What is Autonomic Dysreflexia?

Autonomic Dysreflexia is a medical emergency and a potentially life-threatening condition. It affects people with a spinal cord injury (SCI) at or above the T6 neurological level.  Autonomic Dysreflexia is most likely to occur in people with a complete SCI, but can happen in people with incomplete SCI. 

Recommended resources

Recommended resources that explain Autonomic Dysreflexia include:

Symptoms of Autonomic Dysreflexia

• Sudden hypertension (>20 mm Hg above the usual systolic blood pressure, which may have a lower baseline due to SCI)
• Pounding headache
• Bradycardia (although tachycardia may also occur)
• Flushing of the face
• Profuse sweating above the level of lesion
• Pale, cold skin and piloerection below SCI
• Chills without fever
• Nasal congestion
• Blurred vision
• Shortness of breath, sense of fear or anxiety

Potential causes of Autonomic Dysreflexia

Bladder

• Catheter blockage/catheter tubing kink
• Urinary tract infection (including epididymo-orchitis or prostatitis)
• Bladder or kidney stones
• Urological procedure or inserting a catheter
• Refer to bladder management content (link)

Bowel

• Constipation
• Faecal impaction
• Gaseous distension
• Rectal irritation (e.g. enema or manual evacuation)
• Haemorrhoids
• Fissures
• Refer to bowel management content (link)

Skin

• Ingrown toenail
• Burns
• Pressure area
• Tight clothing
• Refer to Skin/ pressure care content (link)

Other

• Fracture
• Sexual intercourse
• Labour/childbirth
• Severe menstrual cramping

Management of Autonomic Dysreflexia

If left untreated, Autonomic Dysreflexia can cause the blood pressure to rise to dangerously high levels. In the most extreme cases this can result in intracranial haemorrhage, seizures, cardiac arrhythmia, or even death.

It is useful for clinicians to be aware of the management principles of Autonomic Dysreflexia, and for clients to be able to assist in directing care if they are experiencing an episode of Autonomic Dysreflexia.

Following established management guidelines will help to prevent the blood pressure from rising dangerously when trying to address triggers for Autonomic Dysreflexia (e.g. use sufficient lignocaine jelly and allow time for this to take effect before changing catheters or rectal examination; don’t drain an over distended bladder too rapidly)

A good flowchart to assist with management of Autonomic Dysreflexia is available via the Agency for Clinical Innovation

Recurrent Autonomic Dysreflexia

After an episode of Autonomic Dysreflexia clients are more at risk of having another episode in the following days. Clients should watch for symptoms and be aware activities that are normally well tolerated may trigger a further Autonomic Dysreflexia episode (e.g. performing muscle stretches, bowel or bladder care). Invasive procedures should be avoided or delayed for 72 hours.

If clients are having frequent or recurrent Autonomic Dysreflexia episodes, it is important to look for a likely trigger. Clients can then take steps to prevent Autonomic Dysreflexia in the future (e.g. good catheter care to prevent recurrent blockages, skin checks to prevent pressure areas).

Where a trigger is not easily avoided (e.g. sexual activity), developing an action plan that focuses on both prevention and management of the Autonomic Dysreflexia episodes is critical. The medical and nursing staff at Victorian Spinal Cord Service can help clients to develop such plans.

Sometimes, the cause of the Autonomic Dysreflexia episode cannot be found. This may result in frequent or non-resolving episodes of Autonomic Dysreflexia. Admission to hospital is likely to be needed to control blood pressure and to look for the cause of the Autonomic Dysreflexia episodes.

In rare circumstances, daily medications may be prescribed by a GP in consultation with a spinal physician to reduce the risk of Autonomic Dysreflexia in very susceptible people.

Pregnancy

Females with spinal cord injury at or above T6 are at risk of developing Autonomic Dysreflexia during the pregnancy, labour and after the baby is born. The treating obstetrician, anaesthetist, GP and spinal physician need to be aware of this risk. The team should review clinical practice guidelines for managing pregnancy in the setting of SCI.

