Autonomic Dysreflexia

1
Autonomic Dysreflexia

• An Education tool for all
• Health Professionals

2
Learning Outcomes

• Upon successful completion of this educational
  tool staff will be able to
• Understand the physiology behind Autonomic
  Dysreflexia (AD)
• Identify common causes of AD
• Understand treatment protocols of AD
• Know where to seek further assistance if needed

3
Quick links
Click on any of the links below to go directly to
that session OR Just browse through page by page
to see whole presentation Any phrase that is
underlined is also a link to click on Each page
will also have further links at the bottom of the
page.
Physiology of Autonomic Dysreflexia (AD)
Treatment of Bowel Irritation
If drug therapy does not work
Bladder Irritation
Treatment of Interruption to Skin Integrity
Diagram of AD
Bowel Irritation
Signs and Symptoms
Interruption to Skin Integrity
Treatment of other or unknown causes
Common Causes of AD
Other Common Causes
General assessment for AD
Glossary of Terms
Treatment of Bladder Irritation
References
Drug Therapy for AD
4
Physiology of Autonomic Dysreflexia (AD)

• AD is a potentially life-threatening condition
  that people with spinal cord injuries (SCI) above
  the level of the major splanchnic outflow (T6)
  can face. AD can start to occur after the initial
  phase of spinal shock has passed, when the spinal
  reflexes return, and can continue to occur
  throughout their life span.
• People with SCI above T6 will normally have
  unopposed parasympathetic control of the
  circulatory system. This results in the general
  picture of hypotension and bradycardia.
• Below the level of the lesion, the spinal cord
  continues to work normally. When a noxious
  stimulus is detected by the pain receptors in the
  peripheral nervous system, is travels as normal
  through the afferent sensory pathways up the
  spinal cord.

Return to Quick Links
Continued next page
Glossary of Terms
5
Physiology of Autonomic Dysreflexia (AD) - Cont

• Arriving at the spinal lesion it is unable to
  travel further, creating excitation of the
  sympathetic ganglia. This sympathetic response is
  unopposed by the parasympathetic nervous system
  above the level of the lesion.
• This excitation of the sympathetic ganglia below
  the level of injury results in a major reflex
  response of the sympathetic nervous system. This
  is exhibited as a sudden and massive
  vasoconstriction of the blood vessels below the
  level of injury. If the noxious stimulus
  continues to excite the sympathetic ganglia, it
  leads to a further increasing sympathetic reflex
  response of vasoconstriction below the level of
  injury.

Return to Quick Links
Glossary of Terms
Continued next page
6
Physiology of Autonomic Dysreflexia (AD) - Cont

• The unopposed vasoconstriction and resulting
  hypertension is sensed by the baroreceptors in
  the aortic arch and carotid bodies of the heart.
  These receptors send afferent messages to the
  vasomotor centre in the medulla oblongata of the
  brain stem, which result in a response of
  vasodilation and bradycardia. This response
  though, can only occur above the level of lesion,
  creating a parasympathetic response that is
  continually stimulated by the baroreceptors
  responding to the hypertension occurring below
  the level of injury. This results in dilated
  blood vessel in the brain, but overall
  hypertension.
• If these unopposed autonomic systems are allowed
  to continue to increase the result can be
  cerebral haemorrhage, seizures and death.

Return to Quick Links
Diagram of Autonomic Dysreflexia
Glossary of Terms
7
Diagram of Autonomic Dysreflexia

• Distended bladder causes stimulation of pain
  receptors in the bladder wall.
• Pain receptors create a message travelling up the
  afferent pathways of the spinal cord to stimulate
  the sympathetic autonomic nervous system (SANS),
  resulting in hypertension
• Baroreceptors in aortic arch are simulated by the
  hypertension and send messages to the vasomotor
  centre.
• The vasomotor centre send messages of
  vasodilation down to compensate, but only
  effective above the spinal lesion.

Return to Quick Links
8
Signs and Symptoms

• Severe pounding headache due to hypertension
• Hypertension remembering that normally people
  with SCI are hypotensive so the BP may not appear
  to be high, but could be a significant increase
  from their normal.
• Blurred vision
• Profuse sweating
• Blotchy rash and flushing above the level of
• lesion
• Goose bumps
• Chills without fever
• Nasal Stuffiness
• Apprehension and fear
• Bradycardia

Typical Autonomic Dysreflexia rash
Return to Quick Links
9
Common Causes of AD

• The most common causes of AD are
• Bladder irritation
• Bowel irritation
• Skin irritation
• Other cause can be from
• Infection
• Sexual intercourse
• Labour and Childbirth
• Fracture
• Acute abdominal disease
• And any other noxious stimulus below the level of
  lesion.

