What is the management of autonomic dysreflexia?

Management of Autonomic Dysreflexia

For patients with autonomic dysreflexia, immediate identification and removal of the triggering stimulus is the first and most critical step in management, followed by positioning the patient upright, monitoring vital signs, and administering rapid-onset antihypertensives if hypertension persists. 1, 2

Recognition and Immediate Assessment

• Definition: Autonomic dysreflexia (AD) is characterized by sudden, severe hypertension (systolic BP >150 mmHg or 20 mmHg above baseline) in patients with spinal cord injury/lesion at or above T6 level 2

• Key symptoms to identify:

  • Pounding headache
  • Flushing and sweating above the level of injury
  • Bradycardia (or sometimes tachycardia)
  • Visual disturbances
  • Nasal congestion
  • Sense of impending doom 2, 3

Emergency Management Algorithm

1. Identify and remove the triggering stimulus 1, 2

   • Check for bladder distension (most common trigger) → immediate catheterization
   • Check for bowel distension/impaction → digital removal if necessary
   • Loosen tight clothing, remove compression stockings
   • Check for pressure sores, ingrown toenails, or other noxious stimuli

2. Position the patient

   • Elevate head of bed to 45° to promote orthostatic decrease in blood pressure 2

3. Monitor vital signs

   • Check blood pressure every 2-5 minutes until stabilized 2
   • Continue hemodynamic monitoring throughout the episode

4. Pharmacological intervention (if hypertension persists after removing trigger)

   • Use rapid-onset, short-duration antihypertensives:
     • Nitroglycerin 0.4 mg sublingually, OR
     • Nifedipine 10 mg bite and swallow (if not contraindicated) 2
   • For severe cases, consider IV antihypertensives under close monitoring

5. Terminate procedures that may be triggering AD

   • During urodynamic testing or cystoscopic procedures, immediately terminate the study if AD develops 1
   • Drain the bladder immediately and continue hemodynamic monitoring 1

Common Triggers to Assess

• Bladder triggers: distension, UTI, catheterization, blockage
• Bowel triggers: constipation, impaction, digital stimulation
• Skin triggers: pressure sores, ingrown toenails, tight clothing
• Reproductive triggers: sexual activity, menstruation, pregnancy
• Iatrogenic: surgical or diagnostic procedures below the level of injury 2, 3

Special Considerations

• During urodynamic procedures: Hemodynamic monitoring is mandatory for at-risk patients 1
• Persistent AD: For ongoing AD despite bladder drainage, immediately initiate pharmacologic management and escalate care 1
• High-risk patients: Those with cervical stenosis or injuries above T6 require prophylactic measures before procedures 2

Prevention Strategies

• Regular bladder and bowel programs to prevent distension
• Patient and caregiver education about triggers and early symptoms
• Prophylactic antihypertensives before high-risk procedures
• Regular skin care to prevent pressure sores
• Clear communication with all healthcare providers about AD risk 2, 3

Warning Signs for Escalation of Care

• Systolic BP remaining >150 mmHg despite interventions
• Persistent symptoms despite removal of apparent triggers
• Development of seizures, altered mental status, or visual changes
• Symptoms of end-organ damage 1, 2

Autonomic dysreflexia is a medical emergency that requires immediate recognition and treatment to prevent serious complications including stroke, seizures, and death. The cornerstone of management is prompt identification and removal of the triggering stimulus.