What & Why
* Acute generalized sympathetic hyperreactivity in response to triggering stimuli in pts w/spinal cord transection at or above T7 (65-85% risk)
* Cord lesions at or above T5 usually cause full-blown syndrome; lesions at or below T10 result in minimal blood pressure response (if anything); lesions between T5 and T10 result in mild blood pressure elevation and either no sweating or sweating from precordium to ankles
* Develops 2-3 weeks after initial injury
* Triggering stimuli = ANY endogenous or exogenous stimulus occurring below the level of the cord lesion.  (Most common trigger is placement of foley catheter, or distention of any hollow viscus.)  Causes unopposed reflex sympathetic activity (normally controlled by inhibitory impulses from supraspinal centers which cannot travel below the transection).

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Signs/Symptoms
* Profuse sweating, flushing, nasal obstruction, severe headache, difficulty breathing, nausea, shivering, gooseflesh, visual field defects, blurring of vision.
* Severe acute hypertension, bradycardia, arrhythmias, vasodilation above the level of the cord lesion/vasoconstriction below the level of the cord lesion, pallor, changes in skin and rectal temp, visceral contraction, muscle spasm (can cause evisceration during abd closure), ischemic EKG changes, decreased LOC, convulsions, cessation of respiration
* Can lead to pulmonary edema, CV collapse, retinal/subarachnoid/cerebral hemorrhages, seizures, strokes, basilar artery insufficiency, hypertensive encephalopathy, death.

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Treatment
* STOP INITIATING STIMULUS! (if possible)
* Ganglionic blockers (trimethaphan), direct vasodilators (SNP), direct alpha-agonists (phentolamine), GA, spinal anesthesia
* Centrally-acting anti-hypertensives (clonidine) won't work!
* Beta-blockers for tachyarrhythmias
* Can decrease risk (or prevent) by use of neuraxial blockade (spinal >> epidural)

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Perioperative Implications
* Difficult to assess height of neuraxial block due to sensory deficits - can result in inadequate coverage (to prevent AH) or too high block
* May require fiberoptic intubation if unstable C-spine
* May be difficult to extubate due to compromised resp musculature (from initial injury)
* Can occur w/foley catheter placement prior to case
* Can occur post-op w/resolution of block (secondary to pain or distended bladder/rectum)
* If difficulty awakening after severe HTN, consider cerebral bleed
* Severe bradycardia due to post-op inability to void or defecate
* Consider using A-line, consider CVP/PA catheter if poor cardiac function/large vol changes

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