J - AUTONOMIC DYSREFLEXIA (AD)
J.1.1
Be aware that, compared with the general population, individuals with SCI are likely to have the following systolic blood pressure differences:
- In the supine resting position, adults with injuries at or above T1 will likely have low blood pressure (on average systolic blood pressure ~110 mmHg)
- In the seated resting position, adults with injuries at or above T6 will likely have low blood pressure (on average systolic blood pressure ~100 mmHg)
- Age-related changes in blood pressure (i.e., pediatric age group and older individuals) may be different.
J.2.1
Individuals with an SCI at or above T6 may present with the signs and symptoms of autonomic dysreflexia, including:
- Elevated systolic blood pressure greater than 20 mmHg above their usual baseline in adults
- Sudden-onset headache
- Possible bradycardia or tachycardia
- Cardiac arrhythmias, atrial fibrillation, premature ventricular contractions, and atrioventricular conduction abnormalities
- Profuse sweating and/or flushing of the skin, typically (face, neck, and shoulders) or possibly below the level of the lesion
- Piloerection (goosebumps) above or possibly below the level of the lesion
- Blurred vision and/or spots in the individual’s visual fields
- Nasal congestion
- Feelings of apprehension or anxiety
- Few or no symptoms other than elevated blood pressure
J.2.2
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)
J.2.3
Check the individual’s blood pressure. (PVA-AD 2020, p.640; Level C)
J.2.4
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)
J.2.5
If autonomic dysreflexia is diagnosed, identify the trigger(s) in order to manage blood pressure. (PVA-AD 2020, p.640; Level B)
J.2.6
If blood pressure is elevated, immediately sit the individual up and lower the legs, if possible. (PVA-AD 2020, p.640; Level B)
J.2.7
Monitor blood pressure and pulse frequently (every 1 – 2 minutes) until the individual is stabilized. (PVA-AD 2020, p.640; Level B)
J.2.8
Loosen any clothing or constrictive devices. (PVA-AD 2020, p.640; Level B)
J.2.9
Determine whether the individual has recently taken a vasopressor or an antihypotensive agent. (PVA-AD 2020, p.640; Level C)
J.2.10
Quickly survey the individual for other triggers, beginning with the urinary system. (PVA-AD 2020, p.640; Level B)
J.2.11
If an indwelling urinary catheter is not in place, catheterize the individual. (PVA-AD 2020, p.640; Level C)
J.2.12
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)
J.2.13
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)
J.2.14
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)
J.2.15
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)
J.2.16
Avoid applying pressure over the bladder (Credé maneuver) or suprapubic tapping, as this may exacerbate autonomic dysreflexia. (PVA-AD 2020, p.641; Level C)
J.2.17
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)
J.2.18
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)
J.2.19
If the catheter is blocked, remove and replace it. (PVA-AD 2020, p.641; Level C)
J.2.20
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)
J.2.21
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)
J.2.22
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)
J.2.23
Monitor the individual’s blood pressure during bladder drainage. (PVA-AD 2020, p.641; Level C)
J.2.24
If acute symptoms of autonomic dysreflexia persist, including sustained elevated blood pressure, suspect fecal impaction. (PVA-AD 2020, p.641; Level B)
J.2.25
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)
J.2.26
If fecal impaction is suspected, check the rectum for stool, using the following procedure:
- Premedicate with a pharmacological agent.
- With a gloved hand, generously instill a topical anesthetic agent, such as lidocaine jelly 2%, into the rectum.
- Wait 3-5 minutes, if possible, for sensation in the area to decrease.
- Then, with a gloved hand, insert a lubricated finger into the rectum and check for the presence of stool.
- If present, gently remove, if possible.
J.2.27
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)
J.2.28
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)
TriggersAutonomic 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
- Appendicitis
- Bowel distention
- Bowel impaction
- Gallstones
- Gastric ulcers or gastritis
- GI instrumentation
- Hemorrhoids
- Constrictive clothing, shoes, or appliances
- Contact with hard or sharp objects
- Blisters
- Burns, sunburn, or frostbite
- Ingrown toenail
- Insect bites
- Pressure injuries
- 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
- 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)
- Lactation, breastfeeding, mastitis
- Menstruation
- Painful intercourse and/or friction
- Pregnancy, especially labour and delivery, including ectopic pregnancy
- Vaginitis
- 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
J.2.29
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:
- There is poor response to the treatment specified above.
