What is the management of autonomic dysreflexia?

Management of Autonomic Dysreflexia

The immediate management of autonomic dysreflexia requires rapid identification and removal of the triggering stimulus, followed by positioning the patient upright, monitoring vital signs, and administering rapid-onset antihypertensives if hypertension persists. 1

Immediate Management Algorithm

1. Identify and remove triggering stimulus:

   • Check for bladder distension (most common trigger) - catheterize immediately if distended
   • Check for bowel impaction - perform digital rectal examination if necessary
   • Remove tight clothing or compression stockings
   • Stop any ongoing procedures (e.g., urodynamic testing, cystoscopy) 1

2. Position the patient upright to induce orthostatic decrease in blood pressure

3. Monitor vital signs continuously - especially blood pressure and heart rate

4. Administer antihypertensive medication if systolic BP remains >150 mmHg despite above measures:

   • First-line: Nitroglycerin 0.4 mg sublingually OR
   • Nifedipine 10 mg bite and swallow
   • For severe cases: Consider IV antihypertensives under close monitoring 1

High-Risk Patients and Prevention

Patients with spinal cord injuries above T6 are at highest risk for autonomic dysreflexia, which can be life-threatening if not promptly recognized and treated 2. Prevention strategies include:

• Regular bladder and bowel programs to prevent distension
• Prophylactic antihypertensives before procedures in high-risk patients
• Continuous hemodynamic monitoring during procedures
• Adequate anesthesia/analgesia during procedures 1

Recognition of Symptoms

Early recognition is critical. Key symptoms include:

• Pounding headache (cardinal symptom)
• Flushing and sweating above the level of injury
• Diaphoresis
• Bradycardia or tachycardia
• Dizziness and visual disturbances
• Nasal congestion 1

Indications for Escalation of Care

Escalate care immediately if:

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

Pharmacological Management

For patients with recurrent episodes of autonomic dysreflexia without acute precipitating factors, long-term alpha-1 adrenergic blockers may be beneficial:

• Terazosin has been shown to be effective in controlling recurrent autonomic dysreflexia in both adult and pediatric patients with spinal cord injuries 3
• Starting dose: 1 mg for adults, 0.5 mg for children at bedtime
• Dose can be increased gradually (every 3-4 days) until symptoms resolve 3
• Monitor for side effects such as postural hypotension and drowsiness

Special Considerations for Radiological Procedures

Radiological procedures, both diagnostic and interventional, may trigger autonomic dysreflexia in susceptible patients. Planning should include:

• Identification of at-risk patients before booking procedures
• Ensuring appropriate supervision and anesthesiology support
• Education of all staff involved in the procedure 2

Communication and Education

• Educate patients and caregivers about triggers and early symptoms
• Ensure clear communication with all healthcare providers about the risk
• Provide patients with an autonomic dysreflexia emergency card 1

Autonomic dysreflexia is a medical emergency that requires immediate recognition and treatment to prevent serious complications, including stroke, seizures, and death 4. The management approach focuses on prompt identification and removal of triggers, followed by pharmacological intervention if necessary.