Autonomic Dysreflexia

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a guide for nurses

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  • Patients most at risk of AD are those with SCI above T6 who have passed through the acute stage of spinal cord injury (spinal shock). This is a medical emergency and must be treated with prompt action. High blood pressure can lead to heart arrythmias and stroke. Repeated episodes of AD can cause long term organ and vascular damage.
  • this will help to reduce the blood pressure to the head and upper body. Patient must remain sitting up with head of bed elevated to 90 degrees until crisis has passed
  • This will allow pooling of blood in lower extremities to reduce blood pressure. It may also be the source of the crisis. Remove shoes, loosen braces, remove elastic anti-embolism stockings, and inspect for any other sources of pain related to clothing or devices.
  • Attach intermittent BP device and check BP every 5 minutes or more as needed. This will allow you to identify whether or not you have identified the problem. Example, if you cath the patient and that results in an immediate drop in BP then the source has been identified, Otherwise continue to investigate the cause of the crisis. If you have a cardiac patient, apply 6 lead EKG at this time. Some protocols indicate that a systolic BP above 150Hgmm requires pharmaceutical intervention.
  • If the patient has a foley catheter, check for any kinks or obstructions in the tubing. If foley is not draining replace it. Call a doctor if there is any difficulty replacing the foley. If the patient does intermittent cathing, cath the patient to empty the bladder. Apply lidocaine jelly to the urethra 2 minutes prior to cathing to avoid further painful stimuli. If there is a doubt about the bladder being empty, use a bladder scanner. Observe patient's urine. An odor or discoloration may point to bladder infection or kidney problems. Collect sample for analysis.
  • Impacted bowels can often lead to a crisis. Apply lidocaine 2 minutes prior to digital deimpactation. While the patient is in the lateral position, check patient's sacral area and buttocks for pressure ulcers or other causes of pain. Inspect area under patient to make sure they were not lying on any object such as an IV cap. A digical rectal exam may exacerbate the crisis! If blood pressure rises during the examination, stop, instill more lidocaine, and call the doctor.
  • Check for any other sources of pain. Start at the feet and work up. Inspect for ingrown toenails, bites, scratches or other minor wounds. Check for pressure ulcers under the heels. Make sure socks and pants are not tight. Loosen leg braces and pants. Make sure the leg openings of underwear are not constricting the upper thighs. Check to see if female patient has vaginal bleeding or discharge. Check male patients to see if they are lying on the scrotum. Check for discharge or swelling. Make sure patient is not too hot or too cold. Check temperature to detect a possible infection
  • Several situations a patient faces during surgery or outpatient procedures puts them at risk for AD. - Hypothermia: Use warming blankets to prevent hypothermia Use warmed IV fluids. - Positioning: Even if the patient does not feel awkward positioning, their ANS may detect muscle stretching and awkward positions that restrict circulation. - Procedures that puncture and cause pain below the SCI such as an angiogram may cause ADS.
  • The spinal cord patient must be educated on how to stop an AD crisis, and how to guide family and caregivers. They should have an AD kit prepared that has a cath set, lidocaine, prescribed medications, and step by step instructions. If the person or caregivers are not able to perform a cath procedure, the patient should call 911.
  • Autonomic Dysreflexia

