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This information, developed by SCI BC, will help people with spinal cord injury to become familiar with Autonomic Dysreflexia and its symptoms and treatments. It is important that you know about the condition and ensure that your health care team and family members also know about it.

We recommend downloading our AD Wallet Card, developed in conjunction with clinicians at GF Strong, to show your health care team, especially during an emergency. You can download the card here, or contact InfoLine and we will mail you some hard copies.

Definition:                        

Autonomic Dysreflexia (AD), also known as Hyperreflexia, is a potentially dangerous complication of SCI. With AD, an individual’s blood pressure may rise to dangerous levels and if not treated can lead to stroke and possibly death. Individuals with SCI at the T6 level or above are at greater risk. AD usually occurs because of a noxious (irritating) stimulus below the level of the injury. Symptoms include headache, facial flush, perspiration, and stuffy nose.

Description:                    

AD occurs primarily because of an imbalance in the body systems which control the blood pressure. The human body is an incredibly complicated and beautifully balanced machine. There are balances to each system of the body, including blood pressure. 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. Imagine a garden hose with water streaming through it; when you put your thumb over the opening of the hose, reducing the opening for the water flow through, the water shoots out at a higher pressure. Similarly, when the blood vessels are smaller, the blood rushes around your body at a higher pressure.

When a noxious stimulus occurs, 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.

Some of the nerves at the T-6 level also control the blood flow to and from the gut, which is a large reservoir of blood. Uncontrolled activity of these nerves may cause the blood from the gut to flow into the rest of the blood system. The result is that blood pressure can increase to dangerous levels and the increase in blood pressure must be controlled by outside means.

Causes:                           

Irritants, things which would ordinarily cause pain, to areas of the body below the level of spinal injury.

Bladder Most common cause, comes from overstretching or irritation of the bladder wall, including:

• Urinary tract infection (UTI)
• Urine retention
• Blocked catheter
• Overfilled collection bag
• Non-compliance with intermittent catheterization program

Bowel

• Over-distention or irritation
• Constipation/ impaction
• Distention during bowel program (digital stimulation)
• Hemorrhoids or anal infections
• Infection or irritation

Skin-related Disorders Any direct irritants below the level of injury

• Pressure by object in shoe or chair, cut, bruise, abrasion
• Pressure sores
• Ingrown toenails
• Sunburn
• Burns from hot water or cooking
• Tight or restrictive clothing or pressure to skin from sitting; can include a fold in the sock or pants, a rock in the shoe, etc.

 Sexual Activity

• Overstimulation during sexual activity
• Stimuli to the pelvic region which would ordinarily be painful if sensation were present
• Menstrual cramps
• Labor and delivery

Other Causes

• Heterotopic ossification (bone growing in soft tissue areas of the body)
• Acute abdominal conditions (gastric ulcer, colitis, peritonitis)
• Skeletal fractures

Symptoms:

• Hypertension (blood pressure greater than 200/100) Pounding headache
• Flushed (reddened) face
• Red blotches on the skin above level of spinal injury
• Sweating above level of spinal jury
• Nasal stuffiness
• Nausea
• Slow pulse, less than 60 beats per minute
• Goose bumps below level of spinal injury
• Cold, clammy skin below level of spinal injury

Treatments:

The first thing to do is locate and remove the offending stimulus whenever possible. This will often prove successful enough to avoid pharmacological intervention. Once the source of irritation has been removed it will be a good idea to have the individual remain in a sitting up position and take frequent blood pressure checks until the episode had ended.

Solutions to common Causes:

Blocked Catheters The most common cause of AD is a catheter that has become blocked. You will want to check the collection bag, irrigate the catheter and remove any kinks.

Bowel If symptoms begin while digital stimulation is being performed, stop until symptoms quit. If the individual has impacted stool begin disimpaction immediately. If digital stimulation continues to bring on the symptoms you may want to consider abdominal massage or commode-based bowel evacuation methods.

Skin Skin irritation, also a common cause of AD, is most often stopped by loosening the clothing. You will want to check for pressure sores and toenail problems.

Prevention: 

It is important to be constantly aware of the possibility of Autonomic Dysreflexia and do everything possible to avoid it.

• Frequent pressure relief in bed/chair
• Avoidance of sun burn/scald (avoid over exposure, use of minimum 15 SPF sunscreen, watch water temperatures)
• Faithful adherence to bowel program
• Keep catheters clean and remain faithful to catheterization schedule
• Well balances diet and adequate fluid intake
• Compliance with medications