How To Treat "Autonomic Dysreflexia"

I would like to put you in contact with the National Spinal Cord Injury Hotline at 1-800-526-3456, or scihotline@aol.com.  The SCI Hotline is a nationwide network of volunteers who share their knowledge and experience with individuals and families who are dealing with spinal cord injury or disease.  The staff of the Hotline works with people to find answers to questions ranging from therapeutic programs to home modifications, from medical equipment to sports and recreation.  The Hotline facilities their callers search for support and research by referring them to professionals with expertise in SCI/D or others who have personal experience who are in their local area.

I believe the Hotline should be able to answer any questions you have about spinal cord injury/disease.

For more information about the many benefits and discounts you can receive as a PSA member, we invite you to contact PSA Membership Services toll-free at 1-888-772-1711.

Autonomic dysreflexia is a syndrome characterized by abrupt onset of excessively high blood pressure caused by uncontrolled sympathetic nervous system discharge in persons with spinal cord injury. Persons at risk for this problem generally have injury levels above T-6. True autonomic dysreflexia is potentially life-threatening and is considered a medical emergency.

What are signs and symptoms of Autonomic Dysreflexia?

Hypertension (blood pressure greater than 200/100)

Pounding headache (secondary to hypertension/vasodilation)

Flushed (reddened) face (secondary to vasodilation)

Red blotches on the skin above level of spinal injury (secondary to vasodilation)

Sweating above level of spinal injury (secondary to vasodilation)

Nasal stuffiness (secondary to vasodilation)

Nausea (secondary to vagal parasympathetic stimulation)

Bradycardia - slow pulse <60 beats per minute - (secondary to vagal parasympathetic stimulation)

Piloerection ("goose bumps") below level of spinal injury

Cold, clammy skin below level of spinal injury

What sort of things can precipitate this syndrome?

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 - overdistention 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
Overstimulation 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

What can be done to manage an episode of autonomic dysreflexia?

Principle #1 is to 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.

What medical interventions are possible when removal of noxious stimuli doesn't end an episode of autonomic dysreflexia?

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.

How can autonomic dysreflexia be prevented?

Frequent pressure relief in bed/chair
Avoidance of sun burn/scalds (avoid overexposure, use of #15 or greater sunscreen, watch water temperatures)

Faithful adherence to bowel program (no longer than 3 days between bowel evacuations)
Keep catheters clean and remain faithful to intermittent catheterization schedule
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.
====================================
AUTONOMIC DYSREFLEXIA

Autonomic Dysreflexia (ot-toe-NAWM-ick dis-re-FLEX-ee-ah) is an emergency situation. It is a complication that can be seen in almost anyone with a spinal cord injury above thoracic level 6. It is important to be able to recognize this complication and know what causes it and how to treat it as it can be life threatening.

WHAT MAY I SEE AND FEEL?

Symptoms?                                Why does this happen?
(you may not have all of them)

Severe pounding headache                 HIGH BLOOD PRESSURE

Seeing spots in front of your eyes       HIGH BLOOD PRESSURE

Blurred vision                           HIGH BLOOD PRESSURE

Slowed heart rate
Brain's response to high blood pressure

Goose bumps above level of SCI
Body's exaggerated response to continuous dilation of blood vessels

Sweating above level of SCI
Body's exaggerated response to continuous dilation of blood vessels

Flushing of skin above level of SCI
Body's exaggerated response to continuous dilation of blood vessels

Nasal stuffiness
Body's exaggerated response to continuous dilation of blood vessels

IMPORTANT: Uncontrolled high blood pressure is the dangerous part of autonomic dysreflexia, for it may be high enough to
cause a stroke.

WHAT TO DO IF YOU HAVE THESE SYMPTOMS

1. Sit up if you are lying down. This will decrease your blood pressure.

2. Find and remove the cause. Autonomic dysrefiexia usually will not go away until the cause of the problem has been corrected.

3. Check for bladder problems first. If you do not have a catheter in place, catheterize yourself. Empty your bladder slowly by
lifting the draining end of your catheter. If you empty your bladder too fast, you may cause it to go into spasm, which can cau se
your blood pressure to go up again.

4. Check for bowel problems next. If your bladder is not the cause of the high blood pressure, check your bowel for stool. If there is stool in your rectum, you will need to remove it manually. Before removing the stool you should apply numbing medicine to the anus and then wait five minutes for the medicine to work. This will prevent further stimulation to the area, which can cause your blood pressure to go up even more. If over-heated, place a cool damp cloth on your head, at your groin and armpits, and 0 get to a cool place. Check for skin problems. If neither your bowel nor your bladder seems to be the cause strip yourself and look for cuts, bruises, or ulcers on your body. Apply Nitroglycerin ointment to your skin above the level of injury, or take nifedipine if your physician has given you this medication. This will lower your blood pressure while you are trying to find out why this has happened. Only certain patients who get autonomic dysreflexia a lot will be given this medication. GET HELP if you can't find the cause. Call or go to the nearest hospital. Autonomic dysreflexia is an unusual problem, and not all health providers will know how to treat it. A physician should be notified immediately, as this is a medical emergency.

WHAT CAUSES IT? Autonomic dysreflexia is generally brought on by something that would have signalled pain or discomfort in you before your injury. Some possible causes are listed below, with the most common ones first.

A full or distended bladder (frequently caused by a plugged catheter). Stool impaction (severe constipation). Infections (bladder, etc.). Tests and procedures (cystoscopy, gynecological exam). Pressure sores (decubiti). Traumatic pain (severe cuts or broken bones). Hot and cold temperatures. Sunburn. Tight clothes. Pressure on the testicles or penis. Severe menstrual cramps, labor (uterine contractions). Stomach ulcers. Some drugs.

HOW DOES IT HAPPEN?

BEFORE SCI

The Body's Response to Pain

*Blood vessels constrict by reflex activity and raise your blood pressure.

*Nerves send messages up to the brain through your spinal cord, so you actually feel the pain.

*Other nerves send messages up to the brain through automatic pathways other than the spinal cord to tell the brain what is
happening to your blood vessels and blood pressure.

*Brain then sends message down through the spinal cord to dilate (open up) your blood vessels, which will lower your blood
pressure again.

AFTER SCI

The Body's Response to Pain
(Same as above.) You will most likely not feel the pain, because the pain messages cannot pass through the injured spinal cord.

(Same as above.) If your injury is at or above T6 level, your brain cannot get the dilation message back down to the blood vessels below your injury. The reason for this is that the area from T6 to T10 of the spinal cord sends messages to most of the blood vessels in your body. Your blood pressure stays high because the shut-off valve to lower your blood p ressure does not work.

IMPORTANT: Autonomic dysreflexia is like a vicious cycle that cannot be broken until you find the cause and remove it.

CAN AUTONOMIC DYSREFLEXIA BE PREVENTED?

You can prevent these symptoms in many cases, but not always.

Since the most common causes of autonomic dysreflexia are a full or distended (bloated) bladder and impaction of the bowel, you can prevent this from happening by making sure that:

Your bladder is emptied routinely. Your catheter is draining well, and You have routine bowel movements.

You may be one of those people who just has this problem more often than others. In this case, your doctors may put you on medication to prevent it.

REMEMBER: If you do develop autonomic dysreflexia, you will soon learn what causes it for you. It is then that you will be able to treat it quickly and effectively.

CARRY YOUR CARD

If you are at risk for autonomic dysreflexia your nurse will give you a card to carry. Let people know you have this card and use it with medical staff to instruct in Emergency Care.

IT MAY SAVE YOUR LIFE!