Autonomic Dysreflexia Training Session video for Clackamas Community College

Uploaded by ClackamasCommCollege on 02.05.2012

Hello my name is Doctor Jerry Ryan
PhD I'm here today to give a presentation on autonomic dysrelexia 0:00:24.920,0:00:25.779
as a training session for
emergency room staff and EMTs
and autonomic dysrelexia is basically a life-threatening condition
for people spinal cord injuries
the way I'll cover this today
will be - we will talk about
what causes autonomic dysrelexia what it is
what the signs and symptoms are and what the treatment and then we'll have a review
at the end
this presentation is supported by grant number five forty five from the
Paralyzed Veterans of America
Education Foundation and it's produced by
myself Doctor Jerry Ryan
from the Oregon chapter of the Paralyzed Veterans of America
This presentation is
designed to be an introductory overview
and it's derived from the following publications that are produced by the
consortium for spinal cord injury and medicine
and that is funded through the Paralyzed Veterans of America
the two documents that this presentation is taken from
the first one is a clinical practice guidelines for professional medical
it's called the acute management of autonomic dysreflexia
individuals a spinal cord injury presenting to health care facilities
the second document is a consumer guide
and it's called autonomic dysrelexia what you should know
the presentation is intended merely
to raise awareness
about the symptoms and the treatment of on autonomic dysrelexia in persons with
spinal cord injury
has to be used in conjunction with the above cited
viewing this presentation does not substitute for reading the guidelines in
their entirety
I have a special note for the EMTs the information that I'm going
to give in this presentation
because it is not an authorization to disregard your state laws regarding the
limitations of EMT medical care
we will cover some treatment
procedures that probably won't be
legal in some states for them to use so what you should do as an EMT is to
make sure that you
check your state laws on what's going on and
basically for the EMTs this is to let
the ER staff know
about the autonomic dysreflexia in a patient
all right so what is autonomic dysreflexia 0:02:43.889,0:02:45.119 or AD
throughout this I'll say autonomic dysreflexia I may just say dysreflexia
may just say AD they're all interchangeable it's also called hyperreflexia
autonomic dysreflexia is basically an abnormal responsive person with the
spinal cord injury
to some stimulus in a part of the body that's below the injury
and it's an emergency condition
and it's life threatening for the individual so it does require immediate
so for the basis of what on autonomic dysreflexia is
the body controls blood pressure and the body temperature through a series of
and it comes through the autonomic
nervous system
the autonomic nervous system
is both within and outside of your spinal cord
and it runs
parallel with the regular central nervous system
and all these nerves interconnect
and there are controlled by the brain and spinal cord
so what happens in an
episode of
autonomic dysreflexia
is the spinal cord injury basically jeopardizes the person's ability to
control their
body temperature as well as a blood pressure and blood pressure is the key
issue here
what happens are the nerve impulses
are blocked at the site of the injury
and so
the result basically is the
nervous system getting a mixed response or a confused response
and it doesn't have a clear picture of what the stimulus is
so what happens is the autonomic nervous system kicks in
and it basically sends the person's blood pressure through the roof and some
things like that will cover in a moment
now who is at risk
primarily it's quadriplegic
and tetraplegic which is another interchangeable term
patients so injuries above thoracic level six
t six or above are the most common people for autonomic
dysreflexia although there have been cases
as far
as t-10 as far down the spine as t-10 where people can have signs and symptoms
of autonomic dysreflexia
so this information is still be helpful
folks with injuries below t-6
alright the common warning signs
these are some
graphics slides to give you a kind of a
depiction of what the signs are
now the worst and most uh... important sign to take care of
is the fast rapid increase
in blood pressure
the biggest problem here
is the increase in the blood pressure pounding headaches those type of things
and when I say a major increase in blood pressure what we mean is twenty five to
forty points systolic above normal
normal for quadriplegic will not be the typical one twenty over eighty
for example I'm a quadriplegic and
my baseline blood pressure is ninety over sixty
so if i come in presenting at one twenty over eighty
you should be suspecting a problem
pounding headache is another sign of autonomic dysreflexia
goes along with the increase of blood pressure
sweating heavy sweating
in the area of the face neck shoulders
once again it's usually but not always above the point of the spinal
cord injury
the same type of thing happens with the skin
it can change color you can have a little blotches thumbnail sized blotches
of red or the entire
skin can have a flush complexion
and again this is usually above the site of the injury
goosebumps another sign on the skin
again usually above the site
the site of the injury
feeling of tightness in the chest a constriction like you've got a belt around
your chest those types of things trouble breathing
blurred vision or seeing spots uh... primarily related once again to
the blood pressure increase
anxiety or jitters this can also turn into confusion agitation
and a stuffy nose
it's another one of the signs
so symptoms
in review
the elevated blood pressure again this is the most critical aspect of an
autonomic dysreflexia episode
