Autonomic Dysreflexia

Anne SeamanLead NurseDuke of Cornwall Spinal Treatment Centre

What is Autonomic Dysreflexia?

Can occur quickly

Is a life threatening medical emergency

Dysreflexia

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?

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

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

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

Good personal care

Careful bladder and bowel management

Good education

Expert Patient - in control

Most Common Causes?

Research shows that the most common causes

are:1 over distended bladder2 over distended bowel

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

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

Most Common Triggers

Distended bladderDistended bowelSkin breakdownUTIOther 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 Spasticity Sphincter bladder

dyssynergia Appendicitis Orgasm

Burns and Sunburn SIC Enemas Fractures Ovarian cyst DVT & PE Perforated gastric

ulcer Heterotrophic

Ossification Orthastic hypotension Oesophageal reflux

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

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

Some patients may not experience thecommon symptoms,

particularly the thumping headache

May complain of a ‘tight chest’ instead

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

Treatment

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

Treatment 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

Check urine in drainage bag Full, empty and monitor Empty, ?when last emptied

Check for kinks in tubingCheck for signs if catheter is dislodged Any sign of haematurea?Catheter blocked? Change it

Find Cause: Bowel

Last bowel care, ? Result – good/smallLie on left side (head raised)PR checkIf 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?

?Ingrown toe nail?Pressure ulcer

Give analgesia? Give NifedipineCall GP, will need treatment and

possibly Nifedipine SR

Treatment 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

Alert cardCarry medicationCare manual

Rehabilitation Process

AssessmentEducation

Patient, Family, Friends, Carers, Lesson PlanSkills development Skills assessment IndependenceTeaching others

Rehabilitation Process

Developing skillsRecognitionSelf assessment – find causeWhen to take medicationChange catheterBowel careSkin inspection

MonitoringCare planDiary

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

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

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

Latex gloves Polyethylene gloves Anaesthetic lubricating gel Wet wipes (baby wipes), tissues Disposal bag Spare clothing

Don’t Forget

your medication - Nefidepinecheck when it expires keep your alert card with you.Paracetamol for ongoing headacheRadar key for access to Disabled Toilets