What is the management of autonomic dysreflexia?

Management of Autonomic Dysreflexia

The management of autonomic dysreflexia requires immediate intervention to identify and remove the triggering stimulus, with prompt drainage of the bladder being the most critical first step, followed by pharmacologic management if symptoms persist despite stimulus removal. 1

Recognition and Immediate Management

• Autonomic dysreflexia (AD) is a life-threatening emergency condition characterized by sudden severe hypertension, occurring primarily in patients with spinal cord injuries at or above the T6 level 2, 3
• Classic symptoms include systolic blood pressure >150 mmHg and/or 20 mmHg above baseline, flushing, sweating, headache, blurry vision, and a sense of impending doom 1
• Immediate hemodynamic monitoring must be initiated when AD is suspected, especially during urodynamic testing or cystoscopic procedures in at-risk patients 1

Step-by-Step Management Algorithm

1. Identify and immediately remove the triggering stimulus:

   • Terminate any ongoing procedures (e.g., urodynamic testing, cystoscopy) 1
   • Elevate the head of the bed to 45° to promote orthostatic reduction in blood pressure 4
   • Check for bladder distension (most common cause) and immediately drain the bladder 3, 5
   • If a catheter is present and potentially blocked, flush or replace it 2
   • Inspect for other potential triggers: bowel impaction, pressure sores, tight clothing, ingrown toenails 4, 6

2. Continue hemodynamic monitoring throughout management to track response to interventions 1

3. If symptoms persist despite stimulus removal:

   • Immediately initiate pharmacologic management for patients with systolic BP >150 mmHg or 20 mmHg above baseline with persistent symptoms 1
   • Use rapid-acting antihypertensive medications with short half-lives 6
   • Escalate care if blood pressure remains uncontrolled 1

Pharmacologic Management

• For persistent AD despite stimulus removal, antihypertensive medications should be readily available before any urologic procedure 1
• In cases of spinal cord injury with persistent bradycardia related to autonomic dysreflexia:
  • Atropine and inotropes are often used but may not always be effective 1
  • Methylxanthines (theophylline or aminophylline) target the underlying pathology of unopposed parasympathetic stimulation and have shown beneficial effects 1
  • Treatment with methylxanthines can usually be withdrawn after 4-6 weeks 1

Prevention and Education

• Clinicians must educate patients with neurogenic lower urinary tract dysfunction (NLUTD) about signs and symptoms of AD that warrant immediate medical attention 1
• Patients should report new or worsening AD, urinary incontinence, UTIs with fever or flank pain, and difficulties with catheterization 1
• Regular monitoring is essential for high-risk patients, with particular attention to bladder management 1
• For athletes with spinal cord injuries above T6 level, the practice of "boosting" (intentionally inducing AD via bladder distension) should be discouraged due to serious health risks 1

Common Pitfalls and Caveats

• Failure to recognize AD as the underlying cause of symptoms can lead to inappropriate treatments and delayed resolution 2
• Treating only the symptoms without addressing the underlying cause can increase morbidity and mortality 2, 6
• After resolving the trigger (especially with large-volume bladder drainage), patients may become hypotensive and require fluid resuscitation 2
• AD can result in serious complications including seizures, intracerebral hemorrhage, or death if not recognized and treated appropriately 2, 3
• In rare cases, temporary pacing may be considered for hemodynamically significant sinus bradycardia associated with spinal cord injury that is refractory to medical therapy 1