Amy J. Olson RN BSN
Alverno Graduate Student
amyjo@wi.rr.com
Solving the Puzzle of Autonomic Dysreflexia
Objectives of this Tutorial:
• Learner
will be able to explain the
pathophysiology of autonomic dysreflexia (AD)
and the alteration to the generalized stress
response.
• Learner will identify signs and symptoms of AD.
• Learner will be able to list the common causes
of AD.
Objectives continued:
• Learner
will be able to explain how aging,
inflammation, and genetics alter the AD
presentation and process.
• Learner will identify nursing outcomes that are
influenced by properly managing and
preventing AD.
(Microsoft office clip art, 2007)
Navigation through the Tutorial:
Use this button in the upper right corner to access the menu:
Use this button in the lower right corner to go back a page:
(Microsoft Office Clip Art, 2007)
Use this button in the lower right corner to go forward a page:
Use this button in the upper left corner to go back to the very
last slide you viewed:
Click on any underlined words to receive a definition, answer, or to be
taken to another slide for more information.
Menu
Click on the topic to go directly to that page within the tutorial:
Anatomy
Causes
Aging
Patho
Nursing
Interventions
Genetics
Epidemiology
Nursing
Outcomes
Inflammation
Altered
Stress
Response
Signs &
Symptoms
Case Study
References
Review of the Anatomy of the Nervous
System:
Brain
Central Nervous
System (CNS)
Spinal Cord
Nervous System
Peripheral
Nervous system
(PNS)
(Porth & Matfin, 2009)
(Microsoft Office Clip Art,
2007)
Nerves to and
from the CNS
Anatomy of the Peripheral Nervous
System (PNS)
Click on the question for the answer:
• Sympathetic
Autonomic
Nervous System
Somatic Nervous
System
• Parasympathetic
• Allows for voluntary
movement of muscles
within the body
• Receives sensory input
(i.e. the 5 senses)
(Porth & Matfin,
2009)
Which system is
responsible for
Autonomic
Dysreflexia?
The Normal
Sympathetic/Parasympathetic Responses:
Sympathetic
(AKA Fight or
Flight)
Turned on in
response to a
SIGNIFICANT
Stressor
Release of
Epinephrine
and Norepi
BP, HR,
dilated pupils,
diaphoresis,
goosebumps,
vasoconstriction
of blood vessels
Negative feedback
loop
Para-
Sympathetic
(AKA The
relaxing and
digesting mode)
Opposite
response to the
Sympathetic
system
(Lewis et al, 2000, p. 1591)
Increase in
acetylcholine
Vasodilation,
BP, HR,
constricted
pupils,
peristalsis,
What is Autonomic Dysreflexia (AD)?
• An
amplified sympathetic response from a
stimulus (pain, irritant, etc.) that cannot be
resolved by the parasympathetic system due to
a blockage in the spinal cord from an injury
above or at the level of T6.
(Travers, 2009)
(Microsoft Office Clip Art, 2007)
Spinal Anatomy Review:
Click the corresponding
arrow on the diagram
where autonomic
dysreflexia can occur if
the injury is on or above
this level?
Yes anything
T6 and above!
Yes T6 and
above!
Exactly! T6 or
above!
No review this
slide
No review this
slide
No review this
slide
Chart reproduced with permission from the site owner of www.spinalinjury.net
Image available at: http://www.spinalinjury.net/html/_spinal_cord_101.html
Mr. Z
• Mr.
Z is your patient today!
• He is a 65 year old male who is a C3/C4 vent
dependent quadriplegic from a car accident 37
years prior.
• He has been in your ICU for the past week due
to urosepsis (from Gram negative E-coli).
• Is his spinal injury high enough to get
Autonomic dysreflexia?
Yes
Right, T6 and
above!
No
Are you sure?
Go back to this
slide!
Mr. Z continued….
• By
the middle of your shift, Mr. Z’s blood
pressure was 158/110 as read from his left arm
cuff. You begin to suspect he is experiencing
AD. How does AD occur?
Click here to find out!
Pathophysiology of Autonomic Dysreflexia
Stimulus below the
spinal cord injury (pain,
irritation, etc.)
