Autonomic Dysreflexia


Article Author:
Kathrin Allen


Article Editor:
Stephen Leslie


Editors In Chief:
David Wood
Andrew Wilt
Hajira Basit


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
4/8/2019 9:59:32 PM

Introduction

Autonomic dysreflexia is a condition that emerges after a spinal cord injury, usually when the injury has occurred above the T6 level. The higher the level of the spinal cord injury, the greater the risk with up to 90% of patients with cervical spinal or high-thoracic spinal cord injury being susceptible. Dysregulation of the autonomic nervous system leads to an uncoordinated autonomic response that may result in a potentially life-threatening hypertensive episode when there is a noxious stimulus below the level of the spinal cord injury.  In about 85% of cases, this stimulus is from a urological source such as a UTI, a distended bladder, or a clogged Foley catheter. There is a significantly increased risk of stroke by 300% to 400%. Autonomic dysreflexia can occur in susceptible individuals up to 40 times per day. The initial presenting complaint is usually a headache which can be severe.  Susceptible individuals with spinal cord lesions above T6 who complain of a headache should immediately have their blood pressure checked. If elevated, a presumptive diagnosis of autonomic dysreflexia can be made. Prompt recognition and correction of the disorder, usually just by irrigating or changing the Foley catheter, can be life-saving.

Etiology

The etiology is a spinal cord injury, usually above the T6 level. It is unlikely to occur if the level is below T10. The higher the injury level, the worse the severity of the cardiovascular dysfunction. The severity and frequency of autonomic dysreflexia episodes are also associated with the completeness of the spinal cord injury. Patients usually develop autonomic dysreflexia one month to one year after their injury. However, it has also been described in the first days or weeks after the original trauma. Objectively, an episode is defined as an increase in systolic blood pressure of 25 mm Hg.

Epidemiology

Autonomic dysreflexia develops in 20% to 70% of patients with spinal cord injury above the T6 level and is unlikely to develop if the injury is below T10.  Patients prone to this disorder will usually have a history of prior episodes, but health professionals need to be alert to an initial presentation without any prior history of autonomic dysreflexia.

Pathophysiology

Cutaneous or visceral stimulation below the level of the spinal cord injury, initiates afferent impulses that elicit reflex sympathetic nervous system activity. The sympathetic response leads to diffuse vasoconstriction, typically to the lower two-thirds of the body, and a rise in blood pressure. In an intact autonomic system, this increased blood pressure stimulates the carotid sinus leading to a parasympathetic outflow slowing the heart rate via vagal stimulation and causing diffuse vasodilation to balance the original increased sympathetic response. However, in the setting of a spinal cord injury, the normal compensatory parasympathetic response cannot travel below the level of the spinal cord injury, and generalized vasoconstriction continues below the level of injury leading to systemic hypertension. The compensatory parasympathetic response leads to bradycardia and vasodilation, but only above the level of the spinal cord injury.

The most common stimuli are distention of a hollow viscus, such as the bladder or rectum. Pressure ulcers or other injuries such as fractures and urinary tract infections are also common causes. Sexual intercourse can also be a stimulus. Medical procedures, surgeries, and labor and delivery are usually complicated in patients with a history of autonomic dysreflexia as well. Spinal cord injuries below T10 rarely result in autonomic dysreflexia because the splanchnic innervation remains intact and allows for compensatory parasympathetic dilation of the splanchnic vascular bed.

Pharmacological causes of autonomic dysreflexia are rare, but recently a case was reported in a patient receiving combination therapy with duloxetine and amitriptyline.  [1]

History and Physical

The manifestations are variable and include:

  • A severe headache
  • Profuse diaphoresis above the level of injury
  • Flushing above the level of injury
  • Piloerection above the level of injury
  • Dry and pale skin because of vasoconstriction below the level of injury
  • Visual disturbances
  • Nasal stuffiness
  • Anxiety or feelings of doom
  • Nausea and vomiting

Hypertension may be asymptomatic or be severe enough to lead to a hypertensive crisis complicated by pulmonary edema, left ventricular dysfunction, retinal detachment, intracranial hemorrhage, seizures or even death. Bradycardia may also range from minor to resulting in cardiac arrest. Tachycardia is less common than bradycardia but may also occur along with cardiac arrhythmias and atrial fibrillation or flutter. If the patient has coronary artery disease, an episode may cause a myocardial infarction.

