Autonomic Dysreflexia: Unusual and Silent Types

Autonomic Dysreflexia: Unusual and Silent Types

Posted by AskNurseLinda on Sep 11, 2017 10:40 am

There can never be too much said about Autonomic Dysreflexia. This is a condition of many individuals who have a spinal cord injury above T6. Since the anatomy of people’s bodies are fairly the same but not identical and injuries are never alike, AD can affect those with injury or disease including spinal segments as low as T10. 

Most people know where their spinal cord injury or disease is in relationship to the vertebrae in the spine.  Injuries at T4 are at the nipple line. Two finger widths below is T5, two more finger widths below is T6. There is no anatomical landmark that clearly defines the T6 dermatome or area of sensation. If you keep measuring two finger widths down the trunk, you will find T10 is at the level of the belly button. This measuring system, although not perfect, gives you an idea of the mysterious levels of the trunk.

AD is a medical emergency. Many people know the experience of AD and how to treat it. Many healthcare professionals outside of the care of individuals with spinal cord injury or physical rehabilitation do not know about it.

Autonomic Dysreflexia occurs when there is some irritation or pain below the level of injury which is being communicated by your body to your brain but the message cannot get there. Because the brain does not receive the message of ‘trouble’, it cannot send a response to relieve the problem. Spinal cord injury or disease blocks these transmission of messages. As a result, the autonomic nervous system, the part that acts automatically, will constrict your blood vessels. The brain will recognize this problem and will slow your heart and elevate your blood pressure to try to even out the situation.

The symptoms of AD are many. The number one symptom is quick elevation in blood pressure which is 20-40 mm Hg or 20-40 points more than the usual top number of your blood pressure. A pounding headache is the best known symptom. Other just as important issues can include sweating and or flushing of skin mostly above the level of injury but less often, you can sweat below as well, goosebumps, blurry vision or spots in your vision, stuffy nose, anxiety, jitters or feeling like you could jump out of your skin, tightness in your chest, heart flutters or trouble breathing.

These symptoms can be very slight to absolutely raging. It is interesting to note that not all of the symptoms of AD will be present. Sometimes even a seemingly minor symptom can be what you notice. Not all individuals have the pounding headache but they still have AD. Sometimes, a person might notice just a stuffy nose and dismiss it as a cold or allergy. However, if this continues intermittently or only with certain activities, you will want to check your blood pressure to see if it might really be AD.

There are some individuals that have no symptoms of AD at all but there blood pressure goes into the elevated range during certain activities. This is called silent AD. The only way to check for this is to monitor your blood pressure if your catheter becomes clogged or kinked, or during your bowel program. You do not have to do this every time, but occasionally you might want to check your blood pressure. If you have a medical procedure, your blood pressure should be monitored. This is when AD might be discovered for some individuals.

Most people are aware of the main triggers of bladder distention from overfilling, catheter kink, or urinary tract infection. Also, common is bowel impaction or simply doing your routine bowel program. Pressure injury, ingrown toe nails, or any constriction to your skin such as too tight shoes, leg bag overfilling and hanging tightly on your leg, pants that are too tight around the waist, legs or groin can cause AD. Sexual arousal can lead to AD as well. Medical problems such as gall stones, deep vein thrombosis (DVT) or blood clots in your legs or arms and even routine medical tests especially to assess the bladder and bowel or any other medical testing can cause symptoms. An extreme overheating or cold environment can trigger an episode.

But did you know other things can lead to AD? Glare from television or computer screens can be a culprit. Even your cell phone can be an issue. Screens have slight, often visually imperceptible power surges leading to changes in the amount of light produced. This low level change can irritate individuals enough to lead to AD.  Another visual trigger can be video games. Driving on a tree lined street with flashes of light and shade can lead to seizures in some people and AD in some individuals with SCI.

Other bowel issues such as diarrhea could lead to an episode of AD. Sometimes pressure injury that is not yet seen can lead to AD. Toe nails that are long and rubbing against the inside of your shoe can be a trigger. Sperm retrieval for reproduction can initiate an episode so you might want to warn your urologist prior to this procedure.

Sometimes, individuals begin a new therapy routine. The new activity can stimulate an episode of AD but so can the movement of your clothes during the activity. You might have shoes or pants that you have worn many times only to find that in the new positon and with the activity, the waistband now rubs, your knees have pressure or your foot moves within your shoes leading to AD.

Research has demonstrated that as individual’s age, their response and episodes of AD lessens. That is great news. Sometimes, however, AD is not identified until years later after the injury, especially with silent AD. Usually, this new development is due to a change or initiation of new activity.

Almost anything can lead to Autonomic Dysreflexia. If you think you are having symptoms, even minor, evaluate your blood pressure as well as your activity to see if you can modify the situation.

Not treating AD can lead to serious consequences. It is termed a medical emergency due to the elevation in blood pressure which can lead to stroke or even death. Because we know that prompt treatment is necessary, everyone with an SCI should know the treatment process. Basically, treatment is to remove whatever is causing the problem and, if necessary, to treat the elevated blood pressure.

