4. Autonomic Dysreflexia

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

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.

The Problem:

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.

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
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    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
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