The combination of dangerously high blood pressure together with cerebral vasodilation puts the patient at high risk for a hemorrhagic stroke which can be life-threatening.

Evaluation

The evaluation includes obtaining a history of previous episodes, monitoring vital signs and watching for any developing signs and symptoms especially if there is a known trigger.

The key is first to identify patients at risk (spinal cord injury above T6 level) and recognize the key initial symptom which is usually a severe headache from cerebral vasodilation. Should this be encountered, the next step should be to check blood pressure. If elevated, then the patient is at high risk for an episode of autonomic dysreflexia.

The likelihood of autonomic dysreflexia is independently predicted by the level of the spinal cord lesion and the presence of neurogenic detrusor overactivity. Patients at high risk who are getting urodynamic testing should have continuous cardiovascular monitoring.

Treatment / Management

In the event of an episode, vital signs should be closely monitored, and recognition of the trigger should be immediately sought. Blood pressure should be checked at least every 5 minutes, and an arterial line should be considered. The noxious stimuli should be corrected as soon as possible. Bladder and bowel distension are the most common causes. Therefore, restoring bladder drainage is immediately recommended. If the patient has an indwelling catheter, it should be evaluated for malfunction or malpositioning, and a workup for a urinary tract infection should also be performed. A rectal exam should be performed to evaluate for impaction; however, this should be done with care as it can precipitate a worsening crisis due to the stimulation of the procedure.  Sitting the patient upright and removing any tight clothing or constrictive devices will orthostatically help lower blood pressure by inducing pooling of blood in the abdominal and lower extremity vessels as well as removing any possible stimuli. If the trigger cannot be identified and initial maneuvers do not improve the systolic blood pressure below 150 mm Hg pharmacologic management should be initiated. Hypertension should be promptly corrected with agents that have a rapid onset but short duration of action. Examples are nitrates (either nitropaste or sublingual), nifedipine (oral or sublingual), sublingual captopril, intravenous hydralazine, intravenous labetalol (if the heart rate is not too slow), among others. Intravenous infusions such as nitroglycerine or clevidipine are also options; however, placement of an arterial line is recommended for close titration of the infusion.

Women with spinal cord injury who become pregnant are at risk for developing a dysreflexia episode during labor and delivery. In women with spinal cord injury, the symptoms of labor may only be some abdominal discomfort, increased spasticity, and autonomic dysreflexia.  Epidural anesthesia has been reported to be the superior choice for control of autonomic dysreflexia during labor. For cesarean delivery or instrumentally assisted delivery, a spinal or epidural may be used. The American College of Obstetrics and Gynecology states that it is vital that any obstetrician caring for a patient with spinal cord injury be familiar with the complications related to such injuries.

Leakage of urine around catheters that are not obstructed is often due to bladder spasms that may be associated with dysreflexia episodes. For these cases, overactive bladder medications such as oxybutynin and mirabegron can be used.  In severe cases, bladder wall injections of Botox can be used.  Urinary infections may also cause bladder spasms without catheter blockage, but such spasms are usually transient and disappear when the UTI is successfully treated. Constipation may also be a contributing factor. 

