Original Publication
Open Access

Autonomic Hyperreflexia

Published: January 20, 2014 | 10.15766/mep_2374-8265.9682

Included in this publication:

  • Instructor's Guide.docx
  • Scenarios.docx
  • Technical Guide.docx
  • Debriefing Document.docx
  • Evaluation Form.docx

To view all publication components, extract (i.e., unzip) them from the downloaded .zip file.

Editor's Note: This publication predates our implementation of the Educational Summary Report in 2016 and thus displays a different format than newer publications.


This simulation scenario is designed to instruct anesthesia trainees about the occurrence of autonomic hyperreflexia in patients with spinal cord injury. This is a potentially devastating neuroreflex that occurs in patients several weeks after spinal injury. There are two versions of the scenario. In version A, the simulated patient will undergo a classic trigger (uterine manipulation). In version B, the simulated patient will have a less obvious trigger (ankle fracture). The dual cases are used to help teach concepts to junior and senior trainees, respectively. Alternatively, version B can be used for follow up and remediation for trainees who need additional education after participating in version A. Both scenarios can be modified for team training and/or crisis resource management purposes. Autonomic hyperreflexia is a rare event; however, it can lead to dangerous elevations in blood pressure, resulting in stroke or death. It can be a common misconceptions among junior trainees that because a patient is unable to feel an area that is being operated on (because of spinal cord injury) that anesthesia care is not needed. This simulation is designed to address this clinical problem, and reinforce basics of neurophysiology. In our experience with running this simulation, residents in the early years of training are generally not aware of the risk. In our earliest sessions, third-year residents were aware of the risk with an intrauterine procedure and made good choices backed by solid understanding of the neurophysiology. It is because of this that we created version B, which has a less common stimulus that causes the reaction to occur. This version is helpful for the senior trainee, and is also useful as a follow-up for residents who have completed version A. We have piloted the use of this scenario as a team-training exercise with good results. It works best if the patient is an actor and the vitals are generated off of the mannequin (which we move to the side of the room that is not visible to the learners).

Educational Objectives

By the end of this resource, learners will be able to:

  1. Identify the signs and symptoms of autonomic hyperreflexia and precipitating factors.
  2. Generate an anesthetic plan for a patient at risk for autonomic hyperreflexia.
  3. Recognize a rapidly worsening situation and prioritize actions that address critical issues.
  4. Communicate with the surgical team during crisis and engage ancillary staff to assist in patient care.
  5. Discuss the importance of leadership and communication among operating room personnel during times of crisis.
  6. Display compassion and sensitivity to populations at risk.

Author Information

  • Christina Spofford, MD, PhD: University of Iowa Roy J. and Lucille A. Carver College of Medicine
  • Joshua Viggers: University of Iowa Roy J. and Lucille A. Carver College of Medicine
  • Jessica Leinen: University of Iowa Roy J. and Lucille A. Carver College of Medicine

None to report.

None to report.


Spofford C, Viggers J, Leinen J. Autonomic hyperreflexia. MedEdPORTAL. 2014;10:9682. https://doi.org/10.15766/mep_2374-8265.9682