Nerves fire and signals are
sent up the spinal cord
Signals are blocked in the
spinal cord by the level of
injury and flow out the
“sphlanchnic outflow”
(Travers, 2009 )
What part of the PNS will be activated in response to
the accumulation of these blocked nerve firings?
Click on correct answer:
Sympathetic
CORRECT!
ParaSympathetic
No! This is
activated
later!
Patho of Autonomic Dysreflexia continued:
Severe
vasoconstriction of
blood vessels below
the level of injury!
Sympathetic
nervous system is
activated
Bradycardia from
the parasympathetic
system activating
the vagus nerve
(Porth & Matfin, 2009,
p. 1293).
Microsoft clip art 2007
Parasympathetic
system activates
from baroreceptors
sensing high BP!
Blood pressure rises
AD: The Altered Stress Response
• In
a person with an intact spinal cord: the
sympathetic nervous system activates, BP rises,
and then the parasympathetic system kicks in
and stops the SNS through vasodilation of all
vessels.
• In Mr. Z, the parasympathetic system is blocked
at the injury!
(Microsoft Office Clip Art, 2007)
What does this mean?
• Above
Mr. Z’s injury there will be
Parasympathetic activation: Vasodilation
• Below the injury you will continue to see
Sympathetic activation: Severe constriction of
blood vessels which will cause the BP to
continue to climb until AD is rectified!
(Microsoft Office Clip Art, 2007)
AD at a glance:
What will happen to all the blood
vessels BELOW Mr. Z’s injury?
Click on the correct answer:
Vasoconstriction
Exactly!
Image reprinted with permission from eMedicine.com, 2011. Available at
http://emedicine.medscape.com/article/322809-overview
Vasodilation
No, review
the patho
again
Putting AD together:
• Stimulus
below the injury
• Nerve signals from that stimulus are sent
• Signals blocked at injury point
• Sympathetic nervous system activated Hypertension
• Parasympathetic nervous system is activated
but can only reach to the level of injury.
Click box when you are ready for the answer :
What will happen to Mr. Z’s heart rate?
(Porth & Matfin,
2009, p. 1293)
AD’s influence on the
• Bradycardia
• Significant
BP
Atrial Distention:
SNS
activation
(Porth & Matfin,
2009)
Atrial
Distention
and release
of Atrial
Natriuretic
Peptides
(Microsoft Office Clip Art, 2007)
Mr. Z
• Upon
closer assessment, you observe Mr. Z’s
face is quite flushed and warm to the touch.
• You
suspect Mr. Z :
Is probably Febrile
No, reread this
slide
Has significant
vasodilation of the
vessels leading to
his face
Absolutely! This is
due to the
Parasympathetic
activation
Used with permission from Olson Family Photograph Collection (Olson,
2011)
Signs and Symptoms:
• Besides
bradycardia, hypertension, and a
flushed face; what else might Mr. Z have?
*Click on each sign/symptom for more information*
headache
Goose
bumps
sweating
Blotchy
skin
Feeling of
doom
nasal
congestion
Cool
peripheral
extremities
Pupils
constrict
(Porth & Matfin, 2009, pg. 1293)
Blurred
vision
What do you do now?
• You
have assessed Mr. Z’s signs and symptoms
and determined he is dysreflexic. What should
you do next?
Place his bed in
trendelenberg
position?
No! This would
further increase
his BP! Mr. Z
could stroke!!!
Call the
Resident to
assess him?
No, while you
are calling, Mr.
Z’s BP is
climbing!
Place his head
of bed up 90
degrees?
Absolutely!
Take advantage
of a Quad’s
orthostatic
hypotension!
Check his
bladder for
fullness or
place a foley?
No, you will do
this but first
intervene in his
BP!
1st Nursing interventions for AD:
• Head
of bed up to 90 degrees in order to take
advantage of a quad’s orthostatic hypotension.
• Lower the end of the bed (Reverse
Trendelenberg) in order to have feet in a
dependent position.
• Remove or loosen any abdominal binders, ted
hose, SCD’s, and foley leg straps.
(Travers, 2009)
(Microsoft Office Clip Art, 2007)
Second Step:
• After
Mr. Z has been completely upright for 2-3
minutes, you retake his BP (151/102). You
know his baseline is typically 100’s/60’s.
• A good rule of thumb for AD is if your patient’s
BP is twice their usual baseline – you would get
the MD Stat in order to administer a rapid
vasodilator.
