Table 16.
Management strategies for autonomic dysregulation following transverse myelitis
| Problem | Management Strategy |
|---|---|
| Orthostatic hypotension |
Nonpharmacologic: increasing fluid intake; a high salt diet (>8 g/d); avoiding a hot environment; avoiding large carbohydrate-rich meals; avoiding prolonged recumbency; application of external counterpressure (eg, abdominal binding, compression stockings); functional electrical stimulator devices (induces intermittent muscle contractions and therefore increasing venous return); exercise training may also induce positive changes in autonomic cardiovascular regulation. Pharmacologic: midodrine; L-threo-3,4-dihydroxyphenylserine (L-DOPS); fludrocortisone. |
| Thermodysregulation | Adequate hydration. Exercising or working during cooler hours of the day. Cold showers. Regional cooling devices. Precooling by immersing the lower extremities in cold water before thermal stress, allows the lower limbs to serve as “heat sinks.” Dalframpridine. |
| Autonomic dysreflexia |
Acute Management Identify the possible trigger and decrease afferent stimulation. Sit the patient up to cause an orthostatic decrease in the blood pressure. Loosen the clothing and other constrictive devices. Check the blood pressure every 2–5 minutes until the patient is stable. The best antihypertensive medications have a rapid onset and short duration of action (eg, nitrates, hydralazine and immediate-release nifedipine); 10 mg nifedipine may be given using the “bite and swallow” method. Alternatively, 1 inch of 2% nitropaste can be applied above the level of the lesion and wiped off when the hypertensive episode subsides. Preventive Measures Preventative measures are the most effective approach. Prevention of pressure sores and addressing urinary and bowel dysfunction are imperative. Individuals should carry a medical emergency card for AD. Pharmacologic prevention: Alpha-1 antagonists (terazosin and prazosin); gabapentin; prostaglandin E2; phenozybenzamine. |