Autonomic dysreflexia
 R.A.S HEMAT, MB;BCh, FRCSI, DUL.
Autonomic dysreflexia is an acute syndrome of massive disordered autonomic response to a specific stimulus seen in patients with spinal cord injuries above the level of splanchnic outflow. Characterised by excessive sweating, flushing of the face, congestion of the nasal passages, pounding headache, intermittent hypertension (diastolic and systolic), piloerection and bradycardia.
All stimuli acting below the level of injury can evoke the steriotypic response
1-Bladder distension, retention of urine.
2-Clamping of the Foley catheter.
3-Bladder calculi.
4-UTI, acute cystitis, epididmyitis.
5-Loaded colon, anal fissure, flatulence.
6-Acute abdominal conditions.
7-Ejaculation.
8-Labour, uterine contraction and fetal movement.
9-Procedures (cystoscopy).
10-Detrusor-sphincter dyssynergia.
11-Cleansing enemas.
12-Pressure sores.
13-External temperature changes.
14-Scratching the soles of the feet.
15-Skin lesions e.g. ingrowing toe-nails, sunburn.
16-Tight clothing, shoes or leg bag straps.
17-Distension of the renal pelvis.
18-Pressure on the testicles and glans.
19-Sexual intercourse.
20-Intracavernosal injections.
21-Bladder percussion.
22-Renal or biliary colic.
23-Vesicoureteral reflux.
24-Manipulation of an indwelling catheter.
25-Testicular torsion.
Intervention
1-Rapidly identifying and removing the cause of the dysreflexia and lowering the blood pressure are the first priorities.
2-Remove anything that may be stimulating the patient, such as constricting bed linens.
3-Sit the patient up or elevate the head of the bed to 90o, while keeping the feet down, to promote orthostatic reduction of blood pressure.
4-Assess the abdomen for evidence of distended bladder and conclude the need for catheterization. Insert the catheter after liberally lubricating it with Xylocaine to reduce stimulation. Drain the bladder slow while monitoring the patient.
5-Check blood pressure every few minutes, a blood pressure above 200/100 requires monitoring at least every 15 minutes until blood pressure and heart rate are under control. Heart rate and blood pressure should be monitored every four hours for 24 hours.
6-If after the bladder fully drained, no change in the blood pressure, constipation is then the primary factor. Repeat abdominal examination for bowel distension.
7-Gently insert 1 oz of Xylocaine into the rectum. Manually check for fecal impaction & remove all accessible stool.
8-If blood pressure remains high, order hydralazine hydrochloride 20-40 mg iv. Sublingual nifedipine 10-20 mg is alternative treatment.
9-Continue check the blood pressure every 2-3 minutes until returns to normal.
10-Patient must learn how to prevent another episode.
11-Blood pressure should be carefully monitored in patients with injuries at or above T6 who undergo various diagnostic tests and procedures, even if they are asymptomatic.
12-Instruct the patient not to drink several glasses of fluid at one time, which can distend the bladder.
September, 2000
Note: The information in this article has been excerpted from the following books: urotext-ebook simplifying urology, Principles of modern urology, by Dr. R.A.S HEMAT. Permission is granted to copy and redistribute this document electronically as long as it is unmodified. This article may not be sold in any medium, including electronic, CD-ROM, or database, or published in print, without the explicit, written permission of Dr. R. A. S. Hemat.
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