Patients with spinal cord injury and autonomic dysreflexia often undergo medical procedures and surgeries such as urologic instrumentations that can trigger dysreflexia episodes. General or regional anesthesia may be used for these procedures. Regional anesthesia in the form of a spinal anesthetic has the advantage of blocking both limbs of the reflex arc and thereby avoids autonomic dysreflexia. However, determining the level of anesthesia may be difficult, and placement of the spinal may be challenging in patients with spinal cord injuries. An epidural catheter may also be considered for longer cases as it has the advantage of being able to be “topped off.”  Epidurals are subject to incomplete blocks and may be even more difficult to place. If general anesthesia is used and hypertension or other evidence of a dysreflexia episode develops, deepening the level of anesthesia by increasing the anesthetic agent often alleviates the episode. If however, the hypertension is not resolved by deepening the anesthetic, then antihypertensive medications should be used until the stimulus is withdrawn.

The use of 10 ml of 2% lidocaine administered intravesically 4-6 minutes prior to routine Foley catheter changes has been shown to reduce episodes of autonomic dysreflexia significantly in patients at high risk.[2]

Use of botox for chemodenervation of the bladder has also been shown to reduce autonomic dysreflexia in susceptible individuals.[3][4]

Minocycline has been shown to have a neuroprotective effect in animal testing models, but has not yet been shown to have a similar clinical effect in humans.[5][6][7][8][5]

Pearls and Other Issues

Autonomic dysreflexia should be strongly suspected in any spinal cord injured patient with a lesion above T6 who complains of a headache.  A blood pressure reading should be taken immediately, and corrective treatment started if the patient's blood pressure is significantly elevated as most spinal cord injured patients have low blood pressure. Bladder distension from urinary retention or a blocked Foley is the single most common cause of this disorder and irrigating or changing the catheter is often immediately curative. Quick recognition and rapid alleviation of the underlying stimulus may be life-saving.

Enhancing Healthcare Team Outcomes

Patients with spinal cord injury are usually managed by an interprofessional team that includes the trauma surgeon, internist, neurologist, urologist and emergency department physician. Autonomic dysreflexia should be strongly suspected in any spinal cord injured patient with a lesion above T6 who complains of a headache.  A blood pressure reading should be taken immediately, and corrective treatment started if the patient's blood pressure is significantly elevated as most spinal cord injured patients have low blood pressure. Bladder distension from urinary retention or a blocked Foley is the single most common cause of this disorder and irrigating or changing the catheter is often immediately curative. Quick recognition and rapid alleviation of the underlying stimulus may be life-saving.

Nurses play a key role in the monitoring of patients with autonomic dysreflexia. These patients are best managed in the ICU with 24/7 monitoring. These patients are also prone to DVT and pressure sores, hence prophylaxis should be undertaken.[8][9]


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Autonomic Dysreflexia - Questions

Take a quiz of the questions on this article.

Take Quiz
Autonomic dysreflexia can occur when what segment of the spinal cord is injured?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following spinal injury levels is associated with autonomic dysreflexia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient with a complete spinal cord injury at the C7 level who is 8 days out from the injury is discovered to have severe hypertension, profuse sweating, and painful headaches. The patient is diagnosed with autonomic dysreflexia. Which of the following is incorrect?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is the most likely cause of dizziness and light headedness in a patient with a history of a spinal cord injury?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient with spinal cord injury complains of anxiety, perspiration, a pounding headache, chills, and nasal congestion. The heart rate is slow. What should be the initial intervention?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient with a spinal cord injury develops anxiety, hypertension, headache, diaphoresis, chills, nasal congestion, bradycardia, and flushing. What is the most likely cause?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following usually is not a symptom of autonomic dysreflexia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
During therapy a patient develops autonomic dysreflexia. What is the first step in management?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient with spinal cord injury develops signs of autonomic dysreflexia. What should be done immediately?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient with a spinal cord injury (SCI) at C7 is receiving therapy when she develops a severe headache, diaphoresis, and hypertension. What is the most likely diagnosis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient with a C7 spinal cord injury is complaining about having a pounding headache and he has a red face. You decide to take his vitals and note that his blood pressure is 180/95 mmHg. What should be done immediately?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Autonomic dysreflexia is a potentially dangerous situation in spinal cord injured patients. At what level of spinal injury is this condition possible?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Autonomic dysreflexia is a potentially fatal disorder in spinal cord injured patients. What are the symptoms?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Autonomic dysreflexia is characterized by which of the following?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What percentage of episodes of autonomic dysreflexia is caused by urological problems?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient has a T4 spinal cord injury and complains of a severe headache. An indwelling urinary catheter is in place. The monitor shows an increase in systolic blood pressure from 140 to 180 mmHg. Which of the following should be done immediately? Select all that apply.



