Life threatening condition which occurs in patients with spinal cord injuries above the level of T6
Acute disordered or unregulated sympathetic autonomic response to stimuli below the level of the lesion (“syndrome of exaggerated sympathetic activity”).
Triggering stimulus causes sympathetic stimulation, with reflex vasoconstriction (including splanchnic bed of vessels) and systemic hypertension. Reflex vagal mechanisms then cause vasodilation and bradycardia in response – but these parasympathetic signals cannot cross the injured segment – so vasodilation occurs above the lesion (flushing, sweating) and vasoconstriction (cold and clammy) below the lesion.
Generally occurs after spinal shock has settled. More common in cervical injuries > high thoracic.
Signs & symptoms
- Pounding headache
- Hypertension
- Flushing and sweating of face and body above level of lesion
- Bradycardia typically (can be tachycardic)
- Pale cool skin below the lesion
Uncontrolled and untreated hypertension can lead to seizures, intracranial bleeds, hypertensive encephalopathy
Stimuli
Any noxious stimuli below the level of the lesion:
- Bladder stimulation – most commonly full bladder
- Clot retention
- Catheter change
- Instrumentation
- Urodynamics
- UTI
- Stones
- Bowels – rectal distension
- Ingrown toenail
- Sacral ulcers
- Sexual stimulus
- Uterine contraction (pregnancy and delivery)
- Leg fractures or any other typically painful condition
Management of AD:
- Prompt identification and recognition / preparation if undergoing stimulating procedures (not only cystoscopy, including urodynamics, tube changes etc)
- Treat the cause
- Drain the bladder, evacuate the rectum
- Sit patient upright (orthostatic hypotension)
- Loosen clothing or any restriction
- Multidisciplinary management with physicians and anaesthetists
- Sublingual GTN or GTN patch
- Oral nifedipine 5 – 10 mg
- Sublingual clonidine 0.2 mg
- Ongoing monitoring after normotension achieved
- No PDE5 inhibitors for a couple of days if GTN etc used
- Last resort = spinal anaesthetic
- Patient and caregiver education