SA had just got in the door at Stoke Mandeville when his education began on Autonomic Dysreflexia (AD), also known as Hyperreflexia. This is a potentially dangerous complication of spinal cord injury (SCI) so it really is something anyone with an SCI and their loved ones need to know about from day one. I had absolutely no idea such a thing existed and surprisingly, we have found care providers/authorities who are not familiar with it. Either that or they fail to give it the significance it deserves.
Sorry to be dramatic but in AD, an individual’s blood pressure may rise to dangerous level, it can be life-threatening and can be considered a medical emergency because if not treated can lead to stroke and possibly death – eek. AD usually occurs because of irritants, things which would ordinarily cause pain, to areas of body below the level of spinal injury. Put extremely simply, this means anywhere in the area where said person is paralysed. It’s basically the nervous system going crazy. Individuals that have a T-5, or higher, injury are the ones generally subject to suffering from AD.
One of the major ways the body controls blood pressure is by tightening or relaxing little muscles around the blood vessels. When the muscles contract, the blood vessels get smaller and blood pressure increases. Like a garden hose with water streaming through it; when you put your thumb over the opening of the hose, reducing the opening, the water shoots out at a higher pressure. Similarly, when the blood vessels are smaller, the blood rushes around your body at higher pressure. When a noxious stimulus occurs , i.e. an irritant that might normally cause pain, a reflex is initiated that causes the blood vessels to constrict and raises the blood pressure. In an intact spinal cord, this same stimulus also sets in motion another set of reflexes that moderates the constriction of blood vessels. However, in someone who has SCI at the T-6 level or above, the signal which tells the blood vessels to relax cannot get through the spinal cord because of the injury. So this imbalance raises the blood pressure without the body having the ability to bring it back down to a safer level.
Indicators for the onset of AD are:
- Pounding headache (this is the one SA gets first)
- Flushed (reddened) face
- Red blotches on the skin above level of spinal injury
- Profuse sweating above level of spinal injury
- Chills without fever
- Nasal stuffiness
- Blurred vision
- Slow pulse <60 beats per minute (Bradycardia)
- Goose bumps below level of spinal injury
- Cold, clammy skin below level of spinal injury
The sort of things that can precipitate this syndrome are**:
Bladder (most common) – from overstretch or irritation of bladder wall because of:
- Urinary tract infection (UTI)
- Urinary retention
- Blocked catheter
- Overfilled collection bag
- Not catheterising properly or enough
- over-distension or irritation
- Constipation / impaction
- Haemorrhoids or other infections
- Any direct irritant below the level of injury
- Pressure by object in shoe or chair, cut, bruise, abrasion
- Pressure sores (decubitus ulcer)
- Ingrown toenails
- Burns (eg. – sunburn, burns from using hot water)
- Tight or restrictive clothing or pressure to skin from sitting
- Overstimulation during sexual activity
- Stimuli to the pelvic region which would ordinarily be painful if sensation were present
- Menstrual cramps
- Labour and delivery
- Acute abdominal conditions (gastric ulcer, colitis, peritonitis)
- Skeletal fractures
**NB This list is not exhaustive!
Managing an episode of autonomic dysreflexia
I must stress that this information is intended to be for the layperson, i.e. unqualified individual who might be with someone with an SCI when AD occurs. It does not include management processes for those who are involved in carrying out daily care and/or medical treatment. If you are a qualified carer or a nurse and you need me to tell you what to do when AD hits then we’re both in a world of trouble.
The first thing to do is ask your friend/partner etc. if they suspect a cause. Often, locating and removing the offending stimulus can be enough to avoid pharmacological intervention. The most common cause of AD is a catheter that has become inhibited. You will want to check the collection bag to make sure it’s not fit to burst or undo any kinks in the catheter.
Skin irritation, also a common cause of AD, is most often stopped by loosening or adjusting the clothing.
These simple steps can often be enough and if you have successfully removed the source of irritation it will be a good idea to have the individual remain in a sitting up position with their legs lower than their head, until the symptoms pass. Don’t leave them on their own.
If the cause has not been remedied, call an ambulance.
Your friend may be carrying a dose of short acting antihypertensive medication which you may need to help administer at this point until help arrives.
How can autonomic dysreflexia be prevented?
- Frequent pressure relief in bed/chair
- Avoidance of sun burn/scalds (avoid overexposure, use of #15 sunscreen, watch water temperatures)
- Faithful adherence to bowel program
- Keep catheters clean and remain faithful to catheterization schedule
- Well-balanced diet and adequate fluid intake
- Compliance with medications
There is lots more info on AD on the web