What is the management algorithm for autonomic dysreflexia (AD) in spinal cord injury (SCI) athletes?

From the Guidelines

The management algorithm for autonomic dysreflexia (AD) in spinal cord injury (SCI) athletes should prioritize immediate removal of the triggering stimulus, followed by administration of fast-acting antihypertensives if necessary, as outlined in standard protocols for AD management. When managing AD in SCI athletes, it is crucial to consider the potential for serious health problems, including those that may arise from intentional induction of AD, also known as "boosting," which is banned by the International Paralympic Committee 1. The key steps in managing AD include:

• Immediately sitting the athlete upright and lowering their legs if possible
• Loosening any tight clothing or equipment
• Quickly identifying and removing the triggering stimulus, such as a full bladder or skin irritation
• Monitoring blood pressure closely
• Administering fast-acting antihypertensives like nifedipine 10 mg sublingually if systolic BP remains >150 mmHg
• Seeking emergency medical care if symptoms persist Additional considerations for Paralympic athletes include:
• Having an emergency action plan in place during competition/training
• Educating coaches and support staff on recognizing symptoms of AD
• Ensuring quick access to BP monitoring equipment and medications
• Modifying equipment or techniques to reduce triggers if possible, as athletes with spinal cord injuries above the T6 level may be at higher risk of AD 1. The primary goal of AD management in SCI athletes is to rapidly lower dangerously high blood pressure caused by uninhibited sympathetic outflow below the level of injury, thereby preventing complications like stroke or seizures.

From the Research

Management Algorithm for Autonomic Dysreflexia (AD) in Spinal Cord Injury (SCI) Athletes

The management of autonomic dysreflexia (AD) in spinal cord injury (SCI) athletes involves a combination of preventive measures, recognition of symptoms, and prompt treatment. The key elements of the management algorithm are:

• Prevention: Identification of at-risk patients and avoidance of triggers that can precipitate AD, such as manipulation or distention of the genitourinary or gastrointestinal tract, patient positioning, or the use of certain anesthetic techniques 2, 3.
• Recognition: Early recognition of symptoms, including severe hypertension, throbbing headaches, profuse sweating, nasal stuffiness, flushing of the skin above the level of the lesion, bradycardia, apprehension, and anxiety 3, 4.
• Treatment: Prompt administration of pharmacological treatment, such as nitroglycerin ointment, hydralazine, or nifedipine, to manage hypertension and prevent complications 5, 6.
• Monitoring: Continuous monitoring of blood pressure, heart rate, and other vital signs to ensure prompt recognition and treatment of AD episodes 4, 6.

Pharmacologic Management

The pharmacologic management of AD involves the use of medications to control hypertension and prevent complications. The most common first-line medication is nitroglycerin ointment, which is used by 82% of physicians in the United States 5. Other medications, such as hydralazine and nifedipine, may be used as second-line treatments.

Trigger Avoidance

Trigger avoidance is a critical component of AD management. Athletes with SCI should be aware of the potential triggers that can precipitate AD, such as:

• Genitourinary tract manipulation: Avoiding manipulation or distention of the genitourinary tract, such as catheterization or urinary tract infections 2, 3.
• Gastrointestinal tract manipulation: Avoiding manipulation or distention of the gastrointestinal tract, such as bowel movements or gastrointestinal infections 2, 3.
• Patient positioning: Avoiding certain patient positions that can trigger AD, such as sitting or standing 2, 3.
• Anesthetic techniques: Avoiding the use of certain anesthetic techniques that can trigger AD, such as spinal or epidural anesthesia 2, 3.

Education and Awareness

Education and awareness are critical components of AD management. Athletes with SCI, coaches, and medical personnel should be aware of the signs and symptoms of AD, as well as the potential triggers and treatment options. This can help to ensure prompt recognition and treatment of AD episodes, and prevent complications.