- The cause has not been identified.
J.2.30
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)
J.2.31
Following an episode of autonomic dysreflexia, a health care provider should consider the following:
- If the individual is an inpatient or in the clinic, monitor closely for at least 2 hours for recurrent autonomic dysreflexia or hypotension.
- If at home, instruct the individual to seek immediate medical attention if autonomic dysreflexia symptoms reoccur.
- Prescribe a blood pressure monitoring device to the individual for home monitoring.
J.2.32
Document the episode of autonomic dysreflexia and record the effectiveness of the treatment in the individual’s medical record, including the following:
- Presenting signs and symptoms and their course
- Recordings of blood pressure and pulse
- Treatment instituted and response to treatment
- Restoration of blood pressure and heart rate to normal levels for the individual
- 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
- Identification of the cause (trigger) of the autonomic dysreflexia episode
- 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
J.2.33
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.
- Adjust the treatment plan to ensure that future episodes are recognized and treated to prevent a medical crisis or, ideally, are avoided altogether.
- 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.
- Have an ongoing conversation and continue education at annual evaluations or clinic appointments.
- Give a written wallet card/guide or instruction sheet or consider a medical alert bracelet.
J.3.1
Be aware of and educate individuals with SCI at or above T6 that sexual activity may provoke autonomic dysreflexia. (PVA-AD 2020, p.642; Level C)
J.3.2
Be aware that for men and women with SCI at or above T6 who use intense sexual stimulation (including vibratory stimulation), the likelihood of autonomic dysreflexia is increased. (PVA-AD 2020, p.642; Level C)
J.3.3
Encourage individuals with SCI at T6 and above to periodically monitor their blood pressure during sexual activities. (PVA-AD 2020, p.642; Level C)
J.3.4
Individuals prone to autonomic dysreflexia during sexual activity should be encouraged to use a home blood pressure monitor. (PVA-AD 2020, p.642; Level C)
J.3.5
If sexual activity causes symptomatic autonomic dysreflexia, individuals should be encouraged to immediately cease sexual stimulation and follow autonomic dysreflexia protocol. (PVA-AD 2020, p.642; Level C)
J.3.6
Consider instructing and prescribing pharmacological prophylaxis prior to sexual activity in selected individuals who:
- Have no history of symptomatic orthostatic hypotension (OH)
- Are not taking medication that may potentiate hypotension
- Developed autonomic dysreflexia with systolic blood pressure at or above 150 mmHg (i.e., during vibratory stimulation, ejaculation, orgasm, sperm retrieval, or urological procedures)
- Have symptomatic autonomic dysreflexia and/or systolic blood pressure greater than 150 mmHg prior to sexual activity or during sperm retrieval
J.3.7
If pharmacological treatment for autonomic dysreflexia is used in a home setting, instruct individuals on how to recognize, monitor, and treat pharmacologically induced hypotension. (PVA-AD 2020, p.643; Level C)
J.3.8
Instruct individuals at risk of autonomic dysreflexia to recheck blood pressure within 5 minutes of cessation of sexual activity, regardless of symptoms. If the individual’s high blood pressure does not resolve after 5 minutes, refer to steps for treatment of autonomic dysreflexia. (PVA-AD 2020, p.643; Level C)
J.3.9
Instruct individuals that if all conservative home measures to treat autonomic dysreflexia or pharmacologically induced hypotension following sexual activity are unsuccessful, an urgent visit to the emergency department is warranted. (PVA-AD 2020, p.643; Level C)
J.4.1
Prior to the procedure, counsel the individual to:
- Take prescribed medications (such as anticholinergic medications, alpha-blockers)
- Have a recent bowel program (within 1-2 days)
- Treat urinary tract infection, if present
- Hold any as-needed medications that may elevate blood pressure (such as ephedrine, midodrine)
- Hold any medications such as phosphodiesterase inhibitors (PDEis), which may not allow nitrates (nitropaste) to be used to treat autonomic dysreflexia
J.4.2