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is true regarding autonomic dysreflexia? Select all that apply.



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A nurse intern is working with their mentor today on a neurosurgical floor. As they enter the room of a client with a spinal cord injury at the level of T4, they notice a change from their assessment 4 hours ago. A 0800 evaluation revealed goosebumps, increase in spasticity, sweating, oriented times four, urine output in drainage bag of 30 mL, regular bowel movement, no pain, blood pressure 140/90 mmHg, heart rate 58 to 62 beats/min, and temperature 36.8 C (98.2 F). A current assessment at 1200 reveals a pounding, 10/10 headache, nausea with frequent vomiting, blurred vision, profuse sweating, and diffuse goosebumps. Urinary drainage bag has 30 mL of urine output with no documentation of being emptied on flowsheet by the unlicensed assistive personnel. Blood pressure is 240/128 mmHg, heart rate 38 beats/min, and temperature 37.4 C (99.3 F). Based on this clinical scenario, how does the nurse intern and mentor proceed in the management of care for this client? Select all that apply.



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following has not been shown to be useful in treating patients with autonomic dysreflexia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Autonomic Dysreflexia - References

References

Parke SC,Reyes MR, Autonomic Dysreflexia as a Potential Adverse Effect of Duloxetine and Amitriptyline Combination Therapy: A Case Report. PM     [PubMed]
Solinsky R,Linsenmeyer TA, Intravesical lidocaine decreases autonomic dysreflexia when administered prior to catheter change. The journal of spinal cord medicine. 2018 Sep 10;     [PubMed]
Squair JW,Ruiz I,Phillips AA,Zheng MMZ,Sarafis ZK,Sachdeva R,Gopaul R,Liu J,Tetzlaff W,West CR,Krassioukov AV, Minocycline Reduces the Severity of Autonomic Dysreflexia after Experimental Spinal Cord Injury. Journal of neurotrauma. 2018 Dec 15;     [PubMed]
Fougere RJ,Currie KD,Nigro MK,Stothers L,Rapoport D,Krassioukov AV, Reduction in Bladder-Related Autonomic Dysreflexia after OnabotulinumtoxinA Treatment in Spinal Cord Injury. Journal of neurotrauma. 2016 Sep 15;     [PubMed]
Haynes BM,Osbun NC,Yang CC, Ancillary benefits of bladder chemodenervation for SCI neurogenic bladder. Spinal cord series and cases. 2018;     [PubMed]
Novak P, Autonomic Disorders. The American journal of medicine. 2019 Apr;     [PubMed]
Kupfer M,Kucer BT,Kupfer H,Formal CS, Persons With Chronic Spinal Cord Injuries in the Emergency Department: a Review of a Unique Population. The Journal of emergency medicine. 2018 Aug;     [PubMed]
Lofters A,Chaudhry M,Slater M,Schuler A,Milligan J,Lee J,Guilcher SJT, Preventive care among primary care patients living with spinal cord injury. The journal of spinal cord medicine. 2018 Feb 9;     [PubMed]
Davidson R,Phillips A, Cardiovascular Physiology and Responses to Sexual Activity in Individuals Living with Spinal Cord Injury. Topics in spinal cord injury rehabilitation. 2017 Winter;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Pediatrics-Medical Student. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Pediatrics-Medical Student, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Pediatrics-Medical Student, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Pediatrics-Medical Student. When it is time for the Pediatrics-Medical Student board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Pediatrics-Medical Student.