Emergency management of autonomic dysreflexia with neurologic complications.

© 2016 Joule Inc. or its licensors CMAJ 1 A 59-year-old man with a complete (American Spinal Injury Association Impairment Scale A) spinal cord injury at the fourth thoracic vertebra (T4), secondary to a motor vehicle crash 42 years earlier, presented to the emergency department with a 12-hour history of headaches, loss of vision and nausea. He had no documented history of seizure, stroke, traumatic brain injury or diabetes mellitus. On admission, he had substantial hypertension (219/113 mm Hg), heart rate of 56 beats/min and altered level of consciousness (Glasgow Coma Scale score 10/15). Shortly after arrival, the patient had a generalized tonic–clonic seizure, which was witnessed by his spouse and addressed immediately by the emergency department staff. Physical examination showed 3-mm unreactive pupils and a score of 3/15 on the Glasgow Coma Scale. Upon questioning, the patient’s spouse confirmed that the patient had a history of severe and recurrent urinary tract infection with concomitant autonomic dysreflexia; there was no relevant alcohol consumption or use of recreational drugs. The patient was immediately given hydralazine, phenytoin and propofol (for sedation), intubation was performed, and the patient was admitted to the intensive care unit. Following administration of the hydralazine and propofol, his blood pressure promptly declined to 100/50 mm Hg and remained within safe limits (120/80 mm Hg) 12 hours later. Transverse and sagittal magnetic resonance imaging of the head showed subcortical T2 and fluid-attenuated inversion recovery signal abnormalities in the posterior parietal and occipital lobes bilaterally, slightly more predominant on the left (Figure 1). This presentation was deemed consistent with posterior reversible encephalopathy syndrome, secondary to an episode of autonomic dysreflexia, likely due to urinary tract infection. The patient was started on empiric therapy with meropenem, acyclovir and fluconazole (intravenous) and underwent computed tomography of the pelvis, which revealed a left-side nonobstructing renal stone at the ureteropelvic junction, with moderate hydronephrosis. Urine culture confirmed the presence of methicillin-resistant Staphylococcus aureus, at which time the antibiotic therapy was switched to vancomycin (intravenous). During the admission, electrolyte, blood glucose and serum lactate levels and the results of other laboratory tests were unremarkable. On the third day of the intensive care unit stay, the patient underwent extubation and was weaned off propofol. Within six days, the symptoms of posterior reversible encephalopathy syndrome had resolved, and no recurrent seizures or other neurologic sequelae were documented. The patient was discharged on an oral course of phenytoin. By the follow-up appointment two weeks later, no further seizures had occurred, and the phenytoin was discontinued. Long-term followup showed no lasting neurologic impairments.