If prior to the procedure an individual presents with a systolic blood pressure that is greater than 20 mmHg above his or her usual baseline systolic blood pressure, evaluate for possible causes of autonomic dysreflexia and manage and monitor them. (PVA-AD 2020, p.643; Level C)
J.4.3
Consider rescheduling the individual’s procedure if autonomic dysreflexia persists despite finding and correcting any obvious reversible causes. (PVA-AD 2020, p.643; Level C)
J.4.4
Consider decreasing the risk of autonomic dysreflexia before urethral instrumentation, such as cystoscopy, by instilling lidocaine jelly into the urethra at least 3-5 minutes before urethral instrumentation. (PVA-AD 2020, p.643; Level C)
J.4.5
In individuals who are prone to autonomic dysreflexia or have a recent history of autonomic dysreflexia, consider prophylactic pharmacological treatment to decrease the risk of autonomic dysreflexia before cystoscopic procedures and sperm retrieval procedures. (PVA-AD 2020, p.643; Level C)
J.4.6
During sperm retrieval procedures, blood pressure should be monitored at 1-minute intervals. (PVA-AD 2020, p.643; Level C)
J.4.7
During cystoscopic and urodynamic procedures, monitor blood pressure in at least 2-minute intervals, preferably with an automatic blood pressure cuff. Perform more frequent blood pressure readings if the patient is developing autonomic dysreflexia during the procedure. (PVA-AD 2020, p.643; Level C)
J.4.8
Rather than immediately sitting an individual up during cystoscopic and urodynamic procedures, attempt to control autonomic dysreflexia by draining the bladder as needed, and, if not resolved, institute a similar pharmacological strategy as that recommended for the management of autonomic dysreflexia. (PVA-AD 2020, p.643; Level C)
J.4.9
During urological cystoscopic and urodynamic procedures, if autonomic dysreflexia is not controlled by draining the bladder or with pharmacological measures, stop the procedure and sit the individual up. (PVA-AD 2020, p.644; Level C)
J.4.10
Monitor blood pressure after a cystoscopic or urodynamic procedure or after ejaculation until it subsides to near the individual’s baseline. Monitor for continued elevated blood pressure or orthostatic hypotension when the individual is moved to the seated position. (PVA-AD 2020, p.644; Level C)
J.4.11
Autonomic dysreflexia prevention and control will be under the direction of the specialist administering anesthesia to individuals who require it while undergoing electroejaculation. (PVA-AD 2020, p.644; Level C)
J.5.1
Instruct health care professionals that women with SCI who have the potential of developing autonomic dysreflexia are at increased risk of severe autonomic dysreflexia during pregnancy, labour, delivery, and breastfeeding and should be followed by a multidisciplinary team. (PVA-AD 2020, p.644; Level C)
J.5.2
An antepartum consultation with an anesthesiologist and the establishment of a plan for induction of epidural or spinal anesthesia at the onset of labour is recommended to assess the risk of autonomic dysreflexia and to prevent it, in accordance with recommendations of the American College of Obstetricians and Gynecologists. (PVA-AD 2020, p.644; Level C)
J.5.3
In pregnant women prone to autonomic dysreflexia, careful and frequent monitoring of the fetus is recommended, especially during labour and delivery. (PVA-AD 2020, p.644; Level C)
J.5.4
Autonomic dysreflexia must be differentiated from preeclampsia during pregnancy and labour to ensure appropriate treatment. (PVA-AD 2020, p.644; Level C)
J.5.5
Although individuals with SCI may not perceive pain during labour, anesthesia should be used to prevent autonomic dysreflexia in women with SCI at T6 and above. Spinal or epidural anesthesia is the most reliable method of preventing autonomic dysreflexia by blocking stimuli that arise from pelvic organs. (PVA-AD 2020, p.644; Level C)
J.5.6
Educate women who have the potential to develop autonomic dysreflexia that postpartum breastfeeding, breast engorgement, or mastitis may trigger autonomic dysreflexia. (PVA-AD 2020, p.644; Level C)
J.6.1
Inform individuals with SCI that self-induced autonomic dysreflexia (e.g., boosting) to benefit daily activities and/or sports performance is a dangerous practice that can result in uncontrollable, life-threatening increases in blood pressure. (PVA-AD 2020, p.644; Level C)
J.7.1