if you'll note there it's with a normal or low pulse
and speaking with many physicians about this this is the only
time you're ever going to see an elevated blood pressure
with a normal or low pulse and again it's twenty to forty
points above the baseline for that individual you
will probably need to question the individual about what is their baseline
severe and pounding headaches once again accompanied by the blood pressure
the sweating above the level of the injury
nasal congestion
the skin changes again that includes a goose bumps and the
flushing of the skin
or the little blotches
agitation confusion
anxiety jitters
those types of things
now one of the causes of autonomic dysreflexia
as I've stated before
dysreflexia is usually caused by some form of irritation below the level of
the injury
the most common cause
is a bladder problem
either bladder distension
or other urinary complications
the studies show that this is about eighty five to ninety percent of the
time the problem so this should always be the first place you look
to alleviate the situation for the patient
check the urinary system
and note in red at the bottom of the slide IV fluids are not advise prior
to ruling this out this person is going through an episode of dysreflexia for bladder
last thing you want to do is plug an IV into them and give more fluids
the issue is to drain the fluids that they have at that point
right so let's continue with the urinary system i'll go through a couple of
different systems
to check out for causes of autonomic dysreflexia
as i stated bladder distension is the A number one
cause of this problem and that includes blocked catheters and that type of thing
bladder or kidney stones
can also do this as can be doing cystoscopies or any type of urologic
in the g_i_ system
this is the second
area if
the person's bladders draining fine
the second problem to look for is impacted bowel
constitutes probably the remaining ten
ten or so percent
if it's not bladder move to the bowels
so the other problems within the GI system that can cause autonomic
dysreflexia besides bowel distention and impaction would include
gallstones gastric ulcers
any type of the GI exam
can do it
and hemorrhoids can also cause an episode
integumentary system the skin
constricted clothing belts if their shoes are too tight the sock can be
bunched up inside of the shoe
the leg bag urinary leg bag straps could be too tight anything like that
over time can cause an episode of dyreflexia contact with a hard or
sharp object in an area where the person doesn't feel it
burns people have gotten this from having their
feet too close to a heater in the winter time those type things
sunburn infected toenails and ingrown toenails insect bites all of these
and pressure sores if a person has a pressure sore
and they're trying to get up and sit on it their bodies will let him know
that that's not what they need to do
and it'll cause an episode of
reproductive system
the natural act of intercourse and ejaculation can set off
an episode of dysreflexia
as can STDs
epididymitis for men
scrotal compression
or sitting on the scrotum or even having the pants bunched up by the
scrotum can set that off
and for women the menstrual cycle and vaginitis can cause
episodes of dysreflexia
all right those are the three main
areas you start with the urinary bladder and then you move onto the bowel and the
and here are some either systemic causes that are maybe one
to five percent of the time these would be a problem
if you have ruled out the other three
you start looking for DVTs deep vein thrombosis excessive alcohol or caffeine
or any other diuretic consumption of that
fractures bone fractures will
definitely set off an episode of dysreflexia
emboli heterotopic bone
heterotopic bone is basically a calcium deposit in a joint area
on somebody hasn't moved that area for quite some time
some other systemic causes would include boosting
this is something that is done by a SCI athletes I'm not
terribly familiar with it but it is documented in the literature
functional electrical stimulation
that's where they would put the electrical pads on and individual's legs
and stimulate them to
facilitate them pedaling a bicycle for example
this type of stimulation can cause an episode dysreflexia
substance abuse of any type beyond alcohol over-the-counter drugs
prescribed stimulants and any type of substance abuse can set this off
and of course invasive procedures or surgical procedures
would definitely set it off
and for women childbirth is another area that is
of concern for autonomic dysreflexia obviously it's going to happen during
the labor and delivery
portion of the pregnancy it may happen at other times but labor and delivery is
the most common
and everybody involved the entire ob-gyn team needs to be aware of that
and taken precautions prior to
the labor and delivery
now if you think your patient has autonomic dysreflexia
and again I need to make your reminder for the EMTs that you need to check
your state laws
to make sure that you can do some of these procedures and I'm about to cover
with your state law
some of the following procedures can only be performed by
authorized medical personnel and
will not be legal in some states for EMTs so you need to check your state
alright the very first thing to do
if you suspect the individual has autonomic dysreflexia is begin checking
their blood pressure you're going to want to do that every three to five minutes
until you resolve the problem
if the person has signs and symptoms but doesn't have a high blood
pressure yet then you
need to get that individual
to the
consultant that
is appropriate for the symptoms
now if the blood pressure is already elevated
most important thing to do is sit that individual up
once again this is somewhat counter-intuitive people want to lay
