SCI Forum Report & Video

 

Autonomic Dysreflexia

Presented on October 9, 2007, by Janna Friedly, MD, assistant professor in the Department of Rehabilitation Medicine at the University of Washington. Read the report or watch the video from this page.

Autonomic dysreflexia (AD) is a medical problem unique to people with spinal cord injuries (SCI). Although uncommon, it is a serious concern because it can be life threatening and needs immediate attention. If you know what you are looking for, however, it is relatively easy to recognize and treat. But since many health care providers may not be familiar with AD, it is important to understand it yourself and carry a medic alert card. Learn how to prevent, recognize and treat AD in this 35-minute video.

 

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Report

 

Autonomic Dysreflexia
By Janna Friedly, MD

 

Table of Contents

• Introduction
• What is autonomic dysreflexia (AD)?
• How does AD happen?
• Who is at risk for AD?
• Common causes of Ad
• Common warning signs of AD
• How to lower your blood pressure
• What to do if you have AD
• AD tool kit
• Preventing AD
• Key points
• Resources
• References

Introduction

Autonomic dysreflexia (AD) is a medical problem unique to people with spinal cord injuries (SCI). Although uncommon, it is a serious concern because it can be life threatening and needs immediate attention. If you know what you are looking for, however, it is relatively easy to recognize and treat. But since many health care providers may not be familiar with AD, it is important to understand it yourself and carry a medic alert card.

What is autonomic dysreflexia (AD)?

AD is an abnormal response to a problem in your body—pain, pressure, full bladder or bowel—somewhere below the level of your SCI. Because of the SCI, your body doesn't respond properly to signals that something is wrong. Instead, your body may develop a sudden rise in blood pressure, and this can lead to stroke, seizures or death.

How does AD happen?

AD is usually triggered by something that would cause pain or discomfort in a person without SCI, such as a full bladder, tight clothing or an ingrown toenail. In non-injured individuals, the body reacts to pain by narrowing the blood vessels, and this causes blood pressure to increase. Receptors near your brain and heart receive messages from non-spinal cord pathways (nerves in the sympathetic nervous system) that your blood pressure is getting too high, and your brain responds by sending signals down the spinal cord to slow down the heart beat and relax the blood vessels. As the blood vessels open up and widen, blood pressure goes back down. Meanwhile, pain signals coming through the spinal cord have told the brain there is something wrong, so the individual feels the discomfort and knows to do something about it and remove the source of the pain.

In SCI, when something causes pain or discomfort below the level of the injury, the body still responds by narrowing blood vessels and blood pressure starts to rise. And the brain still gets the message from the sympathetic nervous system that there is a problem and sends signals down the spinal cord to slow the heartbeat and open up the blood vessels. This slows your heartbeat and makes you flushed, red or blotchy above the injury, but the signals can’t get past the injury level, so the blood vessels continue to narrow below the injury and the blood pressure keeps rising. Furthermore, all this is happening without your knowing you have a problem below your injury, since the pain message couldn’t travel up your spinal cord to your brain.

Who is at risk for AD?

• SCI at or above the level of T6
• Persons with complete injuries are more likely to experience AD

Some people within this risk group get AD frequently, others get it once in a while, and some don't get it at all. We don't quite understand why some people get it more than others. Furthermore, some people get mild symptoms while others get very severe symptoms. Recent research in animal models indicates that the amount of sensory nerve regrowth right at the level of the SCI may play a role, suggesting that people who have more of that growth and regeneration may be at higher risk of AD (Cameron, 2006).

Common causes of AD

1. Bladder—the most common culprit!
1. Overfull or distended (stretched) bladder.
2. Kinked Foley catheter.
3. Overfilled leg bag.
4. Urinary tract infection.
5. Any obstruction that keeps urine from getting out of the bladder, like a stone.
2. Bowel
1. Over-distension (stretching of rectum or anus) during bowel program.
2. Constipation or impacted stool.
3. Hemorrhoids.
4. Anal fissures or skin breakdown.
3. Skin irritation
1. Prolonged pressure or pressure sore.
2. Ingrown toenail.
3. Sunburn.
4. Tight clothing.
4. Sexual activity
1. Over-stimulation during sex—things that would be painful if you had full sensation.
5. Gynecologic Issues in Women
   1. Menstrual cramps
   2. Labor and delivery.

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Common warning signs of AD

Warning signs vary from person to person: Some people have all of the signs, some only one or two; signs may be obvious in some and more subtle in others. So it's important for each person who is at risk of dysreflexia to get to know their own bodies and know how dysreflexia affects them.

• The most important sign is a sudden, major increase in blood pressure of about 20 to 40 mm Hg (millimeters of mercury) higher than your normal blood pressure.
• Know your normal blood pressure! Since people with SCI usually have a low resting blood pressure (80 or 90 systolic for a cervical injury), a rise to 130 or 140 systolic—normal in someone without SCI—could be dangerously high for a person above T6.
• Pounding headache.
• Sweating above the level of the SCI.
• Flushed or red skin (especially in face and neck).
• Goose bumps.
• Tightness in the chest, blurry vision, anxiety or jitters—often reported as feeling like a panic attack.
• Stuffy nose.

While all these signs and symptoms are uncomfortable and can be very annoying or upsetting, the increased blood pressure is what makes this a medical emergency.