Return to Quick Links
10
General Assessment for AD

• Immediately AD is suspected the situation needs
  to be treated as an emergency
• TWO PEOPLE ARE REQUIRED
• Sit the person up and loosen tight clothing,
  removing compression stocking and abdominal
  binders
• Continually monitor BP
• Commence assessment of cause
• Check for Bladder irritation
• Check for Bowel irritation
• Check for irritation of the skin
• If no obvious cause can be found following this,
  a thorough assessment of other potential causes
  of noxious stimuli needs to be completed
• Remove cause when found and if able
• If the BP is gt170mmHg systolic START DRUG
  THERAPY

Return to Quick Links
Drug therapy for AD
11
Drug therapy for AD

• If the BP is gt170mmHg systolic, drug therapy
  needs to be commenced to
• Reduce the risk of a cerebral incident
• Give more time to find the cause
• The drug of choice is Glyceryl Trinitrate.
• Note Do Not give glyceryl trinitrate if
  sildenafil (Viagra) or vardenafil (Levitra) has
  been taken in the previous 24 hours or tadalafil
  (Cialis) in the previous 4 days.
• AND avoid these medications for 48 hours
  following a severe episode of AD
• Dosages 1 spray of glyceryl trinitrate under
  the tongue,
• OR
• ½ glyceryl trinitrate tablet (Anginine) under
  the tongue,
• OR
• apply 5mg transdermal patch to chest or upper
  arms
• (remove patch once BP settle or becomes too
  low).
• The hypotensive response should begin within 2-3
  mins and last up to 30 mins.
• A second dose of spray or tablet may be given
  after 5 mins if reduction in BP is inadequate or
  if BP rises again

!
IF DRUG THERAPY NOT WORKING
Return to Quick Links
12
IF DRUG THERAPY DOES NOT WORK OR CAUSE IS UNKNOWN

• For further management advice contact
• SPINAL INJURIES UNIT
• PRINCESS ALEXANDRA HOSPITAL
• PH [phone]
• OR
• After Hours Ph [phone] and ask for the
  on-call Medical Officer for the Spinal Injuries
  Unit
• OR arrange transport to the nearest emergency
  department

Return to Quick Links
13
Bladder Irritation

• Irritation of the bladder is one of the most
  common causes of AD. The irritation can present
  as
• Bladder distension i.e. blocked catheter,
  irregular self catheterisation, ineffective
  urodome drainage.
• Infection UTI etc
• Kidney/Bladder stones
• Urological procedures i.e. urodynamics
• The bladder is the first area you need to assess
  of someone experiencing AD.
• Assessment
• If catheter present
• Check for catheter flow, kinks in the tubing, or
  other blockage to the system
• Empty leg bag and estimate volume, is this a
  reasonable volume considering intake and output
  for the day.
• If no catheter
• Is the bladder distended
• How long since last void or self catheterisation
• If no distension of the bladder is found consider
  other causes like infection, or non bladder
  irritation.
• Remember if the BP becomes gt170mmg systolic
  instigate DRUG THERAPY.

Return to Quick Links
Treatment
14
Bowel Irritation

• Irritation to the bowel is also one of the most
  common cause of AD. This usually presents as
• Constipation
• Impaction
• Procedures involving the bowel, i.e. endoscopy or
  electro-ejaculation probe for sperm collection.
• The bowel is the second area you need to assess
  of someone experiencing AD.
• Assessment
• History of poor bowel emptying over recent times
• Gently insert generous amounts of lubricant
  containing a local anaesthetic wait two minutes.
  Then check to see if the rectum is full.
• If the rectum is empty, and a recent history
  indicates that bowel impaction is a probable
  cause then an abdominal x-ray may be needed.
• Remember if the BP becomes gt150mmg systolic with
  bowel irritation instigate DRUG THERAPY.

Return to Quick Links
Treatment
15
Interruptions to Skin Integrity

• Interruption to the skin integrity can also be a
  very common cause of AD. It can present as
• A pressure area
• Any trauma to the skin, i.e. cuts, abrasions,
  burns.
• Ingrown toe nails
• And any other skin complaint that would normally
  cause pain.
• If you have not found a cause of the AD attack
  with the bladder or bowel, then the skin is often
  the next place you need to look.
• Assessment
• Carefully review all areas of the patients skin,
  especially over bony prominences, looking for
  changes to skin integrity. Review any known
  changes to skin integrity for deterioration,
  pressure and/or infection.
• Remember if the BP becomes gt170mmg systolic
  instigate DRUG THERAPY.

Return to Quick Links
Treatment
16
Other Common Causes

• If no obvious cause has been found after the
  assessment of bladder, bowel and skin integrity,
  another cause needs to be considered.
• What were the circumstance when the AD attack
  started?
• Could an event that took place when the AD attack
  started be the cause? (hoisting, exercise, sexual
  intercourse, manipulation of limbs)
• Has the patient has a recent traumatic event?
  (fall out of bed/chair, crack sound on limb
  manipulation)
• Further tests maybe required to establish cause,
  like x-ray, ultrasound etc.
• Other common causes could be
• Infection
• Sexual intercourse
• Labour and Childbirth
• Fracture
• Acute abdominal disease
• Remember if the BP becomes gt170mmg systolic
  instigate DRUG THERAPY.

