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Autonomic Dysreflexia

Autonomic dysreflexia (AD) is a condition that can occur in anyone who has a spinal cord injury at or above the T6 level. It is related to disconnection's between the body below the injury and the control mechanisms for blood pressure and heart function. It causes the blood pressure to rise to potentially dangerous levels.

Autonomic dysreflexia can be caused by a number of things. The most common causes are a full bladder, bladder infection, severe constipation, or pressure sores. Anything that would normally cause pain or discomfort below the level of the spinal cord injury can trigger dysreflexia. Autonomic dysreflexia can occur during medical tests or procedures and need to be watched for.

The symptoms that occur with Autonomic dysreflexia are directly related to the types of responses that happen in the sympathetic and parasympathetic nervous systems. Symptoms such as a pounding headache, spots before the eyes, or blurred vision are the direct result of the high blood pressure that occurs when blood vessels below the injury constrict. The body responds by dilating blood vessels above the injury, causing flushing of the skin, sweating, and occasionally goosebumps. Some patients describe nasal stuffiness and will feel very anxious. Uncontrolled Autonomic dysreflexia can cause a stroke if not treated.

The treatment for Autonomic dysreflexia involves removing the reason for the stimulation. One of the first things a patient can do is to sit up. This naturally decreases blood pressure. If there is a catheter in place, it should be checked to be certain that there is not a kink in the tubing. If there is not a catheter in place, the patient should be catheterized. The bowels should be checked to be certain there is no stool in the rectum. If the symptoms are caused by skin breakdown, the patient should get to an emergency department as soon as possible.

The primary risk of Autonomic dysreflexia is stroke. It is a potentially life-threatening condition. If Autonomic dysreflexia is left untreated, the body's attempt to control blood pressure will severely decrease the heart rate. This, combined with uncontrolled high blood pressure, can be fatal. For this reason, it is very important to treat this condition as soon as possible. The most important thing patients can do to prevent Autonomic dysreflexia from occurring is to take good care of themselves. Patients should monitor bladder output and should maintain a regular bowel program which fully empties the bowels. They should also do regular skin checks to prevent pressure sores from occurring.

Signs & Symptoms
Pounding headache (caused by the elevation in blood pressure)
Goose Pimples
Sweating above the level of injury
Nasal Congestion
Slow Pulse
Blotching of the Skin
Restlessness
Hypertension (blood pressure greater than 200/100)
Flushed (reddened) face
Red blotches on the skin above level of spinal injury
Sweating above level of spinal injury
Nausea
Slow pulse (< 60 beats per minute)
Cold, clammy skin below level of spinal injury

Causes
There can be many stimuli that cause autonomic dysreflexia. Anything that would have been painful, uncomfortable, or physically irritating before the injury may cause autonomic dysreflexia after the injury.

The most common cause seems to be overfilling of the bladder. This could be due to a blockage in the urinary drainage device, bladder infection (cystitis), inadequate bladder emptying, bladder spasms, or possibly stones in the bladder.

The second most common cause is a bowel that is full of stool or gas. Any stimulus to the rectum, such as digital stimulation, can trigger a reaction, leading to autonomic dysreflexia.

Other causes include skin irritations, wounds, pressure sores, burns, broken bones, pregnancy, ingrown toenails, appendicitis, and other medical complications.

In general, noxious stimuli (irritants, things which would ordinarily cause pain) to areas of body below the level of spinal injury. Things to consider include:

Bladder (most common) - from overstretch or irritation of bladder wall
Urinary tract infection
Urinary retention
Blocked catheter
Overfilled collection bag
Non-compliance with intermittent catheterization program
Bowel - over distention or irritation
Constipation / impaction
Distention during bowel program (digital stimulation)
Hemorrhoids or anal fissures
Infection or irritation (eg. appendicitis)
Skin-related Disorders
Any direct irritant below the level of injury (eg. - prolonged pressure by object in shoe or chair, cut, bruise, abrasion)
Pressure sores (decubitus ulcer)
Ingrown toenails
Burns (eg. - sunburn, burns from using hot water)
Tight or restrictive clothing or pressure to skin from sitting on wrinkled clothing
Sexual Activity
Over stimulation during sexual activity [stimuli to the pelvic region which would ordinarily be painful if sensation were present]
Menstrual cramps
Labor and delivery
Other
Heterotopic ossification ("Myositis ossificans", "Heterotopic bone")
Acute abdominal conditions (gastric ulcer, colitis, peritonitis)
Skeletal fractures

Treatment
Treatment must be initiated quickly to prevent complications.

