Autonomic dysreflexia: Difference between revisions
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==Treatment== | ==Treatment== | ||
;HTN should abate once offending agent corrected - normal is SBP 90-110 mmHg | |||
*Check urinary catheter for any blockage or twisting | |||
*If cath blocked, gently irrigate bladder with NS at body temp | |||
*If cath is draining, suspect fecal impaction and check rectum for stool with lidocaine jelly lube - gentle disimpaction to follow | |||
*Place in an upright position to allow gravitational pooling of blood to reduce BP | |||
*Careful inspection of nonsensate areas to identify the source of painful stimuli | |||
**(e.g. catheter, restrictive clothing, leg bag straps, abdominal supports, orthoses) | |||
;BP meds with SBP > 150, use short-acting since offending agent must be corrected; use with caution in CAD | |||
*Nifedipine immediate release | |||
*NTG paste or sublingual NTG | |||
==Disposition== | ==Disposition== | ||
Revision as of 08:18, 28 April 2016
Background
- Syndrome of massive imbalanced reflex sympathetic discharge from strong stimulus below level of spinal lesion
- Carotid and aortic baroreceptors result in strong vagal response with bradycardia and vasodilation above level of injury, but cannot inhibit sympathetics below level of injury - HTN remains dysregulated by the CNS
- Occurring in patients with spinal cord injury (SCI) above the splanchnic sympathetic outflow (T5-T6)
- Splanchnic innervation from T5-T9
- Lesions below T6 allow descending inhibitory PSNS control to decrease splanchnic tone, preventing HTN
- Medical emergency given dangerous sequelae of elevated blood pressure
Common triggers (due to strong stimuli below level of injury)
- Bladder distension ~80%
- Bowel distension, fecal impaction ~15%
- Pressure ulcers
Clinical Features
History
- Unopposed PSNS above lesion
- Burry vision, miosis
- Headaches
- Anxiety
- Bradycardia associated with rises in BP
- Sweating, flushing
- Nasal congestion
- Unopposed SNS below lesion
- Pale, cool skin
- Piloerection, goose bumps
Physical
- A sudden significant rise in systolic and diastolic blood pressures
- Usually associated with bradycardia
- SBP >140 mm Hg (in a patient with SCI above T6)
- Profuse sweating/flushing above the level of lesion (especially in the face, neck, and shoulders)
- Possible to be asymptomatic
Differential Diagnosis
Hypertension
- Hypertensive emergency
- Stroke
- Sympathetic crashing acute pulmonary edema
- Ischemic stroke
- Intracranial hemorrhage
- Preeclampsia/Eclampsia
- Autonomic dysreflexia
- Scleroderma renal crisis
- Acute glomerulonephritis
- Type- I myocardial infarction
- Volume overload
- Urinary obstruction
- Drug use or overdose (e.g stimulants, especially alcohol, cocaine, or Synthroid)
- Renal Artery Stenosis
- Nephritic and nephrotic syndrome
- Polycystic kidney disease
- Tyramine reaction
- Cushing's syndrome
- Obstructive sleep apnea
- Pheochromocytoma
- Hyperaldosteronism
- Hyperthyroidism
- Anxiety
- Pain
- Oral contraceptive use
Diagnosis
Treatment
- HTN should abate once offending agent corrected - normal is SBP 90-110 mmHg
- Check urinary catheter for any blockage or twisting
- If cath blocked, gently irrigate bladder with NS at body temp
- If cath is draining, suspect fecal impaction and check rectum for stool with lidocaine jelly lube - gentle disimpaction to follow
- Place in an upright position to allow gravitational pooling of blood to reduce BP
- Careful inspection of nonsensate areas to identify the source of painful stimuli
- (e.g. catheter, restrictive clothing, leg bag straps, abdominal supports, orthoses)
- BP meds with SBP > 150, use short-acting since offending agent must be corrected; use with caution in CAD
- Nifedipine immediate release
- NTG paste or sublingual NTG
Disposition
- Admission
See Also
References
- Gunduz H, Binak DF. Autonomic dysreflexia: an important cardiovascular complication in spinal cord injury patients. Cardiol J. 2012;19(2):215-9.