Solving the Puzzle of Autonomic Dysreflexia

1. Solving the Puzzle of Autonomic Dysreflexia Amy J. Olson RN BSN Alverno Graduate Student amyjo@wi.rr.com

2. 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.

3. Objectives continued: (Microsoft office clip art, 2007) 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.

4. 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: Use this button in the lower right corner to go forward a page: Click on any underlined words to receive a definition, answer, or to be taken to another slide for more information. Use this button in the upper left corner to go back to the very last slide you viewed: (Microsoft Office Clip Art, 2007)

5. Menu Click on the topic to go directly to that page within the tutorial: Anatomy Causes Aging References Nursing Interventions Genetics Patho Nursing Outcomes Signs & Symptoms Epidemiology Altered Stress Response Case Study Inflammation

6. Review of the Anatomy of the Nervous System: (Microsoft Office Clip Art, 2007) (Porth & Matfin, 2009)

7. Anatomy of the Peripheral Nervous System (PNS) Click on the question for the answer: Which system is responsible for Autonomic Dysreflexia? (Porth & Matfin, 2009)

8. The Normal Sympathetic/Parasympathetic Responses: Negative feedback loop (Lewis et al, 2000, p. 1591)

9. What is Autonomic Dysreflexia (AD)? (Travers, 2009) 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. (Microsoft Office Clip Art, 2007)

10. Spinal Anatomy Review: Click the corresponding arrow on the diagram where autonomic dysreflexia can occur if the injury is on or above this level? Yes anything T6 and above! 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

11. Mr. Z Yes Right, T6 and above! No Are you sure? Go back to this slide! 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?

12. Mr. Z continued…. Click here to find out! By the 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?

13. Pathophysiology of Autonomic Dysreflexia What part of the PNS will be activated in response to the accumulation of these blocked nerve firings? Click on correct answer: Para- Sympathetic No! This is activated later! Sympathetic CORRECT! (Travers, 2009 )

14. Patho of Autonomic Dysreflexia continued: (Porth & Matfin, 2009, p. 1293). Microsoft clip art 2007

15. AD: The Altered Stress Response (Microsoft Office Clip Art, 2007) 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!

16. What does this mean? (Microsoft Office Clip Art, 2007) 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!

17. AD at a glance: What will happen to all the blood vessels BELOW Mr. Z’s injury? Click on the correct answer: Vaso- constriction Exactly! Vaso- dilation No, review the patho again Image reprinted with permission from eMedicine.com, 2011. Available at http://emedicine.medscape.com/article/322809-overview

18. Putting AD together: Click box when you are ready for the answer : What will happen to Mr. Z’s heart rate? 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. (Porth & Matfin, 2009, p. 1293)

19. AD’s influence on the (Microsoft Office Clip Art, 2007) (Porth & Matfin, 2009) Bradycardia Significant Atrial Distention:

20. Mr. Z Is probably Febrile No, reread this slide Has significant vasodilation of the vessels leading to his face Absolutely! This is due to the Parasympathetic activation Used with permission from Olson Family Photograph Collection (Olson, 2011) Upon closer assessment, you observe Mr. Z’s face is quite flushed and warm to the touch. You suspect Mr. Z :

21. Signs and Symptoms: headache Goose bumps sweating Blotchy skin Blurred vision Feeling of doom nasal congestion Cool peripheral extremities Pupils constrict (Porth & Matfin, 2009, pg. 1293) Besides bradycardia, hypertension, and a flushed face; what else might Mr. Z have? *Click on each sign/symptom for more information*

22. What do you do now? Place his head of bed up 90 degrees? Absolutely! Take advantage of a Quad’s orthostatic hypotension! Place his bed in trendelenberg position? No! This would further increase his BP! Mr. Z could stroke!!! Call the Resident to assess him? No, while you are calling, Mr. Z’s BP is climbing! Check his bladder for fullness or place a foley? No, you will do this but first intervene in his BP! You have assessed Mr. Z’s signs and symptoms and determined he is dysreflexic. What should you do next?

23. 1st Nursing interventions for AD: (Travers, 2009) 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. (Microsoft Office Clip Art, 2007)

24. 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)

25. In Mr. Z’s Case: Check the linen for a large wrinkle? No, this has been known to cause AD, but rule out the #1 cause first! Check for a developing pressure sore? No, this has been known to cause AD, but rule out the #1 cause first! Check his bladder for distension? Absolutely! This is the #1 most occurring cause for AD!!!! (Porth & Matfin, 2009) His BP is elevated (but not dangerously high YET, so you can now work to find the cause). What is the first place you should look?

