Autonomic Dysreflexia, and the need for urgent treatment at the onset of an episode.

 

Evidence-based Best Practice:  AD occurs when reflex sympathetic activity below the level of the spinal cord lesion triggers corresponding parasympathetic vagal activity above the lesion.  AD affects >50% of patients with SCI lesions above T6. AD is three times more prevalent with a complete injury. AD is more severe in patients with higher lesions and more complete lesions. A recent study found that 41% of SCI patients had not heard of AD, and 22% reported symptoms consistent with unrecognized AD.

The vast majority of episodes of AD are caused by bladder distension or bowel impaction, but AD has also been found to be caused by skin irritation, sexual activity, or other systemic issues.  Iatrogenic triggers have also been reported, during urological, gastrointestinal or reproductive procedures.  Resting BP typically declines after a spinal cord injury, often to about 90/60 mmHg; thus readings of 120/80 mmHg might be considered elevated. Resting BP should be monitored as a baseline. Management of AD should be treated as a medical emergency:

  1. Place the patient in an upright position
  2. Loosen clothing and other restrictions
  3. Monitor pulse and BP every 2-5 minutes during the episode.
  4. Search for and eliminate the precipitating stimulus (eg., bowel or bladder emptying).
  5. If systolic BP remains at or above 150 mmHg, consider rapid-onset, short duration anti-hypertensives, such as nifedipine, nitrates, and captopril. Avoid nitrates if patient is on PDE5i (such as Viagra)
  6. Continue to monitor BP for at least 2 hours after symptoms resolve, and consider admission if symptoms persist.

 Key Reference:

    Cragg, J., & Krassioukov, A. (2012). Autonomic dysreflexia. Journal of Canadian Medical Association (CMAJ), 8(2), 16–19. http://doi.org/10.1503/cmaj.110859

Additional References (chronological listing):

