Monday, December 4, 2023

Autonomic Dysreflexia Spinal Cord Injury

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How Can You Prevent It

Autonomic Dysreflexia Hyperreflexia Nursing Review: Symptoms, Treatment

There are ways you may be able to prevent autonomic dysreflexia. This means doing things to avoid the things that cause it.

  • To avoid an overfull bladder or urinary tract infections , follow your bladder management program.
  • To avoid an overfull bowel or constipation or gastrointestinal problems such as gallstones, stomach ulcers, or gastritis, follow your bowel management program. Eat fiber and consume fluids as your doctor suggests.
  • To avoid pressure injuries, ingrown nails, or other skin problems, check your skin daily. Make sure that all clothing or devices fit right.
  • Be aware that having sex can cause the condition. Discuss this with your doctor.
  • Be aware of what else can cause the condition. This includes broken bones or other injuries, tight clothing or devices, and extreme temperatures or quick changes in temperature. Discuss this with your doctor. Make sure that all clothing and devices fit right.

What Is Autonomic Dysreflexia

Autonomic dysreflexia is the product of dysregulation of the autonomic system, leading to an uncoordinated response to a noxious stimulus below the level of a spinal cord injury,2 usually in individuals with a spinal cord injury above the level of T6 . It is three times more prevalent in those with complete spinal cord injury than in those with incomplete injury .3 Autonomic dysreflexia is clinically defined as an acute episode of systolic blood pressure elevated 25 mm Hg or above the patients normal measurements.

Symptoms Of Autonomic Dysreflexia

The characteristics of symptoms for AD vary by individual. Some individuals have extremely mild symptoms that are unfortunately often ignored. Others have incapacitating symptoms. Please note any, a few, or all the symptoms can be experienced with AD. Some symptoms will appear with different triggers. Most individuals learn about the pounding headache as a symptom of AD. A pounding headache is the most often cited symptom but any of these symptoms listed can be noted even without the pounding headache. Ignoring any symptom can be life threatening, even if mild. Blood pressure monitoring is essential in detecting AD. Elevated blood pressure above your normal range can lead to stroke, cardiac arrest, seizures, retinal hemorrhage, pulmonary edema and even death if untreated.

Typical symptoms of AD in adults are:


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Triggers For Autonomic Dysreflexia

The detection of AD has been classically noted to be due to a trigger that stimulates the body into an AD episode. A trigger is something that the body perceives as noxious or irritating below the level of injury. If the message that something small or big is bothering the body where sensation is decreased, the sensory nerves cannot effectively or efficiently send a message to the brain to correct the situation. As a result, the ANS would typically send a message to the motor nerves to move the body which would correct the situation. However, due to nerve miscommunication, a total blast of messages is sent. The messages are unable to get through which results in this massive burst of nerve activity in the body, usually above the level of injury.

With the discovery of silent AD, triggers may not be noted or act as a stimulus for an AD episode. In silent AD, blood pressure is affected without the identification of a trigger. An AD episode may occur without symptoms which is why it is called silent AD.

Triggers include a variety of noxious sources or irritations to the body. Common triggers are listed below. Individuals have different triggers. The most common noxious irritations that stimulate episodes of AD are from the bladder, bowel, and skin. However, the list of possible triggers is always increasing. Triggers fit into categories, although your trigger may be quite unique.

Signs And Symptoms Of Autonomic Dysreflexia

Autonomic Dysreflexia

A patient with autonomic dysreflexia may have one or more of the following findings on physical examination:

  • Significant rise in systolic and diastolic blood pressure greater than 20 mm Hg systolic or 10 mm Hg diastolic, above baseline
  • Profuse sweating above the level of lesion – Especially in the face, neck, and shoulders rarely occurs below the level of the lesion because of sympathetic activity
  • Goose bumps below the level of the lesion
  • Flushing of the skin above the level of the lesion – Especially in the face, neck, and shoulders this is a frequent symptom
  • Nasal congestion – A common symptom

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Who Is At Risk For Developing Autonomic Dysreflexia

Not all individuals with spinal cord injuries are at risk for developing autonomic dysreflexia. It is most common following spinal cord injuries at the T6 level or higher. In fact, its suggested that about 50-70% of individuals with T6 or higher level spinal cord injuries experience symptoms of autonomic dysreflexia.