    1. 1. Autonomic Dysreflexia A guide to acute nursing care prevention, and education
    2. 2. Objectives After this presentation you should be able to: <ul><li>Understand what AD is
    3. 3. Know how to manage acute AD crisis
    4. 4. Know some ways to prevent AD
    5. 5. Effectively educate patients on the management and prevention of AD </li></ul>
    6. 6. What is Autonomic Dysreflexia? <ul><li>An abnormal response to painful stimuli below the level of Spinal Cord Injury (SCI) </li></ul><ul><li>Mediated by the Autonomic Nervous System (ANS) </li></ul><ul><li>SCI above T6 </li></ul><ul><li>Causes dangerous high blood pressure </li></ul><ul><li>Emergency! </li></ul>
    7. 7. Pathopysiology http://emedicine.medscape.com/article/322809-overview
    8. 8. Pathophysiology <ul><li>Painful/noxious stimuli occurs below SCI </li></ul><ul><li>Signal is blocked at site of SCI so patient is not aware of pain and cannot correct it </li></ul><ul><li>Autonomic Nervous Stystem responds: </li></ul>(ANS) ---> vasoconstriction below SCI. Sudden rise in blood pressure.
    9. 9. Pathophysiology ANS detects high BP above SCI and attempts to correct it: <ul><li>Bradycardia (vagal nerve)
    10. 10. Vasodilation in head and chest to absorb increased blood flow to upper body </li></ul><ul><li>Negative feedback loop is interrupted by the SCI. </li></ul>Cycle continues until stimulus is removed
    11. 11. Causes #1 cause is a full bladder #2 cause is a full bowel
    12. 12. Causes <ul><li>bladder or kidney infection
    13. 13. gastric ulcers, gallstones, other GI disturbances
    14. 14. tight clothing, leg braces, shoes
    15. 15. patient lying or sitting on hard object
    16. 16. pressure ulcer
    17. 17. ingrown toenail
    18. 18. insect bites and other minor injuries
    19. 19. DVT </li></ul>
    20. 20. Causes <ul><li>sexual activity
    21. 21. menstruation
    22. 22. pregnancy
    23. 23. vaginal infections
    24. 24. extreme temperatures
    25. 25. rapid changes in temperature
    26. 26. positioning problem, lack of circulation to limb
    27. 27. drug stimulants </li></ul>
    28. 28. Signs and Symptoms Systemic <ul><li>Rapid rise in systolic and diastolic blood pressure 20-40 mmHg above patient's baseline.
    29. 29. Bradycardia
    30. 30. Cardiac arrhythmias, A-fib, PVC, AV conduction abnormalities </li></ul>
    31. 31. Observable Signs Above SCI site <ul><li>Profuse diaphoresis
    32. 32. Piloerection
    33. 33. Flusing of skin, especially face, neck, shoulders </li></ul>
    34. 34. Symptoms Patient reports: <ul><li>severe headache
    35. 35. blurred vision
    36. 36. spots in visual fields
    37. 37. nasal congestion
    38. 38. anxiety, sense of impending doom </li></ul>* slient AD does not have symptoms despite signficant elevation in BP
    39. 39. Acute Care Nursing Plan Goals Locate and remove stimuli Lower blood pressure Administer prescribed meds Notify doctor
    40. 40. Step-by-Step Care 1. Sit the patient up
    41. 41. Step-by-Step Care 2. Loosen restrictive clothing
    42. 42. Step-by-Step Care 3. Closely monitor BP
    43. 43. Step-by-Step Care 4. Check the Bladder
    44. 44. Step-by-Step Care 5. Check the bowels
    45. 45. Step-by-Step Care 6. Check for other noxious stimuli <ul><li>toes up </li></ul>
    46. 46. “The Four B's” B ed Up B ladder B owels B ody
    47. 47. Medication Systolic BP > 150mmHg <ul><li>Procardia (nefidipine) </li><ul><li>immediate release tablets, bite and swallow </li></ul><li>Nitrates </li><ul><li>nitroglycerin paste </li></ul><li>Others: mecamylamine, diazoxide, and phenoxybenzamine. </li></ul>
    48. 48. If Unresolved If noxious stimuli not identified and crisis unable to be resolved, <ul><li>In-patient: call doctor
    49. 49. Home Health: consider admitting
    50. 50. Teach patient: call 911 or go to ED </li></ul>
    51. 51. Prevention Prevention is the key to preventing an autonomic crisis! <ul><li>Regular bladder and bowel care
    52. 52. Prevent pressure ulcers
    53. 53. Inspect patient bed often for foreign objects
    54. 54. Check records for past crisis and causes
    55. 55. Avoid tight fitting clothes, changes in temp. </li></ul>
    56. 56. Surgical/Outpatient Testing Prevent Autonomic Dysreflexia <ul><li>hypothermia
    57. 57. positioning
    58. 58. vein/artery access procedures </li></ul>Continuously monitor BP for signs of AD!
    59. 59. Patient Teaching <ul><li>AD kit
    60. 60. cath/bowel care
    61. 61. educate family
    62. 62. card with plan of care
    63. 63. medical bracelet </li></ul>
    64. 64. References Paralyzed Veterans of America/Consortium for Spinal Cord Medicine. Acute management of autonomic dysreflexia: individuals with spinal cord injury presenting to health-care facilities. Washington (DC): Paralyzed Veterans of America (PVA); 2001 Jul. 29 p. Autonomic Dysreflexia in Spinal Cord Injury: Treatment & Medication Author: Denise I Campagnolo, MD, MS, Director of Multiple Sclerosis Clinical Research and Staff Physiatrist, Barrow Neurology Clinics, St Joseph's Hospital and Medical Center; Investigator for Barrow Neurology Clinics; Director, NARCOMS Project for Consortium of MS Centers Glynis Collis Pellat, British Journal of Neuroscience Nursing, Aug/Sept 2010, Vol 6, Number 6, PP 271-275 Autonomic Dysreflexia: What You Should Know, Consortium for Spinal Cord Management. www.pva.org

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