Healthy Living/ Autonomic Dysreflexia

 Autonomic Dysreflexia

 What is autonomic dysreflexia

Autonomic dysreflexia (AD), also known as hyperreflexia, refers to an over-active Autonomic Nervous System, which causes an abrupt onset of excessively high blood pressure. Persons at risk for this problem generally have injury levels above T-5. AD 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
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
Slow pulse (< 60 beats per minute)
Cold, clammy skin below level of spinal injury
Avoiding Autonomic Dysreflexia

Apply frequent pressure relief in bed/chair
Avoid sun burn/scalds
Maintain a regular bowel program
Well balanced diet and adequate fluid intake
Compliance with medications
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.
Carry an intermittent catheter kit when you are away from home
Perform routine skin assessments

 Causes of autonomic dysreflexia

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

Stimuli That Cause Autonomic Dysreflexia:

Bladder (most common)

Urinary tract infection
Urinary retention
Blocked catheter
Overfilled collection bag
Non-compliance with intermittent catheterization program

Constipation / impaction
Distention during bowel program (digital stimulation)
Hemorrhoids or anal fissures
Infection or irritation (e.g. appendicitis)
Skin-related disorders

Any direct irritant below the level of injury
Pressure sores
Ingrown toenails
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

Acute abdominal conditions (gastric ulcer, colitis, peritonitis)
Skeletal fractures
Sitting on one's scrotum

 Treating autonomic dysreflexia

Treatment must be initiated quickly to prevent complications. First, remain in a sitting position, but do apply 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 AD, 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, or
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. If symptoms persist despite interventions such as the foregoing, notify a physician. 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 the suspected cause is the ...

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.
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.
Skin: Loosen clothing. Check for source of potential offending stimulus check for pressure sores including the soles and heels of the feet, toenail problems.
Important Reminder:
If you are unable to find the stimulus causing AD, or your attempts to receive the stimulus fail, you need to obtain emergency medical treatment. Since all physicians are not familiar with AD and its treatment, you should carry a card that describes the condition and the treatment required.