Be aware that orthostatic hypotension, defined as a decrease in systolic blood pressure of = 20 mmHg, may occur in individuals with lesions at T6 and above on the assumption of an upright posture from a supine position, regardless of whether symptoms occur. (PVA-AD 2020, p.644; Level C)
J.7.2
To accurately diagnose orthostatic hypotension in individuals with SCI, perform an orthostatic challenge evaluation (e.g., sit-up test or head-up tilt test). (PVA-AD 2020, p.644; Level C)
J.7.3
To prevent or manage orthostatic hypotension in individuals with SCI, first, consider treating to maintain baseline blood pressure by using nonpharmacological interventions. (PVA-AD 2020, p.644; Level C)
J.7.4
Consider pharmacological interventions to treat both symptomatic and asymptomatic orthostatic hypotension in individuals with established SCI when nonpharmacological interventions prove to be ineffective. (PVA-AD 2020, p.644; Level C)
J.8.1
Monitor for signs and symptoms in individuals with SCI at T6 or above who are at risk for developing hypothermia when exposed to a cold environment. (PVA-AD 2020, p.644; Level C)
J.8.2
If possible, obtain a rectal temperature when evaluating an individual for hypothermia because skin temperate is not accurate for monitoring core body temperature. Oral and tympanic are also acceptable methods of temperature monitoring. (PVA-AD 2020, p.644; Level C)
J.8.3
Use ambient temperature regulation, insulated clothing, blankets, warm humidified air, and intake of warm fluid into the gastrointestinal tract to help prevent and manage hypothermia. Heating devices should be used with extreme caution in insensate areas. (PVA-AD 2020, p.645; Level C)
J.8.4
In cold ambient environments, instruct individuals to consider avoiding alcohol intake, as it causes vasodilation and heat loss. (PVA-AD 2020, p.645; Level C)
J.8.5
Be aware of and discuss with individuals with SCI that certain medications or substances may disrupt temperature regulation (hypo- or hyperthermia), including alpha-agonists (e.g., tizanidine, clonidine), narcotics, oxybutynin, gabapentin, and antidepressants that are norepinephrine and serotonin reuptake inhibitors. (PVA-AD 2020, p.645; Level C)
J.9.1
Monitor for signs and symptoms of hyperthermia in individuals with SCI at or above T6 who are at risk for developing hyperthermia when exposed to a hot environment. (PVA-AD 2020, p.645; Level C)
J.9.2
Treat hyperthermia by decreasing the individual’s core temperature. This includes moving to a cooler environment (preferably an air-conditioned setting), drinking cool liquids, washing with tepid water, and resting. (PVA-AD 2020, p.645; Level C)
J.9.3
Provide education regarding measures to help prevent neurogenic hyperthermia. Preventative measures include wearing appropriate lightweight and light-coloured clothing, maintaining a proper temperature-controlled room (e.g., use of air-conditioning), frequently drinking cold fluids, maintaining appropriate hydration, and having a water spray and/or fan for exposed skin. This is especially important when in a hot environment. (PVA-AD 2020, p.645; Level C)
J.9.4
Be aware of and discuss with individuals with SCI that certain medications or substances may disrupt temperature regulation (hypo- or hyperthermia), including alpha-agonists (e.g., tizanidine, clonidine), narcotics, oxybutynin, gabapentin, and antidepressants that are norepinephrine and serotonin reuptake inhibitors. (PVA-AD 2020, p.659; Level C)
J.9.5
During exercise, individuals with SCI at T6 or above should be monitored for neurogenic hyperthermia. (PVA-AD 2020, Level C)
J.10.1
Evaluation of hyperhidrosis in individuals with SCI at T6, or above T6, should rule out more extensive autonomic dysfunction such as autonomic dysreflexia. (PVA-AD 2020, p.670; Level C)
J.10.2
In the absence of a rise in blood pressure, prevention and management of hyperhidrosis should include identifying other possible triggers. (PVA-AD 2020, p.670; Level C)
J.10.3
In those individuals in whom isolated hyperhidrosis is not associated with an identifiable and modifiable cause, consider empirical treatment with anticholinergic medications unless contraindicated. (PVA-AD 2020, p.670; Level C)
J.10.4
If anticholinergic medications do not relieve hyperhidrosis or are not well tolerated, secondary medications could be considered. (PVA-AD 2020, p.670; Level C)