Key points to note 

• After 28 weeks, women should have their BP checked weekly.
• For women with SCI above T6, a spinal or epidural is recommended at the onset of labour to reduce the risk of Autonomic Dysreflexia.
• Close monitoring of the foetus should occur during labour.
• There should be an understanding that both pre-eclampsia and Autonomic Dysreflexia may cause high blood pressure, and that there are clinical signs that differ between the two conditions.
• Women should be aware that Autonomic Dysreflexia may occur in the post-partum period (e.g. with breast feeding or mastitis).
• Plans about medication use should be made with multi-specialty input for women who are pregnant or breast feeding.

Rural clients and Autonomic Dysreflexia

Autonomic Dysreflexia detected early can often be managed in the community without the need to transfer to a hospital. To make this possible in a rural or remote area, clients and their support people should be trained to help recognise and manage episodes of Autonomic Dysreflexia. Some clients keep an emergency box with supplies to help with management of Autonomic Dysreflexia at home (e.g. client information card, BP machine, lignocaine jelly, medications in consultation with spinal physician).

It is also important for rural clients to know when to call for help, and who to call.

The Victorian Spinal Cord Service team can help with capacity building in the local community when clients leave hospital (e.g. education for local ambulance service, support for GP etc). Please contact the service if more support or education is needed for rural clients.

Autonomic Dysreflexia client and carer education resources

An emergency wallet card should be carried by all clients with SCI at or above T6. This will help emergency responders to quickly understand their needs. (insert link to Austin card)

The Christopher & Dana Reeve Foundation has produced wallet cards written in multi-lingual format. It is important to note that the medications used in Australia may differ from those listed on the Christopher & Dana Reeve Foundation cards, however the multi-lingual resources can be a good starting point for family members or carers who may speak a language other than English.

We would encourage health professionals caring for a SCI patient of non-English speaking background to provide a tailored Autonomic Dysreflexia management plan (translated into the patient’s preferred language) as part of their discharge plan.

Sexual health and Autonomic Dysreflexia

Sex and fertility related interventions may be a trigger for Autonomic Dysreflexia in some individuals. The medical and nursing staff at Victorian Spinal Cord Service can provide advice to clients about Autonomic Dysreflexia, to avoid it negatively impacting on sexual health and wellbeing.

Contacts

Emergency treatment

Call 000 or attend a local hospital emergency department

Urgent medical advice for health professionals

For urgent medical advice via the phone (for referring doctors or emergency workers) contact our Spinal Medical Registrar on call 03 9490 5000.

Education and capacity building

Education and capacity building requests can be directed to a member of our Spinal Community Services team:

Victorian Spinal Cord Service

Tel: 03 9490 7300

References

• ACI clinical practice guidelines for Treatment of Autonomic Dysreflexia for Adults & Adolescents with Spinal Cord Injuries: http://www.aci.health.nsw.gov.au/networks/spinal- cord-injury/resources (Accessed January 2021).
• Milligan J, Lee J, McMillan C, Klassen H. Autonomic dysreflexia: recognizing a common serious condition in patients with spinal cord injury. Can Fam Physician. 2012 Aug;58(8):831-5. PMID: 22893332; PMCID: PMC3418979.
• Krassioukov A, Warburton DE, Teasell R, Eng JJ; Spinal Cord Injury Rehabilitation Evidence Research Team. A systematic review of the management of autonomic dysreflexia after spinal cord injury. Arch Phys Med Rehabil. 2009 Apr;90(4):682-95. doi: 10.1016/j.apmr.2008.10.017. PMID: 19345787; PMCID: PMC3108991.
• Consortium for Spinal Cord Medicine. Clinical practice guidelines: acute management of Autonomic Dysreflexia. Adults with spinal cord injury presenting to healthcare facilities. Paralysed Veterans of America. 2001.