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Autonomic Dysreflexia Also known as Hyper-reflexia

Kathy Rogstad Specialist Nurse in Spinal Cord Injury

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• An over activity of Autonomic Nervous System causing an abrupt onset of excessively high blood pressure.

• Severe headache.• Develops suddenly, potentially life threatening

and medical emergency.• May lead to cerebral haemorrhage, M.I., death if

not treated promptly and correctly.• AT RISK – Complete Injury T6 AND ABOVE.

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• Sympathetic nerves (between 1st thoracic and 1st lumbar segments of cord). Excite body e.g. increase heart rate and B/P.

• Parasympathetic nerves (cranial nerve roots in brain stem and between 2nd and 4th sacral segments of cord. Calm body down e.g. decreasing heart rate and B/P.

Autonomic Nervous System

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• A.D. caused by stimuli creating an exaggerated response of sympathetic nervous system due to lack of control from higher centres.

• Precipitated by specific noxious stimuli from below level of injury (most frequent source of stimuli is an over-distended bladder).

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• Stimuli enters cord. Stops at level of injury.• Enormous sympathetic response activated.• Blood vessel spasticity in abdo/pelvic organs

and skin > vasodilation. B/P rises quickly.• Rising B.P. sensed by nerve endings in aorta

and carotid sinus.

What happens

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• Parasympathetic nervous system activated to try and lower B/P by slowing heart rate and attempting to dilate all blood vessels > vasodilation above level of injury.

• B/P remains elevated until the noxious stimuli is removed.

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• Over-distension / irritation.• U.T.I.• Retention.• Blocked catheter / kinked tubing.• Overfull catheter bag.• Non-compliance with I.C. programme.• Calculi.

Causes of A.D. Bladder

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• Over-distension / irritation.• Rectal over stimulation.• Constipation / impaction.• Haemorrhoids / anal fissures.

Causes of A.D. Bowel

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• Direct irritant below level of injury (e.g. prolonged pressure).

• Pressure ulcers• In-growing toenails.• Burns• Tight / restrictive / creased clothing.• Sitting on testicles.

Causes of A.D. Skin

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• Pregnancy / labour.• Over-stimulation during sexual activity.• H.O.• Acute abdominal conditions.• Fractures.• Instrumentation (e.g. bladder).

Other causes

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• Headache - severe / pounding.• Elevated B/P (compare with baseline observations).• Profuse sweating / flushed face.• Blotchiness of skin above level of injury.• Goose pimples• Nasal stuffiness• Apprehension/Agitation• Bradycardia• Cold, clammy skin below the level of injury

Signs & Symptoms of A.D.

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• Recognise immediately the onset of this condition and initiate measures to lower the blood pressure.

• Remove or control stimuli and prevent dangerous or fatal complications.

• Prevent recurring episodes.

To care for people with A.D.

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• If in chair return the patient to bed• Elevate the head of the bed or hold the patient

in the sitting position to lower the blood pressure – postural hypotension

• Monitor the blood pressure closely• Remove the causative stimuli• Check the bladder for over-distension

Treatment

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• If patient on an intermittent catheterisation programme, catheterise immediately

• If catheter, check it is draining. Look for kinks in the tubing, plugged connections, or a full leg bag.

• Change the catheter without hesitation if no obvious obstruction. Do not attempt washouts. Use anaesthetic gel for lubrication

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• If A.D. persists, using lubrication, gently check the lower bowel for stool and gradually try and remove it.

• If symptoms persist stop procedure and administer anaesthetic gel. Wait 10 minutes and then resume cautiously if symptoms have subsided.

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If the bladder or bowel does not seem to be the course, check for:

• A pressure sore• Ingrown toenail• Fractured bone• Constrictive clothing/shoes• Anything else that may be causing painful

stimuli

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• Nifedipine 10 mg capsule to chew. Repeat after 15 minutes if necessary.

• Others may be recommended, depending on hospital policies.

• A Doctor must prescribe all medications.• If the blood pressure still does not return to

normal, intravenous ganglionic blocking agents will be required.

• (Labetalol 5mg/min. up to 20mg)

Emergency Medications

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• Monitor patients’ B/P and Pulse regularly for 24 hours. • If B/P labile, treatment for a few days with Nifedipine

Retard may be considered.• Provide psychological support• Consider the causes of A.D. for each patient and

initiate management to prevent further episodes if possible.

• Provide optimal bladder and bowel care:• During intermittent catheterisation programme

ensure a desirable balance between intake and output. Urinary output for each catheterisation should not exceed 500mls.

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• Promote unobstructed, gravity-assisted drainage.• Measures to prevent U.T.I., reflux and calculi

formation (e.g. 2.5 to 3 litre input, vitamin C)• Observe the post-operative patient closely• Provide regular and reliable bowel programme.• Provide patient and family education on A.D.• An emergency card with an explanation about A.D.

should be provided and emergency p.r.n. medications prescribed.

• Offer to teach a member of the family how to catheterise.

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