Actionable Nuggets for Spinal Cord Injury

4. Autonomic Dysreflexia

Actionable Nuggets for SCI (2nd ed., 2013)

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 SCI lesions at or above T6. Signs and symptoms of AD include sudden hypertension (an increase in systolic BP greater than 20-40 mmHg), headache, and bradycardia. Untreated AD may result in intracranial hemorrhage, retinal detachment, seizure and death.

Evidence-based Best Practice:

The vast majority of cases of AD are related either to bladder distension or bowel impaction, but AD has also been associated with skin irritation, sexual activity, or other systemic issues. AD occurs when reflex sympathetic activity below the lesion triggers corresponding parasympathetic vagal activity above the lesion.

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 episodic 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
  6. Continue to monitor BP for at least 2 hours after symptoms resolve, and consider admission if symptoms persist.

The Evidence

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.

Key reference:

    Gunduz, H., & Binak, D.F. (2012). Autonomic dysreflexia: An important cardiovascular complication in spinal cord injury patients. Cardiology Journal, 19(2): 215-9.

Additional references:

    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
    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
    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
    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
    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
    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. editors. Spinal Cord Injury Rehabilitation Evidence. Version 4.0. Vancouver http://www.scireproject.com/rehabilitation-evidence/autonomic-dysreflexia
    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
    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
    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
    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
    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
    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
    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.
    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
    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
    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
    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