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  1. Can-SCIP
  2. Recommendations
  3. Guidelines
  4. Section 2 - MANAGEMENT OF SCI COMPLICATIONS

J - AUTONOMIC DYSREFLEXIA (AD)




Individuals with an SCI at or above T6 may present with the signs and symptoms of autonomic dysreflexia, including:

  1. Elevated systolic blood pressure greater than 20 mmHg above their usual baseline in adults
  2. Sudden-onset headache
  3. Possible bradycardia or tachycardia
  4. Cardiac arrhythmias, atrial fibrillation, premature ventricular contractions, and atrioventricular conduction abnormalities
  5. Profuse sweating and/or flushing of the skin, typically (face, neck, and shoulders) or possibly below the level of the lesion
  6. Piloerection (goosebumps) above or possibly below the level of the lesion
  7. Blurred vision and/or spots in the individual’s visual fields
  8. Nasal congestion
  9. Feelings of apprehension or anxiety
  10. Few or no symptoms other than elevated blood pressure
(Adapted from PVA-AD 2020, p.640; Level C)
Be aware that autonomic dysreflexia may appear with minimal or no symptoms (silent autonomic dysreflexia or those with cognitive/verbal communication limitations) despite a significantly elevated blood pressure. (PVA-AD 2020, p.640; Level C)
Check the individual’s blood pressure. (PVA-AD 2020, p.640; Level C)
If signs or symptoms of autonomic dysreflexia are present, but blood pressure is not elevated, and the cause has not been identified, refer the individual to an appropriate consultant, depending on symptoms. (PVA-AD 2020, p.640; Level C)
If autonomic dysreflexia is diagnosed, identify the trigger(s) in order to manage blood pressure. (PVA-AD 2020, p.640; Level B)
If blood pressure is elevated, immediately sit the individual up and lower the legs, if possible. (PVA-AD 2020, p.640; Level B)
Monitor blood pressure and pulse frequently (every 1 – 2 minutes) until the individual is stabilized. (PVA-AD 2020, p.640; Level B)
Loosen any clothing or constrictive devices. (PVA-AD 2020, p.640; Level B)
Determine whether the individual has recently taken a vasopressor or an antihypotensive agent. (PVA-AD 2020, p.640; Level C)
Quickly survey the individual for other triggers, beginning with the urinary system. (PVA-AD 2020, p.640; Level B)
If an indwelling urinary catheter is not in place, catheterize the individual. (PVA-AD 2020, p.640; Level C)
If the elevated blood pressure is at or above 150 mmHg systolic prior to catheterization, consider rapid-onset and short-duration pharmacological management to reduce the systolic blood pressure without causing hypotension. (PVA-AD 2020, p.640; Level C)
Consider the use of an antihypertensive agent (such as nitropaste, nifedipine, hydralazine, or sublingual clonidine) with rapid onset and short duration. (PVA-AD 2020, p.640; Level C)
Prior to the use of nitropaste or any other agent containing nitrate, first, inquire about whether the individual has recently taken a phosphodiesterase type 5 inhibitor (PDE5i). (PVA-AD 2020, p.640; Level B)
Prior to inserting the catheter, instill lidocaine jelly 2% (if immediately available in the room where the individual is being treated) into the urethra and wait approximately 5 minutes, if possible. (PVA-AD 2020, p.641; Level C)
Avoid applying pressure over the bladder (Credé maneuver) or suprapubic tapping, as this may exacerbate autonomic dysreflexia. (PVA-AD 2020, p.641; Level C)
If the individual has an indwelling or suprapublic urinary catheter, check the system along its entire length for kinks, folds, constrictions, or an overfilled drainage bag and for correct catheter placement. If a problem is found, correct it immediately. (Adapted from PVA-AD 2020, p.641; Level C)
If there are no problems with the tubing, drainage bag, or catheter placement and the blood pressure is still elevated, gently irrigate the bladder with a small amount (10-15 cc) of fluid, such as normal saline at body temperature, to determine whether the catheter is blocked. Irrigation should be limited to 5-10 cc for children under two years of age. Do not continue to irrigate or attempt to flush the bladder if the fluid is not draining from the catheter, as this will only cause increased bladder distention and increase blood pressure. (PVA-AD 2020, p.641; Level C)
If the catheter is blocked, remove and replace it. (PVA-AD 2020, p.641; Level C)
If there is a history of difficulty passing a catheter in a male, consider using a coude´ catheter or consult urology. (PVA-AD 2020, p.641; Level C)
Prior to replacing the catheter, consider instilling lidocaine jelly 2% (if immediately available) into the urethra or suprapubic tract and wait 3-5 minutes, if possible. (PVA-AD 2020, p.641; Level C)
If difficulties arise in removing or replacing the catheter, in addition to instilling lidocaine jelly, consider initiating new or increasing previous pharmacological treatment and an emergency urology consultation. (PVA-AD 2020, p.641; Level C)
Monitor the individual’s blood pressure during bladder drainage. (PVA-AD 2020, p.641; Level C)
If acute symptoms of autonomic dysreflexia persist, including sustained elevated blood pressure, suspect fecal impaction. (PVA-AD 2020, p.641; Level B)
If the elevated blood pressure persists at or above 150 mmHg systolic, strongly consider pharmacological management prior to laying the individual down to check for fecal impaction. (PVA-AD 2020, p.641; Level C)

If fecal impaction is suspected, check the rectum for stool, using the following procedure:

