From the Guidelines
Management of autonomic dysreflexia (AD) in the hospital requires immediate intervention to lower blood pressure and remove the triggering stimulus, with clinicians being able to recognize those at greatest risk for AD and having pharmacotherapy readily available, as stated in the 2021 guideline by the American Urological Association 1.
Key Recommendations
- Elevate the patient's head and lower their legs to reduce blood pressure
- Quickly identify and eliminate the cause, which is most commonly bladder distention (requiring catheterization), bowel impaction, skin pressure, or other noxious stimuli below the level of spinal cord injury
- For hypertensive crisis (systolic BP >150 mmHg), administer fast-acting antihypertensives such as nifedipine or nitrates like nitroglycerin, as suggested by the 2021 guideline 1
- Monitoring should continue until blood pressure stabilizes for at least 2 hours
- Prevention strategies include regular bladder and bowel management, pressure relief, and avoiding triggers
Importance of Recognition and Response
AD is a medical emergency occurring in patients with spinal cord injuries at T6 or above, caused by exaggerated sympathetic response to stimuli below the injury level, resulting in dangerous hypertension, bradycardia, headache, and sweating above the injury level. All hospital staff should be trained to recognize these symptoms and respond promptly, as untreated AD can lead to stroke, seizures, or death, highlighting the need for continuous hemodynamic monitoring in patients at risk for AD during urodynamic testing and/or cystoscopic procedures 1.
Pharmacologic Management
For patients with ongoing and persistent AD following bladder drainage, immediate initiation of pharmacologic management and escalation of care is crucial, as stated in the 2021 guideline 1, with patients having a systolic blood pressure greater than 150 mm Hg and/or 20 mm Hg above baseline requiring prompt intervention.
Urodynamic Studies
The concern of causing autonomic dysreflexia during urodynamic studies is life-threatening, and clinicians performing these studies in patients at risk for AD must be adept in its detection and prompt management, including having necessary monitoring equipment and the ability to provide quick drainage and pharmacologic intervention when necessary, as emphasized in the 2012 guideline 1.
From the Research
Management of Autonomic Dysreflexia
- Autonomic dysreflexia is an acute syndrome of excessive, uncontrolled sympathetic output that can occur in patients who have had an injury to the spinal cord (generally at or above the sixth thoracic neurologic level) 2.
- The condition can nearly always be managed successfully, but prompt recognition is essential--without treatment there may be dire consequences, including death 2.
Treatment Approaches
- Captopril appears to be safe and effective for autonomic dysreflexia management, with a study showing that captopril alone was effective in 4 of 5 initial episodes (80%) 3.
- The addition of nifedipine successfully reduced systolic blood pressure in patients who did not respond to captopril alone 3, 4.
- Nitroglycerin ointment is also commonly used as a first-line medication for autonomic dysreflexia, particularly in the United States 5.
Best Practice Recommendations
- A formal pharmacologic management protocol for autonomic dysreflexia should be in place, with a systolic blood pressure threshold for pharmacologic management used by physicians 5.
- Patient characteristics, such as neurological level of injury, should be considered in decisions to use medications for autonomic dysreflexia 5.
- Community nurses should be equipped with the necessary knowledge to help clients with autonomic dysreflexia, as they may come into contact with patients in a dysreflexia crisis requiring prompt emergency treatment 6.