Orthostatic hypotension 

Orthostatic hypotension, also known as postural hypotension, occurs when the blood pressure lowers following or during the transition from a lying to a sitting/upright position. It can occur at any spinal cord injury (SCI) level but most commonly occurs in injuries above the thoracic sympathetic nervous system (SNS) output (at T6 or above).

Orthostatic hypotension management

Monitoring for orthostatic hypotension at any spinal cord injury (SCI) level is important. Transitions between lying, sitting or standing should be taken slowly and with caution. Drops in blood pressure can severely impact a person’s ability to participate in rehabilitation programs and daily activities. It is important to provide education to the person with SCI on common triggers and strategies for managing postural hypotension.

Non-pharmacological strategies: 

• planning and management applicable to the level of SCI 
• ensure adequate oral fluid intake 
• consider an oral fluid bolus around 300ml prior to mobilisation 
• avoidance of diuretics
• ensure salt intake adequate to maintain plasma volume 
• orthostatic management of pre-syncopal symptoms
• mobilisation and transitions to be completed slowly and gradually  
• use of an abdominal binder 
• lower-limb compression garments or stockings are advisable 
• use of a tilt in space wheelchair and tilt in space shower chair, particularly for injuries above T6. Sitting should commence in the wheelchair first, eventually progressing to a commode 
• use of a tilt table. 

Pharmacological strategies: 

• Consider discontinuing medications with hypotensive effects.  
• If conservative measures are ineffective, pharmacological measures may be appropriate. Pseudoephedrine and midodrine are usually trialled, in consultation with a specialty medical team experienced in their use. An example of medication is Pseudoephedrine 30 to 60mg administered 30 minutes before mobilisation. A few second-line agents for profound orthostatic hypotension could also be trialled, including fludrocortisone. Clinicians will need to be mindful that these agents can cause hypertension. This may be problematic if the person is prone to autonomic dysreflexia.  

As sitting tolerance improves and orthostatic hypotension diminishes, pharmacological interventions should be tapered before non-pharmacological interventions.  

Persistent orthostatic hypotension 

A person with a SCI who has persisting orthostatic hypotension, despite both pharmacological and non-pharmacological interventions, should be referred to a specialist in a Spinal Injuries Unit. Additional factors that should be investigated in cases of persistent orthostatic hypotension include:

• illness, which can increase the symptoms of orthostatic hypotension 
• cardiac causes, especially if the person has a pre-existing health condition or has experienced a syncopal event at the time of injury.