Autonomic Dysreflexia is one of the most serious life-threatening conditions which occurs in a high
percentage of patients with lesions at or above the 6th thoracic vertebra (T6). The syndrome occurs as a
result of uncontrolled reflex sympathetic activity resulting in significant rise in blood pressure and is a
response to the stimulus which should be identified.
It is essential that prompt action is taken to reduce the blood pressure and to remov
taken to reduce the blood pressure and to remov the cause of
sreflex a in order to avoid serious and life-threatening complications.
The autonomic nervous system functions at an unconscious reflex level and regulates the internal
environment of the body. The autonomic nervous system consists of two major divisions, the Sympathetic
and Parasympathetic Nervous Systems which normally function in a balanced manner. The Sympathetic
Nervous System stimulates activities to provide a normal response to stress, activity and injury. Autonomic
dysreflexia occurs when there is an irritating stimulus introduced to the body below the level of the injury.
The stimulus results in nerve impulses travelling up the spinal cord which are obstructed on reaching the
level of the injury. The impulses therefore cannot reach the brain but instead activate a reflex which
increases the response of the of the Sympathetic Nervous System. This activity results in vaso-constriction
which in turn will lead to the development of high blood pressure.
Indirectly the brain will appreciate the change in the blood pressure through nerve receptors in the heart
and aorta but cannot, in turn, influence changes below the level of the injury. The changes therefore may be
inappropriate and result in changes in heart rate and blood pressure and affect organs above the level of
injury. There will be concomitant relaxation of blood vessels (vaso dilatation) seen as flushing and blotching
of the skin. In the upper half of the body and face, nasal congestion with the pounding headache are a
feature of the systemic high blood pressure.
A vicious circle of activity will be maintained until the cause is removed and or appropriate treatment is
Feeling of doom, anxiety & apprehension
Flushing and/or blotching above level of cord lesion
Sweating in area above and around the lesion.
Penile erection & seminal fluid emission.
Danger: Can result in Intracranial Haemorrhage.
rise to “normal” lev l of 120/80mm.Hg
l of 120/80mm.H . may represent a significant elev
since blood pressure changes can occur ex
since blood pressure changes can occur ex
fiv minutes until blood pressure control is achieved
Defective drainage system (e.g. kinked tubing/full drainage bag)
Bladder dysfunction is the most common cause of autonomic dysreflexia.
Any of the above may provide a sufficient stimulus to initiate dysreflexia.
8. All other conditions which would have been associated with pain prior to the injury such as anal
1. Reduce the blood pressure by placing the patient in a sitting position and/or raising the head.
3. Give sublingual Nifedipine 10 mg. pierced, bitten or chewed or GTN Spray (If possible monitor blood
pressure every five minutes during the episode). Treatment may be repeated up to four doses (40mg.) over
If catheter present check patency and if blocked or kinked correct the problem.
If not catheterised catheterise immediately and leave on free drainage.
b. If bladder not distended, free drainage established but infection suspected or if re-catheterised give
Check rectum for faecal impaction using KY Jelly or Lignocaine Gel. If impaction present gently carry
If rectum empty consider constipation as a cause and arrange appropriate treatment.
Check Skin for pressure ulcers and abscesses.
Check for other possible stimuli such asin-growing toenail, fractures, deep vein thrombosis and treat
Continue observations, B.P. Pulse, Urine Drainage.
If condition has not resolved or for further advice contact Spinal Unit (Duty SHO) or nearest Accident &
1. Nifedipine, sublingual 10 mg. Bitten or chewed. This may be repeated up to four doses (40mg.) over
2. GTN spray 1- 2 doses under tongue (as alternative to Nifedipine).
3. Diazepam (Diazemuls I.V.) for treatment of associated spasms and for control of fits. May be useful for
control during transfer to Specialist Unit.
4. Lignocaine Gel per rectum/per urethra to block afferent input.
5. Pain - do not use Aspirin or NSAID for analgesia or for relief of headache. Use Paracetamol, Co-
1. Phentolamine 10mg./ml ampoule. Give by I.V. injection 2-5 mg. repeated if necessary, short duration of
Side Effects - Tachycardia, dizziness, nausea and vomiting, angina, chest pains, arrhythmias.
Contra-indications - Hypotension, history of myocardial infarction, angina.
Infuse at 2 mg, per minute, until a satisfactory response is obtained. The infusion should then be
stopped. Effective dose is usually in the range 50-200 mg. Can be used in pregnancy. Give when
patient is in supine or left lateral position. Raising patient to upright position within three hours of
receiving IV Labetalol, should be avoided since excessive postural hypotension may occur.
Direct acting vasodilator. 20 mg, ampoule. Give by slow IV injection or IV infusion 5-10mg IV over 20
mins. Repeat if necessary after 20 - 30 minutes.
Side effects - Tachycardia, fluid retention. (Note: Alpha blockers may be useful if bladder outlet
problems contribute to the dysreflexia).
Autonomic dysreflexia is a dangerous complication of spinal cord injury and causes extreme anxiety to the
patient. When the person with spinal cord injury has been stabilised a full review of the patient’s care and
consideration of precipitating causes should be carried out. This should involve the patient, the family and
all care givers. This process may require an adjustment of the care or treatment plan ideally to prevent a
further medical crisis by anticipatory treatment but also to ensure that any future episodes are fully
recognised and are treated urgently before they become significant.
All patients with a lesion above T6 will be given a written description (this book) of autonomic dysreflexia
and its treatment and will be given a personal card to carry at all times. This is a medical emergency I have a spinal cord injury with paralysis. I suffer from Autonomic Dysreflexia. This can lead to seizure and cerebral bleeding. Symptoms may be: Headache, flushing, sweating and goose bumps. Take Action quickly Please dial 999 immediately Inform Ambulance Service that I have Autonomic
For further information and advice please contact:
The Queen Elizabeth National Spinal Injuries Unit
South Glasgow Universities Hospitals NHS Trust
Copyright 1999 The Queen Elizabeth National Spinal Injuries Unit
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