(Travers, 2009)
(Microsoft Office Clip Art, 2007)
In Mr. Z’s Case:
• His
BP is elevated (but not dangerously high
YET, so you can now work to find the cause).
• What is the first place you should look?
Check the linen
for a large
wrinkle?
No, this has been
known to cause
AD, but rule out
the #1 cause
first!
(Porth & Matfin,
2009)
Check for a
developing
pressure sore?
No, this has been
known to cause
AD, but rule out
the #1 cause
first!
Check his bladder
for distension?
Absolutely! This
is the #1 most
occurring cause
for AD!!!!
The 3 Common Causes of AD:
#3 Skin
impairment
#2 Full
Bowel
#1 Full Bladder
(Travers, 2009)
*Rule out each cause by
working from the bottom
up! Start with the most
common cause first!
Less Common Causes of AD:
• Pregnancy/uterine
contractions
• Procedural/post surgical pain or inflammation
(*Anesthesia should be considered for major
procedures/surgeries despite altered
sensations from the paralysis)
• Fractures
• Bladder stones
• Cystitis
(Louis Calder Memorial Library of the University of Miami/Jackson Memorial Medical
Center, 2009)
(Microsoft Office Clip Art, 2007)
Urinary Management/Bladder
Assessment in AD:
*If the patient does not have an indwelling
catheter – insert one (use 2% lidocaine
lubricant into the urethra)
*If a catheter is already in place, assess for kinks
and patency of the catheter
(if patency is questionable place a new
foley).
(Travers, 2009)
(Microsoft Clip Art, 2007)
Back to Mr. Z…..
• You
have assessed Mr. Z’s bladder for
distension: he has a 22 Fr. Supra Pubic
indwelling foley catheter that you assessed for
patency, kinks in the tubing, or a dislodgement
of the catheter. His urinary drainage system is
patent and intact. Now what should you do?
Turn Mr. Z and
assess for a skin
impairment?
No, remember
to assess from
the bottom –
up! Review this
slide
Consult chart
for last bowel
movement
while
hospitalized?
Absolutely, a full
bowel is the #2
cause of AD!
Lower head of
bed and see if
his BP has
normalized?
No! You haven’t
found the cause
yet, and this
could cause Mr.
Z to stroke!!!!!
Mr. Z’s Chart
• Upon
reviewing Mr. Z’s chart – he has not had
his bowel program done for the entire time he
has been hospitalized (8 days).
• You recheck Mr. Z’s BP (160/109). What is your
next step?
Administer Mr.
Z’s prn oral
laxative?
No, his BP will
continue to
climb while the
laxative is
absorbed! Mr.
Z could have a
stroke!
Call the MD for
a stool softener
order?
No, his BP will
continue to
climb while the
stool softener is
absorbed! Mr.
Z could have a
stroke!
Turn Mr. Z to
his side and
attempt to
remove any
stool present?
Yes! This is the
only option
that will
attempt to
remove the AD
stimulus!
Bowel Assessment/Management in AD:
• Don
gloves and use a lubricant (2% lidocaine
gel).
• Turn patient to their left side and check for
stool.
• No stool present?
**MONITOR PATIENTS BP DURING
THE WHOLE PROCEDURE!
(Agency for Healthcare Research & Quality- U.S. Department of Health & Human Services, 2001)
(Microsoft Office Clip Art, 2007)
Mr. Z’s Bowel Assessment:
• Upon
examination – you find no stool present
in the rectum, but a small amount of brown
liquid pours out during assessment.
• You stop digital stimulation and recheck Mr. Z’s
BP (210/121).
(Microsoft Office Clip Art, 2007)
What is the next intervention?
• You
call Mr. Z’s doctor who promptly orders a
medication STAT! Based on the
pathophysiology of AD and the quick half-life of
the medication needed, what medication
should the doctor order?