everybody down on the stretcher and put an IV in them
in the case of autonomic dysreflexia these are the two worse things you could
you want to keep that person sitting up until their blood pressure is normal

so he'd be sitting up
with their legs dangling is preferred
and just sitting upright
the next thing to do is loosening tight or constrictive clothing
obvious things like shoes socks and again checking the
urinary collection system to
see if the leg straps are too tight anything like that
then again while you do this you continue to monitor the person's blood pressure
and pulse every three to five minutes
now you may begin to look over the patient to see what's causing the problem and you've
already loosened the clothing
so once again we're going to go to the urinary system because again eighty-five
to ninety-five percent of time
this is where the problem lies
if the person does not have an indwelling catheter catheterize the patient at
that point
you'll see the note there that says for the EMTs to check the laws in their
state regarding characterization
now prior to putting in a catheter in this individual
use some two percent lidocaine jelly and give it a couple minutes to numb the
you have to realize this person is already going to an episode of AD
and it's caused by some type of noxious stimuli and you're about to catheterize a
person which is a fairly traumatic
experience so you want to have the area and as numb as possible
if the person already has an indwelling catheter
check the entire system from top to bottom for any type of kinks
any type of blockage
or anything that could be obstructing the flow if you can find the problem
there correct it immediately
now if the catheter appears to be blocked you can flush the catheter
now you want to use body temperature normal saline for this
because once again
the person is going through stimulation
that's noxious and if you start instilling cold water
or cold saline rather and or
the saline's too warm
you're going to add another traumatic
event to the process
so use about ten to fifteen ccs that's plenty of saline
to irrigate the catheter and get flow
and again dont be tapping on the bladder or any type of those techniques to try to
get the bladder to function because you will cause stimulus and spike the
person's blood pressure
now if the catheter's draining
and the blood pressure remains elevated
then proceed to recommendation sixteen which will cover in a moment
if the cathethers not draining
and the blood pressure remains elevated then you need to remove the catheter and
replace it there must be some type of the internal clog
to the system that could be blood clots there could be any number of
that are occluding the catheter at that point
once again
prior to replacing this catheter be sure use that lidocaine jelly
because this is going to be fairly noxious stimulus
to the person and you want to
alleviate that as much as you can
so use the lidocaine jelly and give it about two minutes on that
if you have any difficulty in replacing the catheter
and this oftentimes happens because that person will be
the body will just be
goin through so many things
that the bladder sphincters are going to cooperate like they don't normally do
so you may have to consult an urologist he may have to try to pass a coude
this is something to bear in mind
and all the while you're doing this be sure you also maintaining
monitoring a person's blood pressure and pulse
okay now if you've done all this and
the person still is exhibiting the signs and symptoms and has a high blood
pressure you should suspect fecal impaction that's the number two reason for an
episode of
at this point also if the blood pressure is over one fifty systolic you might
want to consider doing some pharmacologically management
which via short duration type thing
anti-hypertensive agents
primarily that would be nitro paste something that has a rapid onset but a
short duration
once again note for these type of procedures I'm about to explain
EMTs need to check their local state laws
because some of this won't be allowed for EMTs depending on state to
now also if the person's blood pressure
is not about one fifty systolic then you can move right on to number twenty we'll get
to that a second
now if you're going to use an antihypertensive agent with this individual once again
nitro paste would be the selection of choice
it has a rapid onset short duration it quits delivery as soon as the nitropaste
tape is removed
once you
if you were determined to give a person some type of pharmacological
management for their blood pressure
continue to monitor the person's blood pressure
to look for signs of hypotension
because once you relieve the problem that's causing the dysreflexia
then you're going to have a problem with the person's blood pressure bottoming
bottoming out if you put him on some type of antihypertensive prior to that
so keep constant monitoring on the blood pressure
now if a fecal impaction is suspected
and if the blood pressure is less than one fifty systolic
then you'll check the rectum for stool
and do it in the following manner very much like catheterization
you'll use a topical anesthetic once again
to avoid anymore noxious stimulation to the individual
so get some two percent lidocaine jelly and instill it into the rectum
and wait a couple of minutes before you start checking
once you.. once a couple minutes have passed
using a gloved hand obviously and a
lubricated finger again with the
lidocaine jelly
check the rectum for stool and if there is any remove it
now oftentimes the
the stimulus regardless of the
anesthetic jelly
will cause a person's dysreflexia to increase
if that does happen what you want to do is stop and instill more of the topical
anesthetic and give them about twenty minutes for it to take
really good effect
alright now if these if this has not taking care of the problem
