A 64‐year‐old man with a history of quadri‐plegia at the C5–C6 level more than 25 years ago secondary to a motor vehicle accident presented with blisters on both feet and worsening positional hypertension. He had a history of au‐tonomic dysreflexia (AD) with prior urinary tract infections (UTIs) with mild elevations in blood pressure. He noted that over the past 6–8 weeks, he had experienced severe fluctuations in his blood pressure, up to >230 systolic whenever he lays supine (his baseline was 90/40). These episodes were associated with headache, blurry vision, facial flushing, diaphoresis, and spasticity of both arms and legs. He had an indwelling suprapubic catheter and had been treated with multiple antibiotic regimens over the past month for a UTI. His initial exam was significant for blisters on both feet as well as stage 1 and 2 ulcerations on the left lateral thigh, right groin, and sacrum. His neurologic exam was consistent with his C5–C6 spinal cord injury (SCI). The results of a urinalysis from his catheter was consistent with a UTI. A KUB showed a moderate amount of stool throughout his colon. He was unable to tolerate an MRI of his spine because of his autonomic dysreflexia. He was referred to a local outpatient orthopedics clinic that has an upright, multipositional MRI. This study revealed cystic myelomalacia at the site of his previous SCI. In addition to beginning a rigorous bowel regimen, treating his UTI with antibiotics, and alleviating the pressure on his ulcers, he was started on topical nitropaste to use whenever he was supine. After several weeks, his AD had resolved. He was referred to neurosurgery clinic for surgical evaluation of his myelomalacia.
Autonomic dysreflexia is a syndrome in which uninhibited sympathetic output in patients with spinal cord injuries leads to hypertension. It generally occurs in those patients with injuries at or above the T6 level. Common clinical features include diaphoresis above the level of the injury, a bilateral headache, malaise, and nausea. The main feature is an acute elevation in blood pressure. The best approach is prevention of episodes of autonomic dys‐reflexia. Informing patients about proper bladder, bowel, and skin care is paramount. Common precipitants include urinary tract irritants (infection, distension, instrumentation), bowel disorders (fecal impaction, infection or inflammation, hemorrhoids, anal fissures), and dermatologic triggers (pressure sores). Treatment should be first aimed at eliminating such stimuli and, if this fails, starting pharmacologic therapy. The most commonly used medications include nitrates, nifedipine, and captopril.
Awareness of autonomic dysreflexia is low among nonrehabilitation health care providers. Recognition is key to provide timely treatment and to prevent significant harm.
R. Jacobs ‐ none
To cite this abstract:Jacobs R. Spinal Cord Injury and Autonomic Dysreflexia: A True Medical Emergency. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 302. Journal of Hospital Medicine. 2011; 6 (suppl 2). https://www.shmabstracts.com/abstract/spinal-cord-injury-and-autonomic-dysreflexia-a-true-medical-emergency/. Accessed March 30, 2020.