Autonomic Dysreflexia

What is "Autonomic Dysreflexia?"
Autonomic dysreflexia, also known as hyperreflexia, means an over-activity of the Autonomic Nervous System causing an abrupt onset of excessively high blood pressure. Persons at risk for this problem generally have injury levels above T-5. Autonomic dysreflexia can develop suddenly and is potentially life threatening and is considered a medical emergency. If not treated promptly and correctly, it may lead to seizures, stroke, and even death.

AD occurs when an irritating stimulus is introduced to the body below the level of spinal cord injury, such as an overfull bladder. The stimulus sends nerve impulses to the spinal cord, where they travel upward until they are blocked by the lesion at the level of injury. Since the impulses cannot reach the brain, a reflex is activated that increases activity of the sympathetic portion of autonomic nervous system. This results in spasms and a narrowing of the blood vessels, which causes a rise in the blood pressure.

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. abrasion) Pressure sores (decubitus ulcer) Ingrown toenails Burns (eg. . In general. burns. Anything that would have been painful. bruise.prolonged pressure by object in shoe or chair. Things to consider include: • Bladder (most common) . appendicitis) Skin-related Disorders o o o o Any direct irritant below the level of injury (eg. uncomfortable. or physically irritating before the injury may cause autonomic dysreflexia after the injury. This could be due to a blockage in the urinary drainage device. appendicitis. things which would ordinarily cause pain) to areas of body below the level of spinal injury. cut. ingrown toenails. inadequate bladder emptying. such as digital stimulation. bladder infection (cystitis). The second most common cause is a bowel that is full of stool or gas.from overstretch or irritation of bladder wall o o o o o • Urinary tract infection Urinary retention Blocked catheter Overfilled collection bag Non-compliance with intermittent catheterization program Bowel . leading to autonomic dysreflexia. pressure sores. burns from using hot water) .over distention or irritation o o o o • Constipation / impaction Distention during bowel program (digital stimulation) Hemorrhoids or anal fissures Infection or irritation (eg. noxious stimuli (irritants. can trigger a reaction. Any stimulus to the rectum. and other medical complications. or possibly stones in the bladder. . The most common cause seems to be overfilling of the bladder. bladder spasms. wounds.sunburn. Other causes include skin irritations. broken bones. pregnancy.

but do a pressure release immediately. Since a full bladder is the most common cause. perform a catheterization and empty your bladder. Perform a digital stimulation and empty your bowel. check the following: o o o o 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. If you are performing a digital stimulation when the symptoms first appear. colitis. and if your catheter is not draining within 2-3 minutes. If you have a Foley or suprapubic catheter. stop the procedure and resume after the symptoms subside. your catheter must be changed immediately.o • Tight or restrictive clothing or pressure to skin from sitting on wrinkled clothing Sexual Activity o o o • 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 o o o Heterotopic ossification ("Myositis ossificans". You may transfer yourself to bed. If your bladder or bowel are not the cause. the cause may be your Bowel. but always keep your head elevated. check to see if: . If your bladder has not triggered the episode of autonomic dysreflexia. "Heterotopic bone") Acute abdominal conditions (gastric ulcer. check the urinary drainage system. If you do not have a Foley or suprapubic catheter. peritonitis) Skeletal fractures Treatment Treatment must be initiated quickly to prevent complications. • • Remain in a sitting position.

If it occurs while doing a bowel program in bed.1 to 0. soles of the feet. Hydralazine .or when an episode persists even after removal of the suspected cause.check for pressure sores. p. If symptoms persist despite interventions such as the foregoing. p. try commode-based bowel evacuation. irrigate catheter.0. If an intermittent catheterization program is in place. Consider use of a prescribed anesthetic ointment to suppress the noxious stimulus.o.2 mg. notify a physician. Consider use of abdominal massage instead of digital stimulation. Suspected cause = bowel? If episode happens during digital stimulation. Potentially useful agents include: • Immediate/emergent o o o o Procardia . [In hospital-based settings or in high-risk individuals / persons who have recurrent episodes. disimpact. IM/IV .10 mg. stop stimulation until symptoms and signs subside. this alone is successful in allowing the syndrome to subside without need for pharmacological intervention. empty urinary collection bag. Often.remove kinks if found. toenail problems.o.• • • You have a pressure sore You have an ingrown toenail You have a fractured bone. replace it immediately. Suspected cause = skin? Loosen clothing./sublingual Nitroglycerine . It is also good for the person with the symptoms to be sitting up with frequent blood pressure checks until the episode has resolved. If catheter is not draining. Medications Medications are generally used only if the offending trigger/stimulus cannot be identified and removed .1/150 sublingual or 1/2 inch Nitropaste topically Clonidine . Identify and remove the offending stimulus whenever possible. If the issue is impacted stool. consideration should be given having atropine at the bedside] Suspected cause = bladder? Check catheter .10 to 20 mg. Check for source of potential offending stimulus . a straight catheterization should be performed immediately with (slow drainage to prevent bladder spasms).

d. Reminder If you are unable to find the stimulus causing autonomic dysreflexia. Well balanced diet and adequate fluid intake Compliance with medications Persons at risk and those close to them should be educated in the causes. you should carry a card in your billfold that describes the condition and the treatment required. you need to obtain emergency medical treatment. daily Clonidine ("Catapres") . 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. signs and symptoms. If you have spontaneous voiding.• Chronic (recurrent episode prevention) o o Prazosin ("Minipress") . Carry an intermittent catheter kit when you are away from home. use of #15 or greater sunscreen. catheterize yourself as often as necessary to prevent overfilling. first aid. make sure you have an adequate output. Since all physicians are not familiar with autonomic dysreflexia (hyperreflexia) and its treatment.i. and prevention of autonomic dysreflexia. . watch water temperatures) Maintain a regular bowel program. p.0. Perform routine skin assessments. or your attempts to receive the stimulus fail. If you are on an intermittent catheterization program.0.0 mg.o. Prevention The following are precautions you can take which may prevent episodes: • • • • • • • • • • • • • • Frequent pressure relief in bed/chair Avoidance of sun burn/scalds (avoid overexposure.2 mg.5 to 1. b.

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