If you feel ANY of the symptoms of AD, sit as upright as you possible can. The sudden raising of your head will trigger orthostatic hypotension or a sudden drop in blood pressure. Remove anything that is a constriction including clothes, ace wraps, binders or splints. You will do these things quickly as you work your way to get to your catheter.
Check your catheter to make sure urine is flowing freely, that it is not kinked and that the tubing is not constricted around your leg or that the leg bag is hanging to tightly around your leg. If you perform intermittent catheterization, do it. Use anesthetic lubricant. Remove a constricting external catheter. Check your bowel for the presence of stool. You will want to check using an anesthetic lubricant.

Have someone take your blood pressure. Stay upright until your blood pressure improves. This will lower your blood pressure quicker. If your blood pressure does not improve, if you have difficulty in inserting a new catheter, or if you find your bowels are impacted and you or your caretaker cannot remove it, call 911. When traveling to and when in the emergency room, keep your head elevated by sitting up.

The Christopher and Dana Reeve Foundation has a wallet card about AD that you can obtain for free. Get it soon, prior to any trouble. The card has a place for you to record your usual blood pressure. It also has information for medical treatment of AD that your healthcare professional can use to help relieve the AD episode. https://www.christopherreeve.org/living-with-paralysis/free-resources-and-downloads/wallet-cards

If you have frequent episodes of AD, there is medical treatment available to you. This includes medications to control your blood pressure during an AD event. Preventions such as use of anesthetic lubricants for bladder catheterizations and bowel programs can be prescribed. If your AD is triggered by bladder issues or spasms, medication and even botox injections can be helpful.

Treating AD is possible if you know you have it. People with severe symptoms clearly know they have it. Individuals that dismiss the symptoms to other causes or those with silent AD might not know it is present. Be sure to know your usual blood pressure and occasionally check your BP during events such as catheterizing or during your bowel program to assess your situation. Alert your healthcare team during medical procedures so they will check your BP as well. Nurse Linda
 

Re: Autonomic Dysreflexia: Unusual and Silent Types

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Re: Autonomic Dysreflexia: Unusual and Silent Types

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Re: Autonomic Dysreflexia: Unusual and Silent Types

Posted by chefkaren on Dec 4, 2017 2:18 pm

Hi--I'm new here. Trying to get help navigating my issues has been so expensive and misdirected by my care team. I recently had a bad experience after leaving  pain management . I received no support on the medication taper and suffered severe withdrawls. Last week, I experienced severe headaches for 4 days-uncontrolled by medication. Ov er the weekend, I was so uncomfortable, having all the symptoms of AD-I didn't know about it, though. I went to ER and was suspected of gallstones. Everything checked out ok--except the high bloodpressure. I have no history of high blood pressure so this concerns me. I am dealing with a failed pelvic prolapse surgery, which has  severely compromised my anatomy .I have chronic UTI's, and seeing a specialist to find out what options I have. I am still having some issues as of this posting, and will see my neurologist tomorrow. I have so much discomfort! Tingling, goosebumps, unable to eat or drink. I', confused a little regarding the level at which AD becomes a problem;my spinal damage is at L-1 through S-3. This entire journey has been a nightmare of misdiagnosing, due to ignorance. My care team seems to miss the fact that I have partial paralsys, with secondary problems. I don't know what to do or where to go.

Re: Autonomic Dysreflexia: Unusual and Silent Types

Posted by AskNurseLinda on Dec 4, 2017 4:23 pm

Oh, my, you have been through so very much. First, let's start with the AD. It is typically an issue for individuals with T6 or higher levels of injury but there are reports of cases as low as T10.  Even more complicating is the incomplete injury for which all bets are off. You very well could be having episodes of AD.The treatment is to get the blood pressure under control. Your neurologist will be able to make the determination. Take the AD wallet card with you to start your conversation:http://s3.amazonaws.com/reeve-assets-production/AD-Guide_adultweb5-16.pdf
The second issue is your care treatment and plan. Whenever someone feels that their care is less than adequate, a second opinion is always needed. You can find a referral for pain treatment from  your neurologist. The second opinion will either confirm the diagnosis in which case you can choose to continue with the first pain management physician or change to the second. If there is a different diagnosis and you find the treatment more satisfactory, then switch to the second physician. You might just find your doctor patient relationship to be improved with someone else.
Because you are having difficulty with healthcare in your community, you might want to try the Reeve Foundation peer support or  Information and Resource Services. They have knowledge about successful patient treatment in your area and connect you with someone living in your community that can help you find physician resources that include patients with spinal cord injury. Getting matched up with a set of physicians who are used to the needs and issues of individuals with spinal cord injury is important so you can receive the care you need. Nurse Linda

Re: Autonomic Dysreflexia: Unusual and Silent Types

Posted by JessicaL on Dec 7, 2017 5:21 am

Nice! Tanks for this topic!

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