Safety Notice 014/10

Treatment Algorithm for Autonomic Dysreflexia

(Hypertensive Crisis) In Spinal Cord Injury
Symptoms and signs of Autonomic Dysreflexia
ASK PERSON AND CARER IF A CAUSE IS SUSPECTED
(Common causes to exclude first are:
1. Bladder Distension, 2. Constipation).

Monitor BP for 1hr Check Blood Pressure (BP)

Contact Spinal Unit for NO Is BP ≥ 20mmHg above resting level ?
specialist advice if required (NB BP in a person with tetraplegia or high paraplegia is
typically low e.g. 90-100/60mmHg)
Request assistance from
If systolic BP YES another person WARNING:
increases ≥ 20mmHg BEFORE ADMINISTERING ANY
above resting level? NOTE : THIS REQUIRES IMMEDIATE INTERVENTION ANTI-HYPERTENSIVE MEDICATION,
Monitor BP & pulse until symptoms have resolved ALWAYS CHECK FOR RECENT USE
Sit person upright and lower legs, if possible OF MEDICATION FOR ERECTILE
Loosen any tight clothing/leg straps DYSFUNCTION.
Remove compression stockings/abdominal binder DO NOT USE GLYCERYL TRINITRATE
Check for kinked tubing, SPRAY, TABLETS OR PATCH
full leg bag or By indwelling IF SILDENAFIL (VIAGRA) OR
blocked catheter urethral (IDC) CHECK FOR BLADDER DISTENSION VARDENAFIL (LEVITRA)
Estimate volume in leg bag; or suprapubic How does person empty bladder? HAS BEEN USED IN LAST 24
compare with fluid intake & catheter (SPC) HOURS OR TADALAFIL (CIALIS) HAS
usual urine drainage pattern BEEN TAKEN WITHIN LAST 4 DAYS!
MONITOR FOR HYPOTENSION
By intermittent self-catheterisation, reflex or
'spontaneous' voiding
IDC/SPC
is blocked
Irrigate catheter Is glyceryl trinitrate contra-indicated
Is catheter draining Check BP before proceeding. Is systolic BP ≥170mmHg? YES YES
NO gently with or unavailable?
satisfactorily?
no more than NO
30mls of
YES normal saline NO
Administer 1 Nitrolingual spray OR
½ Anginine tablet (¼ tablet in children
between 12-16 years) under tongue.
Insert generous amount of lignocaine 2% Dose can be repeated in 5-10 mins.
Is catheter
NO (topical anaesthetic) gel into urethra;
now draining? Alternatively, apply one 5mg/24hours
wait 3-5 mins and pass/replace catheter
glyceryl trinitrate transdermal
YES patch to chest or upper arm (NB.
Remove patch once stimulus and
If the bladder is overdistended, drain 500mls initially, hypertension has resolved or if
then 250mls every 10-15 mins to avoid hypotension. BP drops too low).

NB. Commence anticholinergic medication Administer 25mg captopril

Monitor BP for 4 hours to (eg Oxybutynin) if the IDC is left in situ. sublingually or other short acting,
ensure no recurrence rapid onset anti-hypertensive agent
- if symptomatic hypotension,
lay the person down and
elevate legs YES Is BP settling down?
- IF SYMPTOMS RECUR
CONTACT A SPINAL NO
PHYSICIAN URGENTLY

CHECK FOR CONSTIPATION

Insert generous amount of lignocaine 2% (topical anaesthetic)
gel into rectum; wait 3-5 mins, then perform gentle PR exam

If rectum is full and systolic

Is rectum empty? NO BP < 150mmHg, perform
manual evacuation
YES

If Systolic BP >
_ 150 mm Hg
LOOK FOR OTHER CAUSES OF NOCICEPTION
Exclude intra-abdominal pathology, epididymo-orchitis, 1. Administer glyceryl trinitrate
pressure sores, burns, ingrown toenail, fracture. or captopril as above.
DISCLAIMER 2. If AD worsens with disimpaction,
Ensure adequate analgesia (eg. morphine) is given when
there is a persisting known cause of noxious stimulation STOP immediately, instill additional
All recommendations are intended for people
with spinal cord injury as a group. Individual topical anaesthetic and recheck the
therapeutic decisions must be made by rectum for the presence of stool after
combining the recommendations with clinical If BP not settling promptly or cause not identified, approximately 20 minutes.
judgement, informed by a detailed knowledge admit to hospital for BP control & investigation.
of the individual person’s unique risks and Intravenous medication may be necessary
medical history, findings on physical
CONTACT SPINAL PHYSICIAN/REGISTRAR ON CALL AT YOUR
examination, as well as the resources available.
NEAREST SPINAL INJURIES UNIT FOR SPECIALIST ADVICE
This revised algorithm was re-endorsed for use
by the Australian and New Zealand Spinal Cord
Society (ANZSCOS) in September 2010.

This project was funded by the Motor Accidents 4 of 4

Authority of NSW. Date: 10th of April 2006
amended by Quality & Safety Unit, NSW Health Department
Date: October 2010