Remain in a sitting position, but do a pressure release immediately. You may transfer yourself to bed, but always keep your head elevated.
Since a full bladder is the most common cause, check the urinary drainage system. If you have a Foley or suprapubic catheter, check the following:
Is your drainage full?
Is there a kink in the tubing?
Is the drainage bag at a higher level than your bladder?
Is the catheter plugged?
After correcting an obvious problem, and if your catheter is not draining within 2-3 minutes, your catheter must be changed immediately. If you do not have a Foley or suprapubic catheter, perform a catheterization and empty your bladder.

If your bladder has not triggered the episode of autonomic dysreflexia, the cause may be your Bowel. Perform a digital stimulation and empty your bowel. If you are performing a digital stimulation when the symptoms first appear, stop the procedure and resume after the symptoms subside.

If your bladder or bowel are not the cause, check to see if:

You have a pressure sore
You have an ingrown toenail
You have a fractured bone.
Identify and remove the offending stimulus whenever possible. Often, this alone is successful in allowing the syndrome to subside without need for pharmacological intervention. It is also good for the person with the symptoms to be sitting up with frequent blood pressure checks until the episode has resolved. [In hospital-based settings or in high-risk individuals / persons who have recurrent episodes, consideration should be given having atropine at the bedside]

Suspected cause = bladder? Check catheter - remove kinks if found, empty urinary collection bag, irrigate catheter. If catheter is not draining, replace it immediately. If an intermittent catheterization program is in place, a straight catheterization should be performed immediately with (slow drainage to prevent bladder spasms).

Suspected cause = bowel? If episode happens during digital stimulation, stop stimulation until symptoms and signs subside. Consider use of a prescribed anesthetic ointment to suppress the noxious stimulus. If the issue is impacted stool, disimpact. If it occurs while doing a bowel program in bed, try commode-based bowel evacuation. Consider use of abdominal massage instead of digital stimulation.

Suspected cause = skin? Loosen clothing. Check for source of potential offending stimulus - check for pressure sores, toenail problems, soles of the feet.

If symptoms persist despite interventions such as the foregoing, notify a physician.

Medications
Medications are generally used only if the offending trigger/stimulus cannot be identified and removed - or when an episode persists even after removal of the suspected cause. Potentially useful agents include:

Immediate/emergent
Procardia - 10 mg. p.o./sublingual
Nitroglycerine - 1/150 sublingual or 1/2 inch Nitropaste topically
Clonidine - 0.1 to 0.2 mg. p.o.
Hydralazine - 10 to 20 mg. IM/IV
Chronic (recurrent episode prevention)
Prazosin ("Minipress") - 0.5 to 1.0 mg. daily
Clonidine ("Catapres") - 0.2 mg. p.o. b.i.d.

Prevention
The following are precautions you can take which may prevent episodes of Autonomic dysreflexia:
Frequent pressure relief in bed/chair
Avoidance of sun burn/scalds (avoid overexposure, use of #15 or greater sunscreen, watch water temperatures)
Maintain a regular bowel program.
Well balanced diet and adequate fluid intake
Compliance with medications
Persons at risk and those close to them should be educated in the causes, signs and symptoms, first aid, and prevention of autonomic dysreflexia.
If you have an indwelling catheter:
Keep the tubing free of kinks
Keep the drainage bags empty
Check daily for grits (deposits) inside of the catheter.
If you are on an intermittent catheterization program, catheterize yourself as often as necessary to prevent overfilling.

If you have spontaneous voiding, make sure you have an adequate output.
Carry an intermittent catheter kit when you are away from home.
Perform routine skin assessments.

Reminder
If you are unable to find the stimulus causing autonomic dysreflexia, or your attempts to receive the stimulus fail, you need to obtain emergency medical treatment. Since all physicians are not familiar with autonomic dysreflexia (hyperreflexia) and its treatment, you should carry a card with you that describes the condition and the treatment required.

Skin Breakdown
pneumonia
Osteoporosis and Fractures
Heterotopic Ossification
Spasticity
Urinary Tract Infections
Autonomic Dysreflexia
Deep Vein Thrombosis
Pulmonary Embolism
Orthostatic Hypotension
Cardiovascular Disease
Syringomyelia
Neuropathic / Spinal Cord Pain
Medication Problems
Hyperthermia
Hypothermia
 


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