This means that individuals with cervical spinal cord injuries and high-thoracic spinal cord injuries are at the highest risk of AD. Although much rarer, it can also occur with injuries below the T6 level. However, it is unlikely to occur in individuals with spinal cord injuries below the T10 level.

Autonomic dysreflexia can occur in individuals with complete or incomplete spinal cord injuries. However, the more severe your injury, the greater the risk of developing AD.

Othercauses of autonomic dysreflexia include:

  • spinal cord tumors
  • Any sort of pressure on the body
  • Menstrual cramps
  • Sexual activity

Individuals with autonomic dysreflexia must keep an eye out for these triggers and try to avoid them as much as possible. In instances when individuals are unaware of triggers, signs of AD may occur. The sooner youre able to identify these signs and symptoms, the sooner you can prevent the response from progressing.

Papers Of Particular Interest Published Recently Have Been Highlighted As: Of Importance

  • Krassioukov A, Biering-Sorensen F, Donovan W, Kennelly M, Kirshblum S, Krogh K, et al. International standards to document remaining autonomic function after spinal cord injury. J Spinal Cord Med. 2012 35:20110 This is the first guideline describing the International Standards to document remaining autonomic function after spinal cord injury. In addition gives an excellent overview on the pathophysiology of autonomic dysfunctions following SCI.

  • Tansey K. The neurophysiology of autonomic dysfunction in SCI: plasticity in the input and output neurons. Emory Univ Atlanta Ga School Of Medicine 2014.

  • Krenz NR, Meakin SO, Krassioukov AV, Weaver LC. Neutralizing intraspinal nerve growth factor blocks autonomic dysreflexia caused by spinal cord injury. J Neurosci. 1999 19:740514.

  • Linsenmeyer TA, Baker ER, Cardenas DD, Mobley T, Perkash I, Vogel LC, et al. Acute management of autonomic dysreflexia: Individuals with spinal cord injury presenting to health-care facilities. Consortium for spinal cord medicine clinical practice guidelines. 2nd ed. Clinical Practice Guidelines. J Spinal Cord Med. 2002 25:S6888 This is the classic well established clinical practice guideline on autonomic dysreflexia. This provides an excellent resource which includes an executive summary for quick reference.

  • Linsenmeyer T, Campagnolo D, Chou I. Silent autonomic dysreflexia during voiding in men with spinal cord injury. J Urol. 1996 155:51922.

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    Treatment For Autonomic Dysreflexia

    AD is a medical emergency. When blood pressure is raised, you need to act immediately. Do not hesitate to call 911 if needed.

  • When AD symptoms are noted, start by first quickly sitting bolt upright. Your torso and hips should be at a 90-degree angle. Have someone help you to a sitting position if you are unable to do this yourself. The sudden change from laying to sitting takes advantage of orthostatic hypotension when your blood pressure suddenly drops as the blood vessels cannot constrict to rush blood to your head fast enough.
  • Continue to monitor blood pressure every 2-3 minutes until it returns to your normal.
  • Loosen anything tight or restrictive on your body while getting into the sitting position.
  • Look for the cause of this episode of AD. Start with checking the three most common triggers for AD. Check urine flow. Catheterize if necessary . Then check the bowel for blockage. Disimpact the bowel if stool is present. Then check the skin removing wrinkles, constrictions or tight clothes. You may know your triggers from previous AD episodes. Correction of your usual trigger source is a good start if you are aware of it. If AD does not start to resolve with corrections, continue to look for and remove triggers below the level of injury.
  • If you have medication prescribed for AD administer it. Medication may consist of an antihypertensive with rapid onset and short duration. Commonly prescribed medications are:
  • Autonomic Dysreflexia Video

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    Treatment Of Autonomic Dysreflexia

    Check the patient’s blood pressure. If the blood pressure is elevated, have the person sit up immediately and loosen any clothing or constrictive devices. Sitting allows some gravitational pooling of blood in the lower extremities and reduces blood pressure. Survey the person for instigating causes, beginning with the urinary system, the most common cause of autonomic dysreflexia.

    If an indwelling urinary catheter is not in place, catheterize the patient. If the individual has an indwelling urinary catheter, check the system along its entire length for kinks, folds, constrictions, or obstructions and for correct placement.

