Autonomic Dysreflexia

People with spinal cord injury (SCI) may be at risk for a serious problem called autonomic dysreflexia (AD). If you have an SCI at level T6 or higher, you should be aware of this problem and how it could affect you.

Understanding AD

AD occurs in episodes. The first one typically happens about 4 to 6 months after the SCI occurred. Episodes are usually triggered by irritation to the body below the point of the SCI.

The irritation, often as minor as a full bladder, causes an abnormal response in the nervous system. This makes the blood vessels tighten. As a result, the blood pressure rises quickly. This can lead to stroke and even death. So, steps must be taken right away to find and relieve the irritation. This may require emergency treatment.

During an AD episode, blood pressure stays high until the irritation is relieved. An AD episode that is not treated can lead to serious complications.

Symptoms of an AD episode

An AD episode can occur at any time. It can have several signs and symptoms. Along with high blood pressure, these include:

• Severe pounding headache
• Changes in heart rate (slow pulse)
• Sweating and blotchiness of the skin above the SCI
• Pale, cold skin below the SCI
• Blurred vision
• Nasal congestion
• Anxiety
• Nausea
• Goose bumps

Triggers of AD episodes

The most frequent triggers of AD episodes are the following:

• A bladder problem. This is most often an overfull bladder, which can happen if the person does not use a catheter. Or it can happen because of a clogged or kinked indwelling catheter. A urinary tract infection (UTI) can also be a trigger.
• A bowel problem. This is often a bowel filled with stool or gas. Or it could be an infection or hemorrhoids. Digital stimulation as part of a bowel program is another possible trigger.
• Other sources of discomfort. These include any other type of irritation. They could be wounds, pressure sores, broken bones, and even ingrown nails or sunburn. Sexual arousal, menstruation, and pregnancy and labor can also trigger an AD episode.

What to do during an AD episode

Immediate treatment of an AD episode is critical. You (or your caregiver) should take the following steps if you have symptoms of an episode:

1. Sit up. This can help lower blood pressure. Keep the head elevated. The legs should be lowered if possible. Also, loosen any tight clothing, such as a belt or bra.
2. Monitor the blood pressure, which is likely to be significantly elevated. Also monitor the pulse rate which is likely to be slower than usual. It should be checked every 2 to 5 minutes until it is stable (for at least 3 consecutive readings), and then for at least 2 hours following the episode
3. Find and relieve the cause of the problem. Check the bladder and bowel first. Check the catheter (if used) and empty the bladder. If the bowel is full, empty it right away. Next, check for skin problems. These could be cuts or any kind of pressure on the skin. Also look for ingrown toenails. And check for any of the other possible triggers listed above.
4. If the problem cannot be found or relieved, call 911 or emergency services right away. In the meantime, certain blood pressure medicines should be taken if they have been prescribed for this purpose. These can help keep the blood pressure under control until the irritation is relieved.

Prevention of AD episodes

AD episodes cannot always be prevented. Good self-care is key to reducing the number of episodes you have. The following steps can help:

• Prevent your bladder from getting too full or infected (such as urinary tract infection or UTI). If you use a catheter, check it regularly for blockages.
• Follow a regular bowel program as instructed by your healthcare provider.
• Change positions often to relieve pressure on the skin from sitting or lying down.
• Watch for sores or pressure spots on the skin.
• Take all medicines as prescribed.
• Choose shoes carefully. Make sure they fit properly and are not too tight. Your healthcare provider may help with this.
• Check that there are no pebbles or other objects in your shoes. Also make sure there are no wrinkles in your socks. Always wear socks with your shoes.
• Avoid getting too much sun. Be sure to wear sunscreen and protective clothing.
• Monitor water temperatures to prevent scalding.
• Be extra careful to avoid falls, especially during transfers.
• Keep a card in your wallet that describes AD, its triggers, and proper treatment. This can help healthcare providers who may not be familiar with the condition.
• Establish a good relationship with a healthcare provider who is familiar with AD and spinal cord injuries.