    Caruso, D., Gater, D., & Harnish, C. (2015). Prevention of recurrent autonomic dysreflexia: a survey of current practice. Clinical Autonomic Research, 25(5), 293-300. http://doi.org/10.1007/s10286-015-0303-0
    Liu, N., Zhou, M., Biering-Sørensen, F., & Krassioukov, A. V. (2015). Iatrogenic urological triggers of autonomic dysreflexia: a systematic review. Spinal Cord, 53(7), 500–509. http://doi.org/10.1038/sc.2015.39
    Zheng, M. M., Phillips, A. A., Elliott, S. L., & Krassioukov, A. V. (2015). Prazosin: a potential new management tool for iatrogenic autonomic dysreflexia in individuals with spinal cord injury?. Neural Regeneration Research, 10(4), 557.
    Danforth, T. L., & Ginsberg, D. A. (2014). Neurogenic Lower Urinary Tract Dysfunction. Urologic Clinics of North America, 41(3), 445–452. http://doi.org/10.1016/j.ucl.2014.04.003
    Faaborg, P. M., Christensen, P., Krassioukov, A., Laurberg, S., Frandsen, E., & Krogh, K. (2014). Autonomic dysreflexia during bowel evacuation procedures and bladder filling in subjects with spinal cord injury. Spinal Cord, 52(6), 494–498. http://doi.org/10.1038/sc.2014.45
    Hubli, M., Gee, C. M., & Krassioukov, A. V. (2014). Refined Assessment of Blood Pressure Instability After Spinal Cord Injury. American Journal of Hypertension, 28(February), 1–9. http://doi.org/10.1093/ajh/hpu122
    Huang, Y.-H., Bih, L.-I., Liao, J.-M., Chen, S.-L., Chou, L.-W., & Lin, P.-H. (2013). Blood pressure and age associated with silent autonomic dysreflexia during urodynamic examinations in patients with spinal cord injury. Spinal Cord, 51(5), 401–405. http://doi.org/10.1038/sc.2012.155
    Liu, N., Fougere, R., Zhou, M.-W., Nigro, M. K., & Krassioukov, A. V. (2013). Autonomic dysreflexia severity during urodynamics and cystoscopy in individuals with spinal cord injury. Spinal Cord, 51(11), 863–867. http://doi.org/10.1038/sc.2013.113
    Wan, D., & Krassioukov, A. V. (2013). Life-threatening outcomes associated with autonomic dysreflexia: A clinical review. The Journal of Spinal Cord Medicine, 37(1), 1–10. http://doi.org/10.1179/2045772313Y.0000000098
    Zhang, Y., Guan, Z., Reader, B., Shawler, T., Mandrekar-Colucci, S., Huang, K., Popovich, P. G. (2013). Autonomic dysreflexia causes chronic immune suppression after spinal cord injury. The Journal of Neuroscience : The Official Journal of the Society for Neuroscience, 33(32), 12970–81. http://doi.org/10.1523/JNEUROSCI.1974-13.2013
    Bauman, C. A., Milligan, J. D., Lee, F. J., & Riva, J. J. (2012). Autonomic dysreflexia in spinal cord injury patients: an overview. The Journal of the Canadian Chiropractic Association, 56(4), 247.
    Courtois, F., Rodrigue, X., Cote, I., Boulet, M., Vezina, J. G., Charvier, K., & Dahan, V. (2012). Sexual function and autonomic dysreflexia in men with spinal cord injuries: how should we treat? Spinal Cord, 50(12), 869–877. http://doi.org/10.1038/sc.2012.83
    Gunduz, H., & Binak, D.F. (2012). Autonomic dysreflexia: An important cardiovascular complication in spinal cord injury patients. Cardiology Journal, 19(2), 215-9.   http://www.ncbi.nlm.nih.gov/pubmed/22461061
    Milligan, J., et al. (2012). Autonomic dysreflexia: Recognizing a common serious condition in patients with spinal cord injury. Canadian Family Physician, 58(8), 831-5. http://www.ncbi.nlm.nih.gov/pubmed/22893332
    Phillips, A. a., Krassioukov, A. V., Ainslie, P. N., & Warburton, D. E. R. (2012). Baroreflex Function after Spinal Cord Injury. Journal of Neurotrauma, 29(15), 2431–2445. http://doi.org/10.1089/neu.2012.2507
    Previnaire, J. G., Soler, J. M., Leclercq, V., & Denys, P. (2012). Severity of autonomic dysfunction in patients with complete spinal cord injury. Clinical Autonomic Research : Official Journal of the Clinical Autonomic Research Society, 22(1), 9–15. http://doi.org/10.1007/s10286-011-0132-8
    Rabchevsky, A.G., & Kitzman, P.H. (2011). Latest approaches for the treatment of spasticity and autonomic dysreflexia in chronic spinal cord injury. Neurotherapeutics, 8(2), 274-282.
    Ho, C.P., & Krassioukov, A.V. (2010). Autonomic dysreflexia and myocardial ischemia. Spinal Cord, 48(9), 714-715.  http://www.ncbi.nlm.nih.gov/pubmed/20125109
    Krassioukov A., et al. (2010). Autonomic dysreflexia. In Eng, J.J., Teasell, R.W., Miller, W.C., Wolfe, D.L., Townson, A.F., Hseich, J.T.C., et al. (Eds.). Spinal Cord Injury Rehabilitation Evidence. Version 4.0. Vancouver http://www.scireproject.com/rehabilitation-evidence/autonomic-dysreflexia
    Furusawa, K. (2009). Topical anesthesia blunts the pressor response induced by bowel manipulation in subjects with cervical spinal cord injury. Spinal Cord, 47(2), 144-148. http://www.ncbi.nlm.nih.gov/pubmed/18626487
    Krassioukov A, et al. (2009). Systematic review of the management of autonomic dysreflexia after spinal cord injury. Archives of Physical Medicine & Rehabilitation, 90(4), 682-95. http://www.ncbi.nlm.nih.gov/pubmed/19345787
    McGillivray, C.F., et al. (2009). Evaluating knowledge of autonomic dysreflexia among individuals with spinal cord injury and their families. The Journal of Spinal Cord Medicine, 32(1), 54-62. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2647501/?report=abstract
    Hitzig, S.L., et al. (2008). Secondary health complications in an aging Canadian spinal cord injury sample. American Journal of Physical Medicine & Rehabilitation, 87(7), 545-55. http://dx.doi.org/10.1097/PHM.0b013e31817c16d6
    Middleton, J.W., Leong, G., & Mann, L. (2008). Management of spinal cord injury in general practice-Part 1. Australian Family Physician, 37(4), 229-33.  http://www.racgp.org.au/afp/200804/200804middleton.pdf
    Valles, M., et al. (2005). Cerebral hemorrhage due to autonomic dysreflexia in a spinal cord injury patient. Spinal Cord, 43(12), 738-40. http://dx.doi.org/10.1038/sj.sc.3101780
    Consortium for Spinal Cord Medicine. (2001). Acute management of autonomic dysreflexia: Individuals with spinal cord injury presenting to health-care facilities. Washington, DC: Paralyzed Veterans Association. http://www.pva.org/site/News2?page=NewsArticle&id=7657
    Teasell, R.W., et al. (2000). Cardiovascular consequences of loss of supraspinal control of the sympathetic nervous system after spinal cord injury. Archives of Physical Medicine & Rehabilitation, 81(4): 506-16. http://dx.doi.org/10.1053/mr.2000.3848
    Curt, A., et al. (1997). Assessment of autonomic dysreflexia in patients with spinal cord injury. Journal of Neurology, Neurosurgery & Psychiatry, 62(5), 473-7. http://dx.doi.org/10.1136/jnnp.62.5.473
    Eltorai, I.M., et al. (1997). Surgical aspects of autonomic dysreflexia. The Journal of Spinal Cord Medicine, 20(3), 361-4. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=9261784
    Braddom, R.L., & Rocco, J.F. (1991). Autonomic dysreflexia. A survey of current treatment. American Journal of Physical Medicine & Rehabilitation, 70(5), 234-41. http://journals.lww.com/ajpmr/Abstract/1991/10000/AUTONOMIC_DYSREFLEXIA__A_Survey_of_Current.2.aspx
     Pine, Z.M., Miller, S.D., & Alonso, J.A. (1991). Atrial fibrillation associated with autonomic dysreflexia. American Journal of Physical Medicine & Rehabilitation, 70(5), 271-3. http://dx.doi.org/10.1097/00002060-199110000-00008
     Yarkony, G.M., Katz, R.T., & Wu, Y.C. (1986). Seizures secondary to autonomic dysreflexia. Archives of Physical Medicine & Rehabilitation, 67(11), 834-5. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=3778184
    Lindan, R., et al. (1980). Incidence and clinical features of autonomic dysreflexia in patients with spinal cord injury. Paraplegia, 18(5), 285-92. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=7443280
    Snow, J.C., et al. (1978). Autonomic hyperreflexia during cystoscopy in patients with high spinal cord injuries. Paraplegia, 15(4), 327-32. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=625432