Autonomic Dysreflexia During a Bowel Program
A 44-year-old man with T6 ASIA A spinal cord injury is 3 months post injury and in inpatient rehabilitation. During a bowel program he develops a pounding headache, blurred vision, and sweating above the clavicles. Blood pressure is 198/110 mmHg, heart rate 52 beats/min, and he has piloerection and flushing of the face. His baseline blood pressure is 110/70 mmHg. He has an indwelling catheter and takes no antihypertensives. The nurse asks whether to give a PRN of metoprolol 25 mg by mouth.
1. What are your immediate steps?
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This is autonomic dysreflexia until proven otherwise. Immediate steps: sit him upright, loosen clothing and the abdominal binder, check blood pressure every 1–2 minutes, and search for and remove the noxious stimulus. In this setting, the bowel program is the likely trigger, so stop it, inspect the rectum for impaction, and check the indwelling catheter for kinks, obstruction, or infection. Do not give the PRN metoprolol first.
2. Why is metoprolol alone problematic, and what pharmacologic alternative would you choose if the pressure remains elevated?
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Metoprolol alone is problematic because beta-blockade can leave alpha-mediated vasoconstriction unopposed, potentially worsening hypertension, and it can cause reflex bradycardia. If blood pressure remains elevated after removing the stimulus (for example, systolic above 150–160 mmHg), use a rapid-onset, short-acting agent such as nitroglycerin ointment, sublingual nifedipine, or captopril, with close monitoring. Avoid long-acting agents that can cause hypotension after the episode resolves.
3. How would you prevent recurrence during future bowel programs?
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Prevention includes a regular bowel regimen, avoiding fecal impaction, using lidocaine gel before bowel programs, monitoring blood pressure before and during the program, and teaching the patient and family to recognize early symptoms. Any recurrent episode should prompt evaluation for urinary, skin, or gastrointestinal sources.