Return to Quick Links
Treatment
!
If cause is not found
17
Treatment of Bladder Irritation

• BP needs to be constantly monitored 1-2 minutely
  and if it raises gt170mmHg then the treatment is
  to cease until it lowers before recommencing.
• If catheter blockage suspected
• Gently irrigate with 30mls of sterile water
• Empty bladder slowly, 500mls initially and then
  250mls every 15mins to avoid sudden drop in BP
• If this is unsuccessful, re-catheterise using
  generous amounts of lubricant containing a local
  anaesthetic
• If bladder distension suspected with no catheter
• Lubricate urethra with generous amounts of local
  anaesthetic jelly, wait two minutes
• Pass catheter into bladder
• Drain slowly as outlined above.
• Remember if the BP becomes gt170mmg systolic
  instigate DRUG THERAPY.

Return to Quick Links
18
Treatment of Bowel Irritation

• BP needs to be constantly monitored 1-2 minutely
  and if it raises gt170mmHg then the evacuation is
  to cease until it lowers before recommencing.
• If the rectum is found to be full.
• If no anaesthetic jelly was used for inspection
  then it must be inserted now. Wait 2 minutes.
• Manual evacuation needs to be commenced gently.
• Remember if the BP becomes gt170mmg systolic
  instigate DRUG THERAPY.

Return to Quick Links
19
Treatment for interruptions to skin integrity

• BP needs to be constantly monitored 1-2 minutely
  and if it raises gt170mmHg instigate Drug Therapy
• If problems with the skin integrity are suspected
  as the cause
• Remove cause of stimulation to pain receptors if
  able i.e. remove excessive pressure.
• Start treatment of potential causes i.e. treat
  infections, ingrown toenail, etc
• If BP does not settle and/or removal of cause
  will take some time, consider pain management.

Return to Quick Links
20
Treatment of other or unknown causes

• BP needs to be constantly monitored 1-2 minutely
  and if it raises gt170mmHg instigate Drug Therapy
• If any other or unknown cause is thought to be
  the contributing factor to the AD, you need to
• Remove cause if able
• If not immediately able to be removed, start
  treatment and monitor
• Consider treatment of symptoms to reduce impact
  of AD, i.e. pain management.

If cause is not found
Return to Quick Links
!
21
Glossary of Terms

• Afferent pathways the route taken by neurons
  from the periphery of the body towards the
  centre.
• Autonomic nervous system the part of the
  nervous system that regulates involuntary body
  functions.
• Baroreceptors pressure sensitive nerve ends in
  the walls of the atria of the heart, the aortic
  arch and carotid sinuses.
• Efferent pathways the route of neurons carrying
  impulses away from the nerve centre.
• Ganglia a knot or knot-like mass of nerve
  tissue.
• Major splanchnic outflow sympathetic nerve
  outflow from the sympathetic ganglia to the blood
  vessels and visceral organs.
• Medulla Oblongata the most inferior part of the
  brainstem which lies between the pons and spinal
  cord and plays an important role in a number of
  vital functions.

Return to Quick Links
Glossary of Terms Continued
22
Glossary of Terms - cont

• Pain receptors a sensory nerve ending that
  responds to painful stimulus.
• Parasympathetic nervous system a component of
  the autonomic nervous system primarily involved
  with protection, conservation and restoration of
  body resources.
• Spinal reflexes any reflex with a pathway
  through the spinal cord and not the brain.
• Spinal Shock a form of shock associated with
  acute injury to the spinal cord, signs include
  temporary suppression of reflexes below injury.
  Can last for hours to months.
• Sympathetic nervous system a component of the
  autonomic nervous. Involved with increasing heart
  rate, constricting blood vessels and sphincters
  and increasing BP.
• Vasomotor Centre a collection of cells located
  in the medulla oblongata of the brain that
  regulates blood pressure and cardiac function via
  the autonomic nervous system.

Return to Quick Links
23
References

• Consortium for Spinal Cord Medicine. 2001. Acute
  Management of Autonomic Dysreflexia Individuals
  with Spinal Cord Injury presenting to Health-Care
  Facilities. Eastern Paralyzed Veterans of
  America, USA.
• Queensland Spinal Cord Injury Service, 2006.
  Management of Autonomic Dysreflexia Queensland
  Health information brochure for health
  professionals.
• Zejdlik, C.P. 1992. Management of Spinal Cord
  Injury. 2nd Edition. Jones and Bartlett
  Publishers, Boston.

Return to Quick Links