    If the catheter appears to be blocked, gently irrigate the bladder with a small amount of fluid, such as normal saline at body temperature. Avoid manually compressing or tapping on the bladder. If the catheter is draining and blood pressure remains elevated, suspect fecal impaction, the second most common cause of autonomic dysreflexia, and check the rectum for stool, using lidocaine jelly as lubricant. If impacted, gentle manual evacuation is recommended.

    Monitor blood pressure and pulse every 2-5 minutes until the patient has stabilized impaired autonomic regulation can cause blood pressure to fluctuate quickly during an episode of autonomic dysreflexia.

    What Happens With Ad

    AD interrupts both the sympathetic and parasympathetic nervous systems. This means that the bodys SANS overreacts to stimuli, such as a full bladder. Whats more, the PANS cant effectively stop that reaction. It may actually make it worse.

    Your lower body still generates a lot of nerve signals after a spinal cord injury. These signals communicate your bodily functions, such as the status of your bladder, bowels, and digestion. The signals cant get past the spinal injury to your brain.

    However, the messages still go to the parts of the sympathetic and parasympathetic autonomic nervous systems that operate below the spinal cord injury.

    Signals can trigger the SANS and PANS, but the brain cant appropriately respond to them, so they no longer work effectively as a team. The result is that the SANS and PANS can get out of control.

    Your heart rate may slow down radically because pressure sensors located in your major arteries respond to the abnormally high blood pressure by sending a signal to your brain. Your brain then tries to lower your blood pressure by slowing down your heart.

    Triggers of AD in people with spinal cord injuries can be anything that generates nerve signals to the SANS and PANS, including:

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    Mechanisms Initiating Autonomic Dysreflexia

    Various stimuli can trigger an unregulated sympathetic reaction causing AD.27314041The onset of AD is usually provoked by the distension of urinary bladder, genitourinary tract infections, urolithiasis, renal colic, catheterization, urodynamic studies, cystoscopy, sexual stimulation, gynecological problems, vaginal examination, distal bowel or rectal stimulation , hemorrhoids, gastrointestinal morbidity , tissue damage , or skin irritation from tight clothing, sunburn, ingrown toe nails, insect bites, dressing changes, rehabilitation, and physiotherapeutic measures.17284042The compression of surrounding organs by enlarged uterus, as well as labors, delivery, breast-feeding, and changes arising during puerperal period are also strong triggering factors in women with cervical or high-thoracic lesions.57404344

    Enhancing Healthcare Team Outcomes

    Pin on Internal Medicine

    Patients with spinal cord injury are usually managed by an interprofessional team that includes the trauma surgeon, internist, neurologist, urologist, and emergency department physician. Autonomic dysreflexia should be strongly suspected in any spinal cord injured patient with a lesion above T6 who complains of a headache. A blood pressure reading should be taken immediately, and corrective treatment started if the patient’s blood pressure is significantly elevated as most spinal cord injured patients have low blood pressure. Bladder distension from urinary retention or a blocked Foley is the single most common cause of this disorder, and irrigating or changing the catheter is often immediately curative. Quick recognition and rapid alleviation of the underlying stimulus may be life-saving.

    Nurses play a key role in the monitoring of patients with autonomic dysreflexia, and they are often the first healthcare personnel to identify the problem. These patients are best managed in the ICU with 24/7 monitoring.

    Autonomic dysreflexia patients are also prone to deep vein thrombosis and pressure sores hence appropriate prophylactic measures should be undertaken.

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    Is There Treatment For Ad

    It is important to know what your baseline blood pressure usually is because it will help you know when you have AD and need to take action. AD will resolve if you follow the steps above to find the source of the problem and fix it. However, AD can occur without any obvious or easily treated cause and you may need to be hospitalized to manage your blood pressure while doctors search for the cause of the AD. Once you have identified the cause of an AD episode, you might need to make some changes in the way you do things to prevent future episodes.

    What Causes Autonomic Dysreflexia

    The autonomic nervous system is responsible for regulating involuntary body functions such as blood pressure, breathing, body temperature regulation, and digestion. When an individual has autonomic dysreflexia, sudden changes in autonomic nervous system functions can be triggered.

    Autonomic dysreflexia may occur following a spinal cord injury because the transmission of messages between the brain, spinal cord, peripheral nerves, and muscles is disrupted. As a result, potentially damaging stimulation below the level of injury can set off a reflex that activates the sympathetic portion of the autonomic nervous system, causing the blood vessels to constrict, which results in a spike in blood pressure.

