Have you ever heard of someone with a spinal cord injury suddenly developing high
blood pressure , severe headaches, and other symptoms? This is the condition we are going to talk about today, called Autonomic Dysreflexia, or AD for short. Don't worry, if you are aware of this, you can control it.
What is AD?
Simply put, Autonomic Dysreflexia (AD) is an abnormal, severe reaction in the nervous system that controls some of the automatic functions of your body (we call this the Autonomic
Nervous System ). It's like a big shock to something small. This
is most often seen in people who have had damage to the spinal cord, the nerve cord inside the spine . This risk is higher if there is damage to the upper chest, we say T6 level (Sixth Thoracic Vertebrae) or above. Now you may be wondering what this thoracic spine is. That is, the middle part of our spine. This is the longest part from the neck to the end of the ribs. It has 12 vertebrae, T1 to T12. The main symptom of AD is
a sudden increase in blood pressure ( hypertension ) . Along with this, a severe headache is also a major symptom. AD often first appears two to three months after a spinal injury and the resulting shock (Spinal Shock, Neurogenic Shock) has subsided. Many people can experience this condition several times in their lives. Some people, especially those with damage above the T6 level, are said to experience it up to 40 times a day. This AD is also called several other names, and your doctor may also call it one of these names: Autonomic Hyperreflexia, Hypertensive
Autonomic Crisis, Sympathetic Hyperreflexia.
Let's learn a little about our Autonomic Nervous System.
Okay, now let's look at what this Autonomic Nervous System is. This is the part of our body that controls many things without us thinking about them. Things like breathing,
heart rate ,
blood pressure , and digestion. This is like the automatic system of our body. There are three main parts to this autonomic nervous system:
- Sympathetic Nervous System (SNS): This is what prepares us for emergencies and dangers. It is the system that triggers the 'fight-or-flight' response.
- Parasympathetic Nervous System (PNS): This does the opposite of what the sympathetic does. That is, it calms the body and helps with the process of 'rest and digest'.
- Enteric Nervous System (ENS): This is what primarily manages our digestive process.
How does AD develop?
Now let's look at what happens when you develop AD. When your spine is damaged, below the point of injury, your sympathetic nervous system (SNS) is activated. As if the SNS is responding that you are in danger. As a result, the blood vessels in your lower body (like your legs, stomach) constrict (this is called vasoconstriction). This causes your blood pressure to rise suddenly. Normally, when your blood pressure increases like this, your parasympathetic nervous system (PNS) is activated, dilating the blood vessels (this is called vasodilation), bringing your blood pressure back to normal. We call this process the baroreflex. However, for someone with a spinal injury, this parasympathetic message cannot travel down from the point of injury. So, what happens is that the blood vessels only dilate in the upper part of the body (above the injury). This is why, because the blood vessels in the lower part of the body continue to constrict (due to the action of the SNS), the blood pressure remains dangerously high.
It's important to understand this: This is why a person with AD may experience different symptoms in different parts of their body at the same time. For example, the skin above the level of the lesion (such as the face, neck, and arms) may be red and sweaty. However, the skin below the lesion (such as the lower abdomen and legs) may be pale, cold, and dry.
Who is more likely to develop AD?
If you look at who gets AD the most, it's those who have spinal cord damage
at or above the T6 level (the sixth thoracic vertebra) . But not everyone gets it. You know, our spinal cord is like a path that carries messages from the brain throughout the body. It's protected by the vertebrae (back bones). Most often, spinal injuries occur in an accident, when this spine is broken by a strong blow. Then the broken bones compress the spinal cord, damaging the nerves in that area.
The risk of developing AD increases with the level of spinal cord damage and how severe the damage is (such as a complete rupture). It is estimated that about 90% of people with spinal cord injuries in the cervical spine or high-thoracic spine will develop AD. Furthermore, pregnant women with spinal injuries at T6 or above are at particular risk of developing AD during childbirth. Therefore, this should also be considered. What are the symptoms of AD?
The symptoms of AD can vary slightly from person to person, but they often come on suddenly. The first major symptom is a severe, throbbing headache. This is caused by a sudden, severe increase in blood pressure. In addition, AD can also cause the following symptoms:- Excessive sweating above the level of back pain.
- A heart rate that is slower than normal (this is called bradycardia).
- Redness of the skin above the lesion on the back and pale, dry skin below the lesion.
- Goosebumps on the body due to back pain.
- Cold skin.
- Nasal congestion.
- Nausea, vomiting.
- Blurred vision.
- Feeling of intense anxiety and fear.
Important: If you experience these symptoms, it is very important to seek medical advice as soon as possible. This could be an emergency.
What are the causes of AD?
