A 35-year-old man with a chronic complete spinal cord injury at T4 suddenly develops throbbing headache, profuse sweating above the lesion, flushing, and a blood pressure of 220/110 mm Hg with bradycardia. His bladder is distended. What is the immediate first step after sitting him upright?

• A Administer intravenous atropine for the bradycardia
• B Drain the bladder by catheterisation to remove the trigger ✓
• C Give intravenous labetalol before any other intervention
• D Perform immediate CT head to exclude intracranial haemorrhage

Explanation

This is autonomic dysreflexia, seen with lesions at or above T6. Bladder distension is the commonest trigger; sitting upright produces orthostatic fall in pressure and catheterising the bladder removes the inciting stimulus, usually resolving the episode. Antihypertensives such as nitrates or captopril are reserved for persisting hypertension after the trigger is removed. Atropine is wrong because bradycardia here is part of the syndrome, not a separate emergency.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.