II. Definition

  1. Hypertensive Urgency in a spine injured patient (above T7) resulting from noxious stimuli below the injury

III. Pathophysiology

  1. Underlying spinal cord injury at or above T6 level
  2. Imbalanced reflex sympathetic discharge, leading to Hypertensive Urgency.
  3. Sympathetic spinal reflexes cause sympathetic ganglia activation and direct Vasoconstriction
  4. Inhibitory parasympathetic response cannot reach below the level of the spinal cord lesion.

IV. Causes: Predisposing Factors (noxious stimuli below spinal cord injury)

  1. Distended Bladder or Urinary Tract Infection (most common)
  2. Constipation
  3. Lower extremity Fracture
  4. Skin dirsuption (e.g. Decubitus Ulcers, Ingrown Toenail)

V. Signs

  1. Systolic Blood Pressure increased 20-40 mmHg over baseline
  2. Altered Heart Rate (typically reflex Bradycardia)
  3. Anxiety
  4. Blurred Vision
  5. Facial Flushing
  6. Headache
  7. Diaphoresis above the level of injury
  8. Piloerection above the level of injury
  9. Cool and clammy below level of injury

VI. Management: Blood Pressure Management

  1. Elevate the head of bed to 90 degrees
  2. Monitor Blood Pressure frequently (every 2 to 5 minutes)
    1. Continue to monitor for at least 2 hours after acute episode resolution
  3. Nifedipine IR 10 mg sublingual
  4. Apply Nitroglycerin paste 1 to 2 inches at above above level of injury
    1. Do not use nitrates if recent use of PDE5 Inhibitor (e.g. Viagra)
    2. Other agents to consider if Nitroglycerin is contraindicated
      1. Prazosin or Terazosin
      2. Captopril
      3. Mecamylamine
      4. Diazoxide
      5. Phenoxybenzamine

VII. Management: Elimination of provocative, noxious stimuli

  1. Remove any tight or restrictive clothing
  2. Place Foley Catheter and perform bladded irrigation
  3. Disimpact patient if indicated
  4. Assess for Pressure Ulcers and other predisposing skin lesions

VIII. Complications: Hypertensive Urgency potential sequelae

IX. Resources

  1. Christopher and Dana Reeve Foundation: Autonomic Dysreflexia resources and wallet card
    1. http://www.christopherreeve.org/adcard

X. References

  1. Email communication with Christian A. Beebe, M.D., M.B.A.
    1. Dr. Beebe's notes are used with his permission
  2. Cragg (2012) CMAJ 184(1): 66
    1. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3255181
  3. EMedicine: Autonomic Dysreflexia in spinal cord injury (accessed 9/16/2015)
    1. http://emedicine.medscape.com/article/322809-overview#showall

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Ontology: Autonomic Dysreflexia (C0238015)

Definition (CCC) Life threatening inhibited sympathetic response to a noxious stimuli in a person with a spinal cord injury at T7 or above
Definition (NAN) Life-threatening, uninhibited sympathetic response of the nervous system to a noxious stimulus after a spinal cord injury at T7 or above
Definition (MSH) A syndrome associated with damage to the spinal cord above the mid thoracic level (see SPINAL CORD INJURIES) characterized by a marked increase in the sympathetic response to minor stimuli such as bladder or rectal distention. Manifestations include HYPERTENSION; TACHYCARDIA (or reflex bradycardia); FEVER; FLUSHING; and HYPERHIDROSIS. Extreme hypertension may be associated with a STROKE. (From Adams et al., Principles of Neurology, 6th ed, pp538 and 1232; J Spinal Cord Med 1997;20(3):355-60)
Concepts Disease or Syndrome (T047)
MSH D020211
ICD9 337.3
ICD10 G90.4
SnomedCT 129618003
LNC MTHU013354
Swedish Autonom dysreflexi
Czech autonomní hyperreflexie, spinální autonomní dysreflexie, autonomní dysreflexie, Antonomní dysreflexie
Finnish Autonominen dysrefleksia
English autonomic dysreflexia, autonomic dysreflexia (diagnosis), Autonomic Dysreflexia, Dysreflexia, Autonomic, Autonomic Dysreflexia, Spinal, Dysreflexia, Spinal Autonomic, Spinal Autonomic Dysreflexia, Autonomic Dysreflexias, Dysreflexias, Autonomic, Autonomic Dysreflexias, Spinal, Dysreflexias, Spinal Autonomic, Spinal Autonomic Dysreflexias, Autonomic Hyperreflexia, Hyperreflexia, Autonomic, Autonomic Hyperreflexias, Hyperreflexias, Autonomic, Autonomic Dysreflexia [Disease/Finding], rndx autonomic dysreflexia (diagnosis), rndx autonomic dysreflexia, autonomic hyperreflexia, dysreflexia, Dysreflexia, Autonomic dysreflexia, Autonomic dysreflexia (disorder), AUTONOMIC DYSREFLEXIA
Spanish Disreflexia autonómica, Disreflexia Autonómica, Disreflexia Autónoma, disreflexia autónoma (trastorno), disreflexia autónoma, disreflexia, Disreflexia Autonómica Espinal, Hiperreflexia Autonómica
Dutch autonome dysreflexie, Autonome dysreflexie, Autonome hyperreflexie, Dysreflexie, autonome, Hyperreflexie, autonome, Spinale autonome dysreflexie
German autonome Dysreflexie, Autonome Dysreflexie, Autonome Hyperreflexie, Dysreflexie, autonome, Hyperreflexie, autonome, Spinale autonome Dysreflexie
Japanese ジリツシンケイイジョウハンシャ, 自律神経異常反射, 自律反射不全, 自律神経反射亢進, 反射亢進-自律神経, 脊髄自律反射不全
Korean 자율 반사이상
Portuguese Disreflexia autónoma, Hiper-Reflexia Autonômica, Hiper-Reflexia Autônoma, Disreflexia Autônoma Medular, Disreflexia Autônoma, Disreflexia Autonômica Medular, Disreflexia Autonômica
Italian Disreflessia autonomica, Disreflessia simpatica
Polish Odruchy wzmożone autonomiczne, Zaburzenia odruchów autonomiczne, Zaburzenia odruchów autonomiczne rdzeniowe
Hungarian Autonom dysreflexia
Norwegian Autonom dysrefleksi, Autonom hyperrefleksi, Dysrefleksi, autonom, Hyperrefleksi, autonom, Spinal autonom dysrefleksi
French Dysréflexie autonome, Hyperréflexie autonome