  1. Premedicate with a pharmacological agent.
  2. With a gloved hand, generously instill a topical anesthetic agent, such as lidocaine jelly 2%, into the rectum.
  3. Wait 3-5 minutes, if possible, for sensation in the area to decrease.
  4. Then, with a gloved hand, insert a lubricated finger into the rectum and check for the presence of stool.
  5. If present, gently remove, if possible.
(PVA-AD 2020, p.641; Level B)
If autonomic dysreflexia becomes worse, or stool cannot be removed, stop the manual evacuation, and administer pharmacological or additional pharmacological intervention and additional topical anesthetic. When blood pressure is stable below 150 mmHg, proceed with an aggressive bowel evacuation regimen. (PVA-AD 2020, p.641; Level B)

If there is no fecal impaction or blood pressure elevation persists despite disimpaction, check for other less frequent causes of autonomic dysreflexia. If there are no obvious triggers or if the blood pressure cannot be managed locally, the individual must be referred to the hospital emergency department for evaluation, management and possible hospital admission. (PVA-AD 2020, p.642; Level C)

Triggers

Autonomic dysreflexia has many potential causes. It is essential that the specific cause be identified and treated in order to resolve an episode of autonomic dysreflexia and to prevent recurrence. Any painful or irritating stimuli below the level of injury may cause autonomic dysreflexia. Bladder and bowel problems are the most common causes of autonomic dysreflexia. The following are some of the more common potential autonomic dysreflexia triggers:

Urinary System
  • Bladder distention
  • Bladder or kidney stones
  • Blocked catheter
  • Catheterization
  • Detrusor sphincter dyssynergia
  • Shock wave lithotripsy
  • Urinary tract infection
  • Urological instrumentation, such as cystoscopy or testing requiring catheterization
GI System
  • Appendicitis
  • Bowel distention
  • Bowel impaction
  • Gallstones
  • Gastric ulcers or gastritis
  • GI instrumentation
  • Hemorrhoids
Integumentary System
  • Constrictive clothing, shoes, or appliances
  • Contact with hard or sharp objects
  • Blisters
  • Burns, sunburn, or frostbite
  • Ingrown toenail
  • Insect bites
  • Pressure injuries
Reproductive System
  • Sexual activity, including sexual intercourse
  • Sexually transmitted diseases
  • High sexual arousal and/or orgasmic release
  • A second orgasmic release or ejaculation soon after the first orgasm will likely provoke more severe autonomic dysreflexia
Male
  • Ejaculation
  • Epididymitis
  • High-intensity vibrators used to induce ejaculation
  • Priapism (especially from intracavernosal injection)
  • Prostatitis
  • Scrotal compression (sitting on scrotum)
  • Sperm retrieval (EEJ and vibratory stimulation)
Female
  • Lactation, breastfeeding, mastitis
  • Menstruation
  • Painful intercourse and/or friction
  • Pregnancy, especially labour and delivery, including ectopic pregnancy
  • Vaginitis
Other Causes
  • Boosting (an episode of autonomic dysreflexia intentionally caused by an athlete with SCI in an attempt to enhance physical performance)
  • Deep vein thrombosis
  • Excessive alcohol intake
  • Excessive caffeine or other diuretic intake
  • Fractures or other trauma below the level of injury
  • Functional electrical stimulation
  • Heterotopic bone
  • Over-the-counter or prescribed stimulants
  • Pulmonary emboli
  • Substance abuse
  • Sunburn
  • Syringomyelia
  • Surgical or invasive diagnostic procedures
  • Unguis incarnatus

While the individual is being evaluated in the emergency department, continue to closely monitor blood pressure to guide pharmacological management of autonomic dysreflexia and investigate other causes. Consider hospital admission if:

  1. There is poor response to the treatment specified above.
  2. The cause has not been identified.
(PVA-AD 2020, p.642; Level C)
After successful identification of the trigger and treatment of the elevated blood pressure, monitor the individual for symptomatic hypotension every 2-5 minutes until the blood pressure is stable. (PVA-AD 2020, p.642; Level C)

Following an episode of autonomic dysreflexia, a health care provider should consider the following:

  1. If the individual is an inpatient or in the clinic, monitor closely for at least 2 hours for recurrent autonomic dysreflexia or hypotension.
  2. If at home, instruct the individual to seek immediate medical attention if autonomic dysreflexia symptoms reoccur.
  3. Prescribe a blood pressure monitoring device to the individual for home monitoring.
(PVA-AD 2020, p.642; Level C)

Document the episode of autonomic dysreflexia and record the effectiveness of the treatment in the individual’s medical record, including the following:

  1. Presenting signs and symptoms and their course
  2. Recordings of blood pressure and pulse
  3. Treatment instituted and response to treatment
  4. Restoration of blood pressure and heart rate to normal levels for the individual
  5. Diagnosis of a history of autonomic dysreflexia in order to inform future clinicians of the risk in the individual and prior response to treatments initiated
  6. Identification of the cause (trigger) of the autonomic dysreflexia episode
  7. Whether the individual is comfortable, with no signs or symptoms of autonomic dysreflexia or secondary complications, such as neurological changes, increased intracranial pressure, or heart failure
(PVA-AD 2020, p.642; Level C)

After the individual with SCI has been stabilized, review the precipitating cause of the autonomic dysreflexia episode with the individual, family members, significant others, and caregivers to educate them regarding instigating factors, recognition, management, and prevention of future autonomic dysreflexia episodes.

  1. Adjust the treatment plan to ensure that future episodes are recognized and treated to prevent a medical crisis or, ideally, are avoided altogether.
  2. Discuss autonomic dysreflexia during the individual’s education program so that he or she will be able to minimize the risks known to precipitate autonomic dysreflexia, solve problems, recognize early onset, and obtain help as quickly as possible.
  3. Have an ongoing conversation and continue education at annual evaluations or clinic appointments.
  4. Give a written wallet card/guide or instruction sheet or consider a medical alert bracelet.
(PVA-AD 2020, p.642; Level C)