26. The 3 Common Causes of AD: *Rule out each cause by working from the bottom up! Start with the most common cause first! (Travers, 2009)

27. Less Common Causes of AD: (Microsoft Office Clip Art, 2007) (Louis Calder Memorial Library of the University of Miami/Jackson Memorial Medical Center, 2009) 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

28. Urinary Management/Bladder Assessment in AD: (Travers, 2009) (Microsoft Clip Art, 2007) *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).

29. Back to Mr. Z….. Turn Mr. Z and assess for a skin impairment? No, remember to assess from the bottom – up! Review this slide Consult chart for last bowel movement while hospitalized? Absolutely, a full bowel is the #2 cause of AD! Lower head of bed and see if his BP has normalized? No! You haven’t found the cause yet, and this could cause Mr. Z to stroke!!!!! 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?

30. Mr. Z’s Chart Administer Mr. Z’s prn oral laxative? No, his BP will continue to climb while the laxative is absorbed! Mr. Z could have a stroke! Call the MD for a stool softener order? No, his BP will continue to climb while the stool softener is absorbed! Mr. Z could have a stroke! Turn Mr. Z to his side and attempt to remove any stool present? Yes! This is the only option that will attempt to remove the AD stimulus! 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?

31. Bowel Assessment/Management in AD: (Microsoft Office Clip Art, 2007) (Agency for Healthcare Research & Quality- U.S. Department of Health & Human Services, 2001) 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!

32. Mr. Z’s Bowel Assessment: (Microsoft Office Clip Art, 2007) 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).

33. What is the next intervention? Nifedipine Yes! This is available in sublingual form which allows for quick absorption Metoprolol No! This is an anti-hypertensive (Beta-Blocker), but it is not as fast acting as sublingual Nifedipine Timolol No! This is an anti-hypertensive (Beta-Blocker), but it is not as fast acting as sublingual Nifedipine (Microsoft Office Clip Art, 2007) 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? (Deglin & Vallerand, 1999)

34. Other Medications used for AD: (Microsoft Office Clip Art, 2007) (Agency for Healthcare Research & Quality – U.S. Department of Health & Human Services, 2001) • Sodium Nitroprusside • Isosorbidedinitrate • Nitroglycerin ointment • Hydralazine • Mecamylamine • Diazoxide • Phenoxybenzamine • Captopril • Prazosin

35. Special Considerations: (Microsoft Office Clip Art, 2007) If your 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).

36. 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)

37. Epidemiology of AD Will you take care of a high SCI injury who could have AD? (National SCI Statistical Center, 2010) 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!

38. Inflammation’s Role in AD: (Porth & Matfin, 2009) What will happen to these pain signals? Patho? Any Pressure Sore below the level of injury could cause AD: (Microsoft Office Clip Art, 2007)

39. 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) Nifedipine No! This is short acting. Review this slide! Low dose anti-hypertensive Yes! A pressure sore will take days to heal!

40. Aging and AD (Microsoft Office Clip Art, 2007) (Pine et al, 1991) SCI Patients are living longer than ever with advances in medical technology. HIGH risk for Atrial Fibrillation during AD!

41. Considerations for Elderly AD Candidates: Why? Thinner Skin with Age Decreased Bowel Motility Decrease in Bladder Size (Porth & Matfin, 2009) Give Nifedipine CAUTIOUSLY! At an increase Rx for developing the top 3 causes of AD:

42. Genetics & AD The Study? What does this mean for AD in SCI patients in the future? (Cameron et al, 2006) (Microsoft Office Clip Art, 2007) 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!

43. Nursing Outcomes Death Stroke Seizure Loss of Vision Loss of hearing Heart failure Kidney failure Nurses are key in prevention of further loss of functioning! Through prompt identification and management of AD, nurses will prevent adverse patient outcomes! Prevention of the following: (Microsoft Office Clip Art, 2007)

44. Educate Educate Educate! (Microsoft Office Clip Art, 2007) Click on all the answers that are right! Signs and Symptoms of AD! Absolutely! He has been a quad for a while – but this could save his life! Importance of adhering to Bowel Program! Absolutely! A full bowel is the #2 cause of AD! Mr. Z’s risk for developing Atrial Fibrillation with AD? Absolutely! He is 65 years old and is at risk! Important Nursing Outcome! Decrease Patient and family Knowledge Deficit Regarding AD! What about AD would you have wanted to teach to Mr. Z and his family?

45. 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!

46. 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

47. 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/​

48. 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: WoltersKluwer 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

49. 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