1. A guide to acute nursing care
prevention, and education
Jane Sarnicki, RN
Darshani Sukumaran, RN

2. After this presentation you should be able to:
● Understand what autonomic dysreflexia (AD) is
● Know how to manage an acute AD crisis
● Know some ways to prevent AD
● Effectively educate patients on the management and
prevention of AD

3. ●An abnormal response to painful stimuli below the level of
Spinal Cord Injury (SCI)
●Mediated by the Autonomic Nervous System (ANS)
●Also known as hyperreflexia and autonomic disautonomia
●Most common in an SCI above T6 (6th thoracic nerve) level
●Can cause dangerously high blood pressure
● A Medical Emergency!

4. Patients most at risk of AD are those with SCI above T6
who have passed through the acute stage of spinal cord
injury and have had a return of reflex activity.
It is a medical emergency and must be treated with
prompt action.
High blood pressure can lead to heart arrhythmias and
stroke. Repeated episodes of AD can cause long term
organ and vascular damage.

5. http://emedicine.medscape.com/article/322809-
overview

6. ● Painful/noxious stimuli occurs below SCI level
● Signal is blocked at site of SCI so patient is not aware
of pain and cannot correct it
● Autonomic Nervous Stystem responds:
(ANS) ---> vasoconstriction below SCI. Sudden rise in
blood pressure.

7. ANS detects high BP above SCI and attempts to
correct it:
●Bradycardia (vagal nerve)
●Vasodilation in head and chest to absorb increased
blood flow to upper body
●Negative feedback loop is interrupted by the SCI.
Cycle continues until stimulus is removed

8. #1 cause is a full bladder
#2 cause is a full bowel

9. ● bladder or kidney infection
● gastric ulcers, gallstones, other GI disturbances
● tight clothing, leg braces, shoes
● patient lying or sitting on hard object
● pressure ulcer
● ingrown toenail
● insect bites and other minor injuries
● DVT

10. ● sexual activity
● menstruation
● pregnancy
● vaginal infections
● extreme temperatures (hot or cold)
● rapid changes in temperature
● positioning problem, lack of circulation to limb
● drug stimulants

11. Systemic:
● Rapid rise in systolic and diastolic blood pressure 20-40
mmHg above patient's baseline.
● Bradycardia
● Possible cardiac arrhythmias, A-fib, PVC’s, AV
conduction abnormalities

12. Above SCI site
● Profuse diaphoresis
● Goosebumps (piloerection)
● Flushing of skin, especially face, neck, shoulders (may
have ‘blotchy’ appearance

13. Patient reports:
● severe headache
● blurred vision
● spots in visual fields
● nasal congestion
● anxiety, sense of impending doom
* silent AD does not have symptoms despite significant
elevation in BP

14. Locate and remove stimuli
Lower blood pressure
Administer prescribed meds
Notify doctor

15. 1. Sit the patient up
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

16. 2. Loosen restrictive clothing
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.

17. 3. Closely monitor BP
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. For 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 150 Hg/mm requires
pharmaceutical intervention.

18. 4. Check the Bladder
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.
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.

19. 5. Check the bowel
Impacted bowels can often lead to a crisis. Apply lidocaine 2 minutes prior to digital
dis-impaction.
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 digital rectal exam may exacerbate the crisis. If blood pressure rises during the
examination, stop, instill more lidocaine, and call the doctor.

20. 6. Check for other noxious stimuli on their body, from
the toes up.

21. 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

22. Bed Up
BP
Bladder
Bowels
Body

23. Systolic BP > 150mmHg
● Procardia (nefidipine)
– immediate release tablets, bite and swallow
● Nitrates
– nitroglycerin paste
● Others: mecamylamine, diazoxide, and phenoxybenzamine.

24. If noxious stimuli not identified
and crisis unable to be resolved,
● In-patient: call doctor
● Home Health: call 911 make sure situation explained
● Teach patient: call 911 or go to ED

25. Prevention is often the key to preventing an
autonomic crisis!
● Regular bladder and bowel care
● Prevention of pressure ulcers
● Inspect patient bed often for foreign objects
● Check records for past crisis and causes
● Avoid tight fitting clothes, abrupt changes in temp.

26. Prevent Autonomic Dysreflexia
● hypothermia
● positioning
● vein/artery access procedures
● Continuously monitor BP for signs of AD! Nurse to inform
radiology, OR or other testing areas of risk.
● Ensure AD history/risk is on face sheet and clearly visible on
chart

27. 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 if ordered.
- 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.

28. ● AD kit for home/travel
● Catheter/bowel care
● Educate family/friends
● ID card with plan of care
● Emergency app on phone
● Medical bracelet

29. 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.
Denise I Campagnolo, MD, MS, Autonomic Dysreflexia in Spinal Cord Injury: Treatment & Medication, Barrow Neurology
Clinics, St Joseph's Hospital and Medical Center; Investigator for Barrow Neurology Clinics; Director, NARCOMS Project for
Consortium of MS Centers, 2009
Glynis Collis Pellat, Spinal Surgery for Acute Traumatic Spinal Cord Injury: Implications for Nursing, 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