    During an episode of autonomic dysreflexia, the opposing portion of the autonomic nervous system, called the parasympathetic nervous system, is unable to appropriately counter this sympathetic reflex.

    Usually, the brain sends messages throughout the body to inform you of what the noxious stimulus is so that you can remove it. For example, if you touch a hot object, your brain will immediately send signals to move away from it. When the stimulus is removed, the sympathetic nervous systems fight or flight response is no longer needed, thus the brain sends signals to relax the blood vessels and reduce blood pressure.

    Now that you understand why autonomic dysreflexia occurs after spinal cord injury, lets discuss who is at risk of developing it.

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    Treatments For Autonomic Dysreflexia

    Medications for Autonomic Dysreflexia usually consist of antihypertensive drugs for a short duration and rapid onset of symptoms.

    • Nitro paste- For topical application. ½ for patients 13 years old and below and 1 for 14 and above, to be applied every 30 minutes. Wash off the paste if blood pressure is back to normal to avoid hypotension.
    • Nifedipine- is given sublingually if the nitro paste is unavailable. It may be administered every 30 minutes if needed. Give 0.25-0.5 mg/kg for patients 13 years old and below and 10mg per dose for 14 yrs old and above.
    • Antihypertensives are given through IV. It is usually done in a closed control setting like the ICU since it requires constant monitoring
    • Alternative medications used to treat autonomic dysreflexia included: Terazosin, Sildenafil, Captopril, and nitrates.

    If A Patient Has An Episode Of Autonomic Dysreflexia:

    What is Autonomic Dysreflexia?
  • Loosen or remove any tight clothing
  • Monitor BP every 2-5 minutes
  • Check bowel and bladder
  • Insert indwelling catheter if not already in place/ rectal examination
    • If systolic BP > 150mmHg instigate immediate pharmacological management:
    • 10 mg Nifedipine sublingual or chewed or GTN spray 1-2 sprays, repeat every 20-30 min if needed
    • An individual with a spinal cord injury above T6 typically has a normal systolic Blood Pressure in the 90-110mmHg range. Therefore, a BP of 20-40mmHg above baseline may be a sign of Autonomic Dysreflexia .
    • Remind patients and their carers about prevention and management of Autonomic Dysreflexia and encourage patient to carry Nifedipine/GTN.

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    Autonomic Dysreflexia And Pregnancy

    The epidemiological study of Lee et al56showed that more than 50% of SCI in women are at or above T6. Moreover, many of them are young and able to get pregnant. Whereas the occurrence, causes, and symptomatology of AD are similar in men and women, the pregnancy represents the unique situation, requiring a different approach and special attention.4043The most common complications of pregnancy in tetraplegic/paraplegic women with high-level thoracic SCI are urinary tract infections and constipation accompanied with fecal bowel impaction. In the third trimester of gestation, problems with respiration, increased spasticity, preeclampsia, as well as preterm labor and delivery usually between the 32nd and 37th week of gravidity may occur.404344The preeclampsia characterized by the triad of hypertension, proteinuria, and edemas57might represent a very serious condition when associated with AD.

    If You Are Experiencing An Episode Of Autonomic Dysreflexia

    If you experience an episode of AD, you need to figure out the cause and fix it.

    First, you should get into the sitting position or elevate you head as much as possible. This will help to drop your blood pressure. Since bladder issues are the most common cause of AD, you or a caregiver should check your bladder. If you manage your bladder through intermittent catheterization, you or your caregiver should catheterize your bladder. If you have an indwelling catheter, check for kinks or blockage, and make sure your drainage bag is not too full. Irrigate your catheter to clear any blockage.

    Next, check for bowel issues. You or your caregiver should perform digital stimulation to empty your bowel. Loosen any tight or restrictive clothing, such as belts or abdominal binder, untie shoes, and if you wear support hose, remove them. Check your bed or wheelchair to make sure you are not sitting on anything that may be causing pressure.

    If your symptoms persist, or if your systolic blood pressure goes above 150 and stays there after you have checked all the above causes, you may need to use medications prescribed by your doctor to decrease your blood pressure. These medications should only be used as prescribed by your physician.

    You also should seek emergency medical treatment if you are unable to get your symptoms to resolve.

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