Nifedipine
Yes! This is
available in
sublingual form
which allows for
quick absorption
Metoprolol
No! This is an antihypertensive
(Beta-Blocker), but
it is not as fast
acting as
sublingual
Nifedipine
Timolol
No! This is an antihypertensive
(Beta-Blocker), but
it is not as fast
acting as
sublingual
Nifedipine
(Deglin & Vallerand, 1999)
(Microsoft Office Clip Art, 2007)
Other Medications used for AD:
• Sodium
Nitroprusside
• Isosorbide dinitrate
• Nitroglycerin ointment
• Hydralazine
• Mecamylamine
• Diazoxide
• Phenoxybenzamine
• Captopril
• Prazosin
(Agency for Healthcare Research & Quality – U.S. Department of Health & Human
Services, 2001)
(Microsoft Office Clip
Art, 2007)
Special Considerations:
• If
your patient has a stimulus of AD that is not
able to be resolved quickly (i.e. surgical
incision, pressure sore, bone fracture), he may
need a low-dose anti-hypertensive daily for a
few weeks.
• Anti-hypertensive medication may result in
rebound hypotension (esp. orthostatic
hypotension).
(Microsoft Office Clip Art, 2007)
What happens to Mr. Z?
• Due
to your AMAZING nursing care, you are
able to get Mr. Z a sublingual nifedipine right
away - (preventing a stroke, seizure, or even
death)!
• Mr. Z’s BP decreases from the nifedipine and
the surgery team is called. He is found to have
an impaction that requires surgery!
(Microsoft Office, Clip Art, 2007)
Epidemiology of AD
• 250,000-300,000
Spinal Cord Injured patients
in America
• 42% are Quadriplegic
• 12,000 new spinal injuries per year
• 1/3 – 1/2 of all SCI patients are re-admitted to
the hospital each year!
Will you take care of a high SCI injury who could have
AD?
(National SCI Statistical Center, 2010)
Inflammation’s Role in AD:
• Any
Pressure Sore below the level of injury
could cause AD:
Tissue Damage
from
Circulation
Prostaglandins
and
leukotrienes
released
Permeability
of vascular
tissue
(Porth & Matfin,
2009)
Pain signals
sent up the
spinal cord!
(Microsoft Office Clip Art, 2007)
What will happen
to these pain
signals?
Patho?
Fluid pools
into
surrounding
tissue
AD from a Pressure Sore:
Your patient has a stage III
pressure sore what might you
need ordered in order to prevent
AD symptoms?
(Microsoft Office Clip Art, 2007)
Nifedipine
No! This is
short acting.
Review this
slide!
Low dose antihypertensive
Yes! A
pressure sore
will take days
to heal!
Aging and AD
• SCI
Patients are living longer than ever with
advances in medical technology.
• HIGH risk for Atrial Fibrillation during
AD!
Stiffer Vasculature
with Age
(Microsoft Office Clip Art, 2007)
Bradycardia
during AD
Atrial
Fibrillation
Risk Factors
Change in Cardiac
tone
(Pine et al, 1991)
Atrial Distension
Considerations for Elderly AD Candidates:
• Give
Why?
Nifedipine CAUTIOUSLY!
• At an increase Rx for developing the top 3
causes of AD:
Thinner Skin with
Age
Decreased Bowel
Motility
(Porth & Matfin,
2009)
Decrease in Bladder
Size
Genetics & AD
• After
a spinal injury there is significant growth
of Calcitonin Gene-related Peptideimmunoreactive (CGRP+) within the spinal
cord. (This growth perpetuates AD)
• An exciting study,(Cameron, 2006), was done
on rats that involved manipulation of
the genes!
The Study?
(Cameron et al, 2006)
What does this mean for AD in SCI patients
in the future?
(Microsoft Office Clip Art, 2007)
Nursing Outcomes
• Through
prompt identification and
management of AD, nurses will prevent
adverse patient outcomes! Prevention of the
following:
Death
Stroke
Seizure
Loss of
hearing
Heart
failure
Kidney
failure
Nurses are key in prevention of
further loss of functioning!
(Microsoft Office Clip Art, 2007)
Loss of
Vision
Educate Educate Educate!
• Important
(Microsoft Office Clip
Nursing Outcome!
Art, 2007)
Decrease Patient and family Knowledge Deficit
Regarding AD! What about AD would you have
wanted to teach to Mr. Z and his family?
Click on all the answers that are right!
Signs and
Symptoms of
AD!
Absolutely! He
has been a quad
for a while – but
this could save
his life!
Importance of
adhering to
Bowel Program!
Absolutely! A
full bowel is the
#2 cause of AD!
