CHHS16/002

Canberra Hospital and Health ServicesClinical ProcedureAutonomic DysreflexiaContents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................2

Alerts.........................................................................................................................................2

Scope........................................................................................................................................ 2

Section 1 – Recognition of Autonomic Dysreflexia....................................................................2

Section 2 – Treatment of Autonomic Dysreflexia......................................................................4

Implementation........................................................................................................................ 4

Related Policies, Procedures, Guidelines and Legislation.........................................................5

References................................................................................................................................ 5

Search Terms............................................................................................................................ 5

Attachments..............................................................................................................................6

Doc Number Version Issued Review Date Area Responsible PageCHHS16/002 1 29 Jan 2016 01 Jun 2019 RACC 1 of 7

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS16/002

Purpose

This procedure provides information, direction and a clinical algorithm for the recognition and management of an episode of autonomic dysreflexia in spinal cord injured patients.

Scope

Alerts

An episode of autonomic dysreflexia is always considered a medical emergency and requires immediate intervention.

This procedure applies to nursing and medical staff who provide clinical care to spinal cord injured patients.

Nursing and medical staff providing clinical care to spinal cord injured patients must have current theoretical and clinical knowledge in the recognition and management of autonomic dysreflexia.

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Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

This Standard Operating Procedure (SOP) describes for staff the process to

CHHS16/002

One or more of the following signs and symptoms will be present: Sudden throbbing or pounding headache Sudden sweating above the level of the injury Sudden appearance of red/pink rash above the level of the injury Sudden pale skin below the level of the injury Sudden stuffy nose Apprehension or anxiety Hypertension Bradycardia

Headache is often the first sign that most spinal injured people are aware of. It is important to note that this is not the type of headache that starts slowly and gets worse over a number of hours. It is a sudden pounding headache which rapidly increases in pain and intensity. Most people with a spinal cord injury easily recognise this type of headache once they have experienced it once.

Common causes Bladder issues (most common cause of autonomic dysreflexia) - distended bladder,

kidney or bladder stones, urinary tract infection, blocked catheter, defective drainage system, high pressure voiding, insertion of a catheter, catheter tubing which is kinked.

Bowel issues - constipation, faecal impaction, rectal irritation (e.g. enema or manual evacuation), haemorrhoids.

Skin problems - ingrown toenail, pressure ulcer, contact burns, scalds or sunburn, tight clothing.

Other - any irritating/noxious stimulus including: fracture, epididymo-orchitis, distended stomach, deep vein thrombosis and labour or severe menstrual cramping.

Patients with a spinal cord injury at or above the T6 level should: Have an appropriate management plan for bladder and bowel care Have a current medication order for administration of medication as per treatment

algorithm (see attachment) Be educated in identifying causative factors, prevention strategies and early

management of autonomic dysreflexia.

Patients in the communityPatients in the community with a spinal cord injury at or above the T6 level are to consult with their General Practitioner to obtain ongoing prescriptions and ensure that the medication is available in their home during catheter changes attended to by community nurses.

The community nurse will leave an emergency catheter pack in the house containing a catheter, lubricant containing local anaesthetic, sterile gloves.

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Section 2 – Treatment of Autonomic DysreflexiaDoc Number Version Issued Review Date Area Responsible PageCHHS16/002 1 29 Jan 2016 01 Jun 2019 RACC 3 of 7

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CHHS16/002

First line treatment of autonomic dysreflexia Sit the person as upright as possible Remove or loosen all tight clothing – including binders, TED stockings, belts Commence treatment as per algorithm (see attachment - Treatment Algorithm for

Autonomic Dysreflexia (Hypertensive Crises) In Spinal Cord Injury, New South Wales Department of Health)

Note: Blood pressure for spinal cord injured patients is typically low e.g. 90-100/60mmg.If you are unable to take blood pressure or do not have access to this equipment follow the algorithm omitting the blood pressure section.

Note: Autonomic dysreflexia is always considered a medical emergency and can be life threatening. For patients in the community: Call 000 for ACT Ambulance Service if additional support is required.

Follow up careFollowing an episode of autonomic dysreflexia explain to the patient: They may experience a residual headache up to one week post the dysreflexic episode

(this is not the same intensity headache as in a dysreflexic episode). Try to avoid procedures that triggered the episode for at least 48 hours e.g. rectal

stimulation/catheter manipulation. There is a possibility of increased susceptibility to further episodes over the following

few days and it is important to remain vigilant with self care.

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ImplementationThis procedure is available on the ACT Policy Register for all staff.Community nurses are educated in the recognition and management of autonomic dysreflexia by the Nurse Practitioner Rehabilitation and Continence CNC.Nurses in the hospital are educated by the ward CDNs.

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Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

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Related Policies, Procedures, Guidelines and Legislation

PoliciesNursing and Midwifery Continuing Competence Policy

ProceduresCHHS Bowel Assessment and Management Clinical ProcedureCHHS Urology - catheter management and bladder irrigation Clinical Procedure

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References

Treatment Algorithm for Autonomic Dysreflexia (Hypertensive Crises) In Spinal Cord Injury, New South Wales Department of Health: Safety Notice 014/10 (2006 amended 2010).

Middleton J (2010) NSW State Spinal Cord Injury Service: Treatment of Autonomic Dysreflexia for adults and adolescents with spinal cord injuries. A medical emergency.

The Complete Drug Reference Copyright 2009 Pharmaceutical Press. (Captopril).

Krassioukov, A. Warburton, D. Teasell, R. A Systematic Review of the Management of Autonomic Dysreflexia Following Spinal Cord Injury. Arch Pphys Rehabil. 2009: 90(4): 682-695. 2009

Sweetman SC (2009). Martindale: The Complete Drug Reference (36th edition ed.). London: Pharmaceutical Press.

Sublingual captopril - a pharmacokinetic and pharmacodynamic evaluation. Al-Furaih TA, McElnay JC, Elborn JS, Rusk R, Scott MG, McMahon J, Nicholls DP. Eur J Clin Pharmacology 1991 40: 393-398.

Evaluation of Captopril for the Management of Hypertension in Autonomic Dysreflexia: A Pilot Study. Esmail Z, Shalansky KF, Sunderrji R, Anton H, Chambers K, Fish W. Archives of Physical Medicine & Rehabilitation 2002, Vol 83, 604-608.

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Search Terms

Autonomic dysreflexia, Dysreflexia, Hyperreflexia, Spinal cord injury, Dysreflexic, Autonomic nervous system, Catheter, Bowel

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Attachments

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CHHS16/002

Attachment 1: Treatment Algorithm for Autonomic Dysreflexia (Hypertensive Crises) In Spinal Cord Injury, New South Wales Department of Health

Disclaimer: This document has been developed by ACT Health, <Name of Division/ Branch/Unit> specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Date Amended Section Amended Approved ByEg: 17 August 2014 Section 1 ED/CHHSPC Chair

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CHHS16/002

Attachment 1: Treatment Algorithm for Autonomic Dysreflexia (Hypertensive Crises) In Spinal Cord Injury, New South Wales Department of Health

Doc Number Version Issued Review Date Area Responsible PageCHHS16/002 1 29 Jan 2016 01 Jun 2019 RACC 7 of 7

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register