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Orthostatic Hypotension (OH) is defined as a decrease in systolic blood pressure of 20 mmHg or more, or diastolic blood pressure of 10 mmHg or more with changes in position, which, for people with spinal cord injury, may be especially problematic when changing from supine to sitting or standing. OH can also occur even after sitting in wheelchair. OH is most common in tetraplegia, high thoracic injuries, or at any level of injury following prolonged bed rest. Major causes include:
  • decreased sympathetic response to position changes and the loss of reflex vasoconstriction;
  • decreased vascular tone;
  • excessive venous pooling in the lower limbs; and
  • decreased venous return resulting in decreased cardiac output.

Signs and Symptoms

  • light headedness
  • fainting
  • dizziness
  • pallor
  • blurring or changing in vision
  • fatigue
  • nausea
  • excessive sweating above the level of injury
  • muscle weakness
  • syncope (side-effect that can result from cerebral flow reduction)

Treatment Considerations

  • Patient Education (Goal is to mitigate signs and symptoms rather than normalize blood pressures)
  • Non pharmacological
    • Postural changes
    • Gradual postural changes from supine to sitting, then standing
    • Compression stocking or custom hose with abdominal binder when up out of bed
    • Adequate Hydration
    • Increased salt intake
    • Wheelchair with elevated leg rests, reclining or tilt in space
  • Pharmacological
    • Midodrine: Alpha adrenergic agonist leading to vasoconstriction. Usual doses are 2.5 mg twice daily or three times a day. Max dose is 30 mg/day. Avoid giving after 5:00 pm to avoid supine hypertension.
      • Side Effects: Hypertension, Headaches, Tachycardia, Parasthesias, Pruritis
    • Fludrocortisone (Florinef): Mineralocorticoid. Starting dose is 0.1 mg daily. Max dose is 0.4 mg/day. Dose adjustments recommended weekly or biweekly. Should be discontinued when appropriate.
      • Side Effects: Hypertension, edema, Hypokalemia, Hypernatremia, Hypomagnesemia, Avoid in congestive heart failure.
    • Pseudoephedrine: non selective alpha and beta receptor agonist. Dose: 12.5 to 25 mg three times a day.
      • Side Effects: Tachycardia, arrhythmias, supine hypertension, tremor, Insomnia, Diaphoresis, Urinary retention



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The University of Alabama at Birmingham Spinal Cord Injury Model System provides this website as an auxiliary resource for the primary care of patients with spinal cord injury.The contents of this website were developed under a grant from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR grant number 90SIMS0020). NIDILRR is a Center within the Administration for Community Living (ACL), Department of Health and Human Services (HHS). The contents of this website do not necessarily represent the policy of NIDILRR, ACL, HHS, and you should not assume endorsement by the Federal Government.