Mr. Z’s risk for
developing
Atrial Fibrillation
with AD?
Absolutely! He
is 65 years old
and is at risk!
What is the Necessary Missing Piece of
the Puzzle of Autonomic Dysreflexia?
Click on the puzzle piece for the answer!
Prompt identification
and intervention by ALL
Nurses!
References
•
•
•
•
Agency for Healthcare Research & Quality - U.S. Department of
Health & Human Services. (Eds.). (2001, July 29). Acute management
of autonomic dysreflexia: Individuals with spinal cord injury
presenting to health-care facilities. Retrieved February 2, 2011, from
AHRQ: Agency for Healthcare Research & Quality Web site:
http:/​/​www.guideline.gov/​content.aspx?id=2964
Cameron, A. A., Smith, G. M., Randall, D. C., Brown, D. R., &
Rabchevsky, A. G. (2006). Genetic manipulation of intraspinal
plasticity after spinal cord injury alters the severity of autonomic
dysreflexia. The Journal of Neuroscience, 26(11), 2923-2932.
Deglin, J. H., & Vallerand, A. H. (1999). Davis's Drug Guide for Nurses
(6th ed.). Philadelphia: F.A. Davis Company.
eMedicine.com. (Ed.). (2009, July 2). AD Image. Retrieved February 1,
2011, from eMedicine.com Web site:
http:/​/​emedicine.medscape.com/​article/​322809-overview
•
•
•
•
Lewis, S. M., Heitkemper, M. M., & Dirksen, S. R. (2000). Medical
Surgical Nursing: Assessment and Management of Clinical Problems
(5th ed., Vol. 2). St. Louis, MO: Mosby.
Lin, V. W., Cardenas, D. D., & Cutter N.C. (2003). Spinal Cord Medicine:
Principles & Practice. New York: Medical Publishing.
Louis Calder Memorial Library of the University of Miami/​Jackson
Memorial Medical Center. (2009). Other Complications of Spinal Cord
Injury: Autonomic Dysreflexia (Hyperreflexia): Symptoms and
Causes. Retrieved January 27, 2011, from Rehab Team Site Web site:
http:/​/​calder.med.miami.edu/​pointis/​symptoms.html
National SCI Statistical Center. (2010, February). Spinal cord injury
facts and figures at a glance. Retrieved February 15, 2011, from
National Spinal Cord Injury Statistical Center Web site:
https:/​/​www.nscisc.uab.edu/​
•
•
•
•
Olson A. (2011). Olson Family Picture [Photograph]. Retrieved from
Olson Family Photograph Collection. Used with Permission
Pine, Z. M., Miller, S. D., & Alonso, J. A. (1991). Atrial fibrillation
associated with autonomic dysreflexia. American Journal of Physical
Medicine & Rehabilitation, 70(5), 271-273.
Porth, C. M., & Matfin, G. (2009). Pathophysiology: Concepts of
Altered Health States (8th ed.). Philadelphia: Wolters Kluwer
Health/​Lippincott Williams & Wilkins.
Schuijt, G. B. C., & Menarini, R. P. M. (2007). Bowel dysfunction in
spinal cord injury patients: Pathophysiology and management.
Pelviperineology: a Multidisciplinary Pelvic Floor Journal, 26(2).
Retrieved January 7, 2011, from Pelviperineology Web site:
http:/​/​www.pelviperineology.org/​practicalboweldysfunction_in_spinal_cord_injury.html
•
•
•
•
Spinal Cord Injury Information Pages Associates. (2009, March 23).
Autonomic Dysreflexia. Retrieved January 29, 2011, from Spinal Cord
Injury Information Pages Web site: http:/​/​www.sci-infopages.com/​ad.html
Travers, P. L. (2009). Autonomic dysreflexia: A clinical rehabilitation
problem. Retrieved January 26, 2011, from
http:/​/​www.neuroanatomy.wisc.edu/​selflearn/​AutonDys.htm
Weaver, L. C. (2002). What causes autonomic dysreflexia after spinal
cord injury? Clinical Autonomic Research, 12(6), 424-426.
www.spinalinjury.net. (n.d.). Anatomy Chart. Retrieved January 31,
2011, Used with Permission www.spinalinjury.net Web site:
http:/​/​www.spinalinjury.net/​html/
​_spinal_cord_101.html