How to lower your blood pressure

1. Fix the problem—whatever it is!
   Identify what the problem is and take care of it (see What to do if you have AD, below). If that doesn’t lower your blood pressure, go to step 2.
2. Use blood pressure medication prescribed by your doctor, usually nitroglycerin paste applied to the surface of your skin, where it gets readily absorbed into your blood stream and brings down your blood pressure very quickly. As soon as you figure out what’s causing the problem and the dysreflexia goes away, you can just wipe it right off.
   
   About nitroglycerin paste:

• Caregivers should apply nitroglycerin paste with gloves, if possible, otherwise wash hands quickly after applying.
• Follow directions provided by your health care provider for the amount to apply (usually about ½ inch of paste to start) and where to apply it (typically trunk or shoulders, but wherever it is easiest).
• Do not use nitroglycerin paste if you have taken Viagra within 24 hours, since blood pressure may plummet dangerously. If you go to an emergency room for AD, tell them if you have taken Viagra.

What to do if you have AD

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1. Sit straight up to lower your blood pressure, or elevate your head in bed and lower your legs.
2. Quickly remove or loosen anything tight or causing pressure, such as:
   1. Abdominal binder
   2. Catheter tape, leg bag straps
   3. Elastic hose or bandages
   4. Clothes
   5. Shoes or braces
3. Check your blood pressure every five minutes. If your blood pressure remains elevated for more than 10 minutes and you have blood pressure medicine prescribed by your doctor, take it as prescribed. Make sure you know your doctor's recommendations for how high your blood pressure needs to be before you use nitroglycerin paste or another blood pressure medicine. This is different for each person, but is often 150/90.  If you do not know, call a professional to assist you.
4. Check your bladder.
   1. Indwelling or Foley catheter:
      1. Check catheter for kinks.
      2. Empty the drainage bag.
      3. Consider irrigating bladder with saline (only if you have experience with this; use 30 cc at most) to dislodge anything that might be blocking the inside of the Foley.
   2. Intermittent catheterization
      1. Catheterize your bladder—use lidocaine gel (an anesthetic, or numbing, gel).
      2. If catheter doesn’t pass through and you still have symptoms, call 911.
5. If you suspect your bowels as a cause, do a bowel program if you can, but make sure to use lidocaine gel for the digital stimulation.
6. If you follow the above suggestions and the symptoms get worse or persist —STOP and go to the emergency room.
7. If the symptoms do go away, write down what symptoms you had and what you did to fix the problem, because oftentimes this is what is going to happen in the future. Let your healthcare provider know about the episode of AD and how you handled it, since there may be some other things that they can recommend to prevent it from happening again.
8. If symptoms come back again, repeat the steps and call your healthcare provider or go to the emergency room.

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AD tool kit

Anyone who is at risk for dysreflexia or has had dysreflexia in the past should keep a tool kit on them at all times.

• AD instruction card to explain dysreflexia to healthcare providers, who may not know what it is or what to do about it, so they will treat it quickly and correctly (ask your rehabilitation provider for an AD instruction card, or obtain one from the PVA; see Resources, below).
• Medical card with identification, list of medical problems and medications, and your normal blood pressure.
• Blood pressure cuff.
• Catheter and insertion supplies.
• Irrigation syringe and sterile water or saline solution.
• Lidocaine gel.
• Gloves.
• Prescription medications for AD, such as nitroglycerin paste, from your healthcare provider. Replace your nitroglycerin paste prescription every six months.

Preventing AD

As with most things in SCI, prevention is really key. Since we know what some of the triggers are for dysreflexia, it makes it easier to know what to do to prevent it.

• Bladder
• Foley catheter:
• Keep tube free of kinks.
• Empty collection bag frequently.
• Check inside of the tube frequently for any kind of grit or deposit that may indicate that you have an infection or a stone or that your Foley catheter needs to be changed or irrigated.
• Intermittent catheterization:
• Avoid an overfull bladder!
• Bowel
• Maintain a regular bowel program.
• Avoid constipation.
• Eat fiber (fruits and vegetables)
• Drink enough water.
• Get treatment for hemorrhoids.
• Skin
• Do pressure reliefs frequently.
• Check skin vigilantly every day for pressure sores or skin problems.
• Avoid tight or restrictive clothing.
• Check clothing for sharp or hard objects that can rub or cause pressure (for example, buttons on rear pants pockets).
• Avoid sunburns and extremes of temperature (hot or cold).

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Key points

• AD is potentially life-threatening and needs immediate attention!
• Be prepared. Learn to recognize how your body feels when you have dysreflexia and what the triggers usually are.
• Stay calm, sit straight up, and fix the problem.
• If it doesn't go away, get help immediately!

Resources

Autonomic Dysreflexia: What You Should Know, a consumer guide published by the Consortium for Spinal Cord Medicine and the Paralyzed Veterans of America (PVA). Download the guide for free from the PVA Web site at http://www.pva.org/site, or call the PVA Publications Distribution Center toll-free at 888-860-7244 to receive a free copy in the mail ($3 shipping charge). A wallet-size information card is included in the printed guide.

References:

1. Autonomic Dysreflexia: What You Should Know, consumer guide, Consortium for Spinal Cord Medicine, Paralyzed Veterans of America, Washington DC, 1997.
2. Cameron AA, Smith GM, Randall DC, et al. Genetic manipulation of intraspinal plasticity after spinal cord injury alters the severity of autonomic dysreflexia. J Neurosci. 2006 Mar 15:26(11):2923-32.

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