Autonomic Dysreflexia

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Autonomic Dysreflexia

• Geri Claxton, RN

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Outline

• Definition
• Other names
• Causes
• Common symptoms
• What do you do when it happens?
• Inpatient protocol
• Education (Drs, health care providers, emergency
  technicians)
• Questions?

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Definition

• A sudden nervous system response to a condition
  that irritates the body
• It can happen to people with a spinal cord injury
  at the thoracic (T) 6 level or higher
• It is common
• It is a MEDICAL EMERGENCY that raises the blood
  pressure so high, that it can cause death if not
  taken care of right away
• AKA Autonomic hyperreflexia, dysreflexia, A/D

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Definition

• A sudden nervous system response to a condition
  that irritates the body
• It can happen to people with a spinal cord injury
  at the thoracic (T) 6 level or higher
• It is common
• It is a MEDICAL EMERGENCY that raises the blood
  pressure so high, that it can cause death if not
  taken care of right away
• AKA Autonomic hyperreflexia, dysreflexia, A/D

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Definition

• A sudden nervous system response to a condition
  that irritates the body
• It can happen to people with a spinal cord injury
  at the thoracic (T) 6 level or higher
• It is common
• It is a MEDICAL EMERGENCY that raises the blood
  pressure so high, that it can cause death if not
  taken care of right away
• AKA Autonomic hyperreflexia, dysreflexia, A/D

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Causes

• Full bladder
• Full bowel or constipation
• Bladder infection or bladder stones
• Tests done on the bladder
• Pressure sores
• Ingrown toenails
• Labour and delivery

• Genital stimulation (or pressure)
• Ejaculation
• Tight clothing or shoes
• Severe menstrual cramps
• Fractures bones (traumatic pain)

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Causes

• Abdominal medical problems
• Gall stones
• Appendicitis
• Kidney stomes
• ulcers

• Hot and cold temperatures
• Sunburn
• Some drugs
• e.g. digoxin

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Common Symptoms

• Sudden severe rise in blood pressure
• Pounding headache
• Change in heart rate
• Flushed skin above level of injury
• Sweating above or below level of injury
• An aura

• Anxious feeling
• Blurred vision
• Stuffy nose
• Shivering above level of injury
• Goose bumps below level of injury
• Pale skin below level of injury

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Wallet Sized Card
Medical Alert Autonomic Dysreflexia (AD) AD is
a potentially life threatening complication of
spinal cord injury above T7 level. It is caused
by an unopposed sympathetic nervous system
response to noxious stimulation below the level
of the injury. Blood pressure may rise
dangerously. The most typical cause of AD is
distended bladder. Other causes could be
distended bowel, pressure sore, in-grown toenail,
etc.

• Autonomic Dysreflexia Treatment 
• Raise the head of the bed by 90? or sit person
  upright.
• Monitor BP every 5 minutes.
• Check for sources of AD drain bladder first,
  consider using topical anesthetic jelly for
  lubrication of catheter.
• Check rectum for stool. Apply anesthetic jelly
  to rectal wall before manipulation. Use digital
  stimulation to promote reflex defecation.
• Check for other sources of AD such as ulcer,
  fracture, in-grown toenail, etc.

• If SBP is above 150 mmHg after above checks, give
  captopril 25 mg sublingually x1. Advise patient
  to avoid swallowing until tablet dissolved.
• If SBP still greater than 150 mmHG at 30 minutes
  post-captropril then give immediate release
  nifedipine 5 mg capsule via the bite and wallow
  method.
• ONLY IN A HOSPITAL SETTING
• Repeat nifedipine 5 mg bite and swallow 15
  minutes after the initial nifedipine dose if SBP
  still greater than 150 mmHg.
• Consider intravenous agents for hypertension if
  hypertension is refractory.

Symptoms may include elevated blood pressure
(normal after SCI may be 90/60), headache,
sweating, flushed face, anxiety, bradycardia.
Treatment is to remove the cause. Once the cause
is removed the BP will return to normal
immediately.
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What to do if it happens 1

• Sit up of up if you are lying down this will
  decrease your blood pressure
• Find and remove the cause it usually will NOT
  go away until the cause is removed or corrected
• Loosen tight clothing, legbag straps, shoes

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What to do if it happens 2

• Check for BLADDER problems
• empty bladder with in/out catheter
• check for kinks in tubing
• check for full legbag
• change foley catheter

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What to do when it happens 3

• Check for BOWEL problems
• Do rectal check if there is stool, remove it
  gently.
• Use xylocaine gel to decrease potential
  stimulation which could cause BP to increase even
  more

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What to do when it happens 4

• Check for SKIN problems
• Do a thorough check of the skin from top to
  bottom, front to back
• Check buttocks, feet, toenails, etc
• Use a mirror and/or get help from someone

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What to do when it happens 5

• If you cant find the cause, SEEK MEDICAL
  ATTENTION at the nearest hospital
• Remember NOT ALL HEALTH PROVIDERS WILL KNOW HOW
  TO TREAT IT!

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Prevention

• Do regularly scheduled bladder and bowel programs
• Do routine skin care and nail care
• Avoid extreme hot or cold
• Take prescribed medications

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Autonomic Dysreflexia Protocol

• Place stamp outlining data collection information
  required in the progress notes of the chart upon
  each episode of AD
• Use usual nursing non-drug measures for AD
• If SBP?150mmHg after routine non-drug measures,
  give captopril 25mg sublingually X 1. Advise
  patient to avoid swallowing until tablet
  dissolved (3min)

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Autonomic Dysreflexia Protocol

• Measure and record blood pressure at baseline,
  15, 30, 60 min post captopril. Perform each
  blood pressure reading twice, then average.
• If SBP still ?150mmHg at 30 min post captopril,
  then give immediate release nifedipine 5mg
  capsule via the bite and swallow method.
• Measure and record blood pressure at 15 and 30
  min post nifedipine.

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Autonomic Dysreflexia Protocol

• Repeat nifedipine 5mg bite and swallow 15 min
  after the initial nifedipine dose if SBP still
  ?150mmHg .
• Call physician if
• SBP still ?150mmHg 15 min post second nifedipine
  dose (i.e. 30 min post initiation of nifedipine)
• Patient displays signs of hypotension (e.g.
  syncope, dizziness) or SBP lt 70mmHg
• There is concern any time during the episode

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Education

• Family members
• Family physicians
• Health care providers
• Attendants, homecare nurses, etc
• Emergency technicians
• Ambulance attendants, etc

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Contact Info

• GF Strong Outpatient Nurse (Geri Claxton)
• 604 737-6322
• GFS Toll-Free
• 1-866-906-1888