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 References

Nursing
Patho Genetics
Interventions

Signs & Nursing

Epidemiology Outcomes
Symptoms

Altered
Case Study Inflammation Stress
Response
 Review of the Anatomy of the Nervous
System:

Brain
Central Nervous
System (CNS)
Spinal Cord
Nervous System
(Microsoft Office Clip Art,
2007)
Peripheral
Nerves to and
Nervous system
from the CNS
(PNS)

(Porth & Matfin, 2009)

Anatomy of the Peripheral Nervous
System (PNS) Click on the question for the answer:

• Sympathetic Which system is

responsible for
Autonomic
Autonomic
Nervous System
• Parasympathetic Dysreflexia?

• Allows for voluntary

movement of muscles
Somatic Nervous within the body
System
• Receives sensory input
(i.e. the 5 senses)

(Porth & Matfin,

2009)
 The Normal
Sympathetic/Parasympathetic Responses:

BP, HR,
Sympathetic dilated pupils,
Turned on in
Release of diaphoresis,
response to a
Epinephrine goosebumps,
(AKA Fight or SIGNIFICANT
and Norepi vasoconstriction
Flight) Stressor
of blood vessels

Negative feedback
loop

Para- Vasodilation,
Opposite
BP, HR,
Sympathetic response to the Increase in
constricted
(AKA The Sympathetic acetylcholine
pupils,
relaxing and system
peristalsis,
digesting mode)
(Lewis et al, 2000, p. 1591)
 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
Yes anything
arrow on the diagram
T6 and above!
where autonomic
dysreflexia can occur if
the injury is on or above
this level?
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?
No
Yes
Are you sure?
Right, T6 and
Go back to this
above!
slide!
Mr. Z continued….
• Bythe 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,
What part of the PNS will be activated in response to
irritation, etc.)
the accumulation of these blocked nerve firings?

Click on correct answer:

Nerves fire and signals are
sent up the spinal cord

Para-
Sympathetic
Signals are blocked in the Sympathetic No! This is
CORRECT! activated
spinal cord by the level of later!
injury and flow out the
“sphlanchnic outflow”
(Travers, 2009 )
Patho of Autonomic Dysreflexia continued:

Severe
Sympathetic
vasoconstriction of
nervous system is Blood pressure rises
blood vessels below
activated
the level of injury!

Bradycardia from Parasympathetic

the parasympathetic system activates
system activating from baroreceptors
the vagus nerve sensing high BP!

(Porth & Matfin, 2009,

p. 1293).

Microsoft clip art 2007

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:

Vaso-
Vaso- dilation
constriction No, review
Exactly! the patho
again

Image reprinted with permission from eMedicine.com, 2011. Available at

http://emedicine.medscape.com/article/322809-overview
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 Atrial Distention:

SNS Atrial
BP Distention (Microsoft Office Clip Art, 2007)
activation
and release
of Atrial
Natriuretic
Peptides

(Porth & Matfin,

2009)
Mr. Z
• Upon closer assessment, you observe Mr. Z’s
face is quite flushed and warm to the touch.

• You suspect Mr. Z :

Has significant
vasodilation of the
vessels leading to Used with permission from Olson Family Photograph Collection (Olson,
2011)
Is probably Febrile
his face
No, reread this
Absolutely! This is
slide
due to the
Parasympathetic
activation
Signs and Symptoms:
• Besidesbradycardia, hypertension, and a
flushed face; what else might Mr. Z have?
*Click on each sign/symptom for more information*

Goose Blotchy Blurred

headache sweating
bumps skin vision

Cool
Feeling of nasal Pupils
peripheral
doom congestion constrict
extremities

(Porth & Matfin, 2009, pg. 1293)

 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 head
Place his bed in of bed up 90
trendelenberg degrees?
position? Absolutely!
No! This would Take advantage
further increase of a Quad’s Check his
his BP! Mr. Z Call the orthostatic bladder for
could stroke!!! Resident to hypotension! fullness or
assess him? place a foley?
No, while you No, you will do
are calling, Mr. this but first
Z’s BP is intervene in his
climbing! 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:
• HisBP 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 Check for a

for a large developing Check his bladder
wrinkle? pressure sore? for distension?
No, this has been No, this has been Absolutely! This
known to cause known to cause is the #1 most
AD, but rule out AD, but rule out occurring cause
the #1 cause the #1 cause for AD!!!!
first! first!