we need to start
looking for the less frequent causes at this point you've taken care of
loosening the clothing you've checked the urinary bladder
and all connective tubing and you've checked the bowels
at this point you may want to
consider hospitalizing the patient
until you find out what the cause is
now this is the follow-up care
any time a person has an episode of dysreflexia
they need to be instructed
to continue to monitor their symptoms for at least a couple of hours to make
sure that it doesn't re-occur
and part of that training will also be
educate the individual to
seek some medical attention should it recur
and if the person is an inpatient
then according to who his primary health care team is they should be
monitoring him
for all the signs and symptoms for two hours as well
once again you would consider admitting an individual to the hospital
primarily at the signs and symptoms of dysreflexia do not resolve
if you have not been able to find the problem
or if they just had a poor response to what you have done
anyway you may have to hospitalize them
and also
if you suspect there's any kind of obstetrical complications
in a female with
a spinal cord injury presenting with dysreflexia
further items in the follow-up include documenting the episode of dysreflexia
in the patient's medical record
that includes
all the presenting signs and symptoms and what their course was
throughout the episode what the treatment was that you
instituted with the individual
all the recordings of blood pressure readings and pulse and i'd like to point
out that
the reason for taking them every three to five minutes is once you find the cause
it will take the body three to five to even ten minutes before the blood
pressure goes back to its normal baseline
and another thing that you would want to include in your patient's records is
of course his response to treatment
you'll need to evaluate
the effectiveness of the treatment
according to the outcome
the outcomes are the obvious that the cause of dysreflexia has been
identified and resolved
that the blood pressure has gone back to its baseline
and here i point out that's ninety two hundred ten systolic it's not the one
twenty over eighty
that traditionally would be a baseline
Another criteria is that the press rate has gone back to normal and the
individual is comfortable exhibiting no further signs of dysreflexia
including the high blood pressure cranial pressure
or a risk of heart failure
once the person has been stabilized
you'll want to review the entire
cause of the dysreflexia episode with the individual
his friends his family his significant others and anyone who brought him
there or came
with him
so that they can be educated on it and understand why it happened and take care
of it in the future in a preventative fashion
which is number twenty seven
give the individual an educational plan
basically to prevent and to treat it in an emergency
on their own
and so basically you would adjust their treatment plan
so that they recognize those further episodes and that they can take care of
at home
and ideally they would avoid them altogether

in addition to that you want the person
to be able to minimize the risks of getting that and to solve the
problem when it comes up so they're not constantly calling nine one one if
their catheter's blocked or something like that
that they can understand exactly what's going on take the steps
to resolve it before it occurs so that there
they've reduced the incidence
and then if it does occur for whatever reason they can troubleshoot
and find out what's going on to resolve it themselves as quickly as possible
and at the time of the patient's discharge
you'll want to get them as much information about autonomic dysreflexia as possible
that includes a
consumer wallet card
that's available through
it has all the signs and symptoms
listed on it
and they come in both english and spanish
the card looks
like this
and that has all the signs and symptoms in and it even has the treatment program
written on it if you ever have a patient with spinal cord injury and you
suspect autonomic dysreflexia and they hand you this card please look at it i've
had the unfortunate occurrence myself
of having a dysreflexic episode
and i gave this to the EMTs they set it aside and gave it to the ER
physician and
they set it aside
spinal cord injury patients pretty much know their body and know what the
problems are
so it's very important to listen to the patient
but you do want to give the patient one of these cards they're available through
the PVA website
and then if you have a patient has continuously reoccurring autonomic
dysreflexia you need to schedule some detailed medical exams to find out
exactly what the underlying cause is
and this is important for the emergency room staff and for the EMTs you can get
the entire clinical guidelines
and the consumer guide
they're available to download on the paralyzed veterans of america website
that website is w_w_w_ dot p_v_a_ dot org
the particular documents that you'll want to download
are the ones that this presentation is taken from
as a professional clinical practice guidelines
which is the acute management of autonomic dysreflexia in
individuals with spinal cord injury presenting to health care facilities
the other document is autonomic dysreflexia what you should know that's the
consumer guide that's available both in english and spanish
print copies of these documents
are available through the PVA distribution center it has a toll-free number
one eight eight
eight six zero
seven two four four
and if you have further questions about this there's a PVA healthcare hotline
that you can also call toll free
that's one eight hundred
two three two
one seven eight two
again this presentation's been produced by myself doctor jerry ryan with the
oregon chapter of paralyzed veterans of america