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Autonomic Dysreflexia. Anne Seaman Lead Nurse Duke of Cornwall Spinal Treatment Centre . What is Autonomic Dysreflexia?. Can occur quickly Is a life threatening medical emergency. Dysreflexia. First described in 1917,

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Autonomic Dysreflexia

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autonomic dysreflexia

Autonomic Dysreflexia

Anne Seaman

Lead Nurse

Duke of Cornwall Spinal Treatment Centre

what is autonomic dysreflexia
What is Autonomic Dysreflexia?

Can occur quickly

Is a life threatening medical emergency

  • First described in 1917,
  • It is a protective mechanism that tells the person that something is wrong
  • Important to view it as a positive warning sign
  • Also known as autonomic hyperreflexia,
who is at risk
Who is at risk?
  • Occurs in 83-85% of tetraplegic and high level paraplegic persons injured (T6 and above)
  • If is going to occur, it usually begins within the first few months following spinal shock
what happens
What happens
  • SCI results in the nerve pathways to the brain are interrupted.
  • When there is pain or discomfort below the level of your SCI it triggers a nervous system reflex response
  • This begins a rapid increase in your blood pressure
  • This will continue until the cause is found and treated
possible consequences of ad
Possible Consequences of AD
  • Retinal haemorrhage in the eye
  • Apnoea - breath holding
  • Stroke
  • Renal (Kidney) failure
  • Subarachnoid (Brain) haemorrhage
  • Seizures (Fits)
  • Cardiac dysrhythmias (Heart changes)
  • Cardiac arrest
  • Death

All are rare

prevention of ad
Prevention of AD
  • Good personal care
  • Careful bladder and bowel management
  • Good education
  • Expert Patient - in control
most common causes
Most Common Causes?

Research shows that the most common causes


1over distended bladder

2 over distended bowel

(Ceron & Rakowski-Reinhardt 1991, Dunn 1991, Finocchiaro &

Herzfeld 1990, McGuire & Kumar 1986 cited Adsit & Bishop 1995)

most common triggers
Most Common Triggers
  • Distended bladder
  • Distended bowel
  • Skin breakdown
  • UTI
  • Other causes of pain or discomfort
other possible triggers
Ingrown toenails

External temperature extremes

Clothing or shoes too tight

Digital stimulation of the bowel

Bladder spasm and stones


Sphincter bladder dyssynergia



Burns and Sunburn




Ovarian cyst


Perforated gastric ulcer

Heterotrophic Ossification

Orthastic hypotension

Oesophageal reflux

Other Possible Triggers
response to raised bp
Response to Raised BP
  • The body does try to reduce the BP,
  • only able to do so above the level of injury,
  • which produces the well recognised symptoms of autonomic dysreflexia
signs and symptoms
Signs and Symptoms
  • Headache - sudden & thumping
  • Flushed face – vasodilitation
  • Blotching of the skin – erythema
  • Goose bumps below the level of the lesion
  • Pallor below the level of the lesion
  • Increased blood pressure
  • Bradycardia
  • Profuse sweating
  • Nasal stuffiness
  • Fear
patient specific symptoms
Patient Specific Symptoms

Some patients may not experience the

common symptoms,

particularly the thumping headache

May complain of a ‘tight chest’ instead

other signs and symptoms
Other Signs and Symptoms
  • Increased spasm and spasticity
  • Nausea
  • Respiratory difficulties
  • Heart beat changes
  • Impending sense of doom
  • Vision changes
  • Metallic taste in the mouth

Are you at risk of AD?

  • Level of SCI ? T6 or above
  • Extent of SCI ?complete/?incomplete
  • Previous episodes
  • Usual cause
  • Post SCI new normal BP
  • Carers or you need to act quickly & calmly,
  • Enlist help if needed
  • Sit upright if in bed (helps to lower BP)
  • BP monitored every 3-5 mins in hospital
  • Loosen tight clothing & binders
  • Assess for cause – bladder & bowel first
  • Prepare for catheter change or bowel care
find cause bladder
Find Cause: Bladder
  • Check urine in drainage bag
    • Full, empty and monitor
    • Empty, ?when last emptied
  • Check for kinks in tubing
  • Check for signs if catheter is dislodged
  • Any sign of haematurea?
  • Catheter blocked? Change it
find cause bowel
Find Cause: Bowel
  • Last bowel care, ? Result – good/small
  • Lie on left side (head raised)
  • PR check
  • If full will need manual evacuation
  • Local anaesthetic gel (3 mins)
  • Gentle Manual Evacuation (ME)
  • Let AD resolve and then perform usual bowel care
other cause
Other Cause?
  • ?Ingrown toe nail
  • ?Pressure ulcer
  • Give analgesia
  • ? Give Nifedipine
  • Call GP, will need treatment and possibly Nifedipine SR
  • Administer
    • Nifedipine 5mg crush and swallow
    • Or GTN 300Micrograms/nasal spray

(Only if diastolic BP is greater than 100mmHg)

Patient should have a supply

  • If this is unsuccessful and cause is not found inform a Dr/GP/go to ED as Phentolamine 5-10mg IV may be required
  • Time will be running out
patient information
Patient Information
  • Alert card
  • Carry medication
  • Care manual
rehabilitation process
Rehabilitation Process
  • Assessment
  • Education
      • Patient, Family, Friends, Carers,
      • Lesson Plan
      • Skills development
      • Skills assessment
      • Independence
      • Teaching others
rehabilitation process24
Rehabilitation Process
  • Developing skills
      • Recognition
      • Self assessment – find cause
      • When to take medication
      • Change catheter
      • Bowel care
      • Skin inspection
  • Monitoring
      • Care plan
      • Diary
ad diary
AD Diary
  • This diary is intended for you to use and keep as a record of your episodes autonomic dysreflexia. The intention is not for you to keep records indefinitely, but until you feel confident in your ability to recognise your symptoms together with any trends in the causes to help you to prevent further episodes.
  • Name:
  • Level of SCI …………………. Complete Incomplete Date of SCI ……………
  • Normal BP…………/…………….
Date of Autonomic Dysreflexia episode ………………………..

Symptoms: Put an ‘X’ in the box of all the symptoms you experienced.

 Pounding headache

 Heavy sweating

 Blurred vision

 Tight chest

 Blotchy/flushed skin above SCI

 Goose bumps

 Anxiety/fear

 Difficulty breathing

 Other:

Cause: Comments:…………………………..…………………..
  • Did you need medication? Yes No
  • What did you take? ………... Dose(s) ……………….
  • Did you have any difficulties managing the episode?  Yes  No
  • Comments: …………………….………………………..
ad kit
AD Kit

It is advisable to carry suitable equipment

  • going out
  • on holiday

If you out and unable to find a suitable place to manage

an episode of AD call 999 for help.

In your local area HAVE A PLAN.

catheter supplies
Catheter Supplies
  • Hand wipes or gel
  • Syringe to remove catheter if using an indwelling catheter
  • Spare catheter correct size
  • Bladder syringe
  • Insertion supplies including hand wipes and gloves
  • Sterile syringe to put water into the balloon, sterile water
  • Disposal bag
  • Spare clothing if you usually bipass the catheter/leak
bowel care supplies
Bowel Care Supplies
  • Latex gloves
  • Polyethylene gloves
  • Anaesthetic lubricating gel
  • Wet wipes (baby wipes), tissues
  • Disposal bag
  • Spare clothing
don t forget
Don’t Forget
  • your medication - Nefidepine
  • check when it expires
  • keep your alert card with you.
  • Paracetamol for ongoing headache
  • Radar key for access to Disabled Toilets