(Porth & Matfin,

2009)
The 3 Common Causes of AD:

#3 Skin
impairment
*Rule out each cause by
working from the bottom
#2 Full up! Start with the most
common cause first!
Bowel

#1 Full Bladder

(Travers, 2009)
 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

(Microsoft Office Clip Art, 2007)

(Louis Calder Memorial Library of the University of Miami/Jackson Memorial Medical
Center, 2009)
 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?
Lower head of
Turn Mr. Z and Consult chart bed and see if
assess for a skin for last bowel his BP has
impairment? movement normalized?
No, remember while No! You
to assess from hospitalized? haven’t found
the bottom – Absolutely, a full the cause yet,
up! Review this bowel is the #2 and this could
slide cause of AD! 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?
Turn Mr. Z to
Administer Mr. Call the MD for
his side and
Z’s prn oral a stool softener
attempt to
laxative? order?
remove any
No, his BP will No, his BP will
stool present?
continue to continue to
Yes! This is the
climb while the climb while the
only option
laxative is stool softener is
that will
absorbed! Mr. absorbed! Mr.
attempt to
Z could have a Z could have a
remove the AD
stroke! stroke!
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! (Microsoft Office Clip Art, 2007)

(Agency for Healthcare Research & Quality- U.S. Department of Health & Human Services, 2001)
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?

Metoprolol Timolol
No! This is an anti- No! This is an anti-
Nifedipine
hypertensive hypertensive
Yes! This is
(Beta-Blocker), but (Beta-Blocker), but
available in
it is not as fast it is not as fast
sublingual form
acting as acting as
which allows for
sublingual sublingual
quick absorption
Nifedipine Nifedipine (Microsoft Office Clip Art, 2007)

(Deglin & Vallerand, 1999)

 Other Medications used for AD:
• Sodium Nitroprusside
• Isosorbide dinitrate
• Nitroglycerin ointment
• Hydralazine
(Microsoft Office Clip
Art, 2007)
• Mecamylamine
• Diazoxide
• Phenoxybenzamine
• Captopril
• Prazosin

(Agency for Healthcare Research & Quality – U.S. Department of Health & Human
Services, 2001)
 Special Considerations:
• Ifyour 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 Prostaglandins Permeability
from and of vascular
leukotrienes tissue
Circulation released
(Porth & Matfin,
2009)

Fluid pools
Pain signals
into
sent up the
surrounding
spinal cord!
tissue

What will happen

to these pain
signals?
(Microsoft Office Clip Art, 2007)
Patho?
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)

Low dose anti-

Nifedipine hypertensive
No! This is Yes! A
short acting. pressure sore
Review this will take days
slide! to heal!
 Aging and AD
• SCIPatients 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)

Atrial
Bradycardia Fibrillation Atrial Distension
during AD
Risk Factors

Change in Cardiac
tone
(Pine et al, 1991)
Considerations for Elderly AD Candidates:
• Give Nifedipine CAUTIOUSLY! Why?

• At an increase Rx for developing the top 3

causes of AD:

Thinner Skin with Decreased Bowel Decrease in Bladder

Age Motility Size

(Porth & Matfin,

2009)
 Genetics & AD
• After a spinal injury there is significant growth
of Calcitonin Gene-related Peptide-
immunoreactive (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:
Loss of
Death Stroke Seizure
Vision

Loss of Heart Kidney

hearing failure failure

Nurses are key in prevention of

further loss of functioning!
(Microsoft Office Clip Art, 2007)
Educate Educate Educate!
• ImportantNursing Outcome! (Microsoft Office Clip
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
Mr. Z’s risk for
Symptoms of Importance of
developing
AD! adhering to
Atrial Fibrillation
Absolutely! He Bowel Program!
with AD?
has been a quad Absolutely! A
Absolutely! He
for a while – but full bowel is the
is 65 years old
this could save #2 cause of AD!
and is at risk!
his life!
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/​practicalbowel-
dysfunction_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-info-
pages.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