The main cause of AD is the spinal cord injury that we have already discussed. The autonomic nervous system of people with AD is over-responsive to certain stimuli. Usually, when the body experiences a noxious stimulus below the level of the spinal cord injury, the sympathetic nervous system becomes highly activated, causing a large number of blood vessels to contract (vasoconstriction). This 'noxious stimulus' is anything that actually damages tissue and can cause pain, but sometimes the pain is not felt. It can be anything from an itch that you can't scratch to a full bladder. Apart from spinal cord injuries, there are some other conditions that can cause AD, but they are very rare:- Intramedullary Astrocytoma - A cancer of the central nervous system.
- Multiple Sclerosis (MS).
- Guillain-Barré Syndrome.
- Side effects of some medications.
- Severe head injuries and other brain disorders.
- Subarachnoid Hemorrhage (SAH) - bleeding in the brain.
- Use of illegal stimulant drugs such as cocaine and amphetamines.
Triggers of AD
If you are at risk for developing AD, it is important to be aware of the things that can trigger this condition. This way, you can avoid them and treat them quickly if AD symptoms appear. AD is often triggered by problems related to:- Bladder.
- Bowel (that means intestines).
- Skin.
Bladder-related causes
Bladder problems are the leading cause of AD - they account for about 85% of AD cases. Most often, the cause is a blockage in the passageway through which your urine flows, causing your bladder to fill too full (Bladder Distension). This can be caused by:- If you have a Foley catheter inserted, it may become kinked or blocked.
- Bladder spasms.
- Bladder stones.
- Urinary Tract Infections (UTIs).
Sometimes, tests such as cystoscopy or urodynamic testing can also trigger AD. Causes related to the large intestine
The large intestine, or bowel, is the second most common cause of AD. AD can occur when the intestines are overstretched. The reasons for this are:- Fecal impaction.
- Constipation.
- Flatulence, flatulence.
- Enemas.
- Manual defecation.
And other infectious conditions in the intestines, for example:- Diarrhea.
- Diverticulitis.
- Crohn's disease.
- Anal fissures.
- Hemorrhoids.
Things like this can also trigger AD. Skin-related causes
Skin problems are the third most common cause of AD. There are several possible causes:- Pressure injury / Bedsore.
- Cuts, bruises.
- Skin rashes.
- Clothes getting tight, snagging, getting too big.
- An itch that cannot be felt or scratched.
- Ingrown toenails.
How do you know if you have AD?
There is no single test that can definitively diagnose AD. Therefore, doctors and those who care for you will mainly base their diagnosis on the following:- Your medical history , especially information about a back injury.
- Your current blood pressure compared to your normal blood pressure. Generally, if your systolic blood pressure is more than 150 mmHg, or about 40 mmHg higher than your normal level, it is considered a sign of AD.
- Symptoms , especially severe headaches.
If you have symptoms of AD but don't think you have a spinal injury, your doctor may want to do a full examination of your nervous system and do other tests to find the cause of your symptoms. These may include:- Blood and urine tests.
- CT scan (CT - Computed Tomography scan) or MRI scan (MRI - Magnetic Resonance Imaging scan).
- ECG (Electrocardiogram - EKG).
- Spinal tap / Lumbar puncture.
- Tilt-table test.
- Drug tests.
- X-rays.
How is AD treated?
The first step in treating AD is to have the patient lie down, lower their legs, and remove any tight clothing. This helps to lower blood pressure. In most cases, AD goes away when the trigger is removed. Therefore, the next step is to identify and eliminate the trigger, if possible, before giving medication. For example, here are some things your doctor or caregiver can do to identify and correct the trigger:- Checking whether urine is flowing properly, or fixing it.
- If someone has a Foley catheter, check it for blockages or defects and fix them.
- Testing a urine sample to see if there is a urinary tract infection (UTI), and if so, giving antibiotics.
- Examine the rectum to see if there is a fecal impaction, and if so, remove the stool.
Many people who have experience with AD are well aware of this and are prepared to implement a treatment plan. In an emergency: If the trigger cannot be found, and basic measures do not lower the blood pressure, emergency treatment is needed to lower the blood pressure. In such a case, call 119 (or the appropriate emergency number), or seek medical help immediately.
You will then be given fast-acting medications such as nitrates, hydralazine, labetalol, or nifedipine to lower your blood pressure. During treatment, your medical team will monitor your vital signs and check your blood pressure frequently. Can AD be prevented?
It is not always possible to prevent AD. However, if you have a spinal injury, especially above the T6 level, these things may help prevent AD:- Emptying the bladder regularly and taking care not to let it fill up.
- Managing pain.
- Taking care of your intestines is essential to preventing stool blockage and constipation.
- Taking proper care of your skin is essential to preventing bedsores and skin infections.
- Preventing urinary tract infections (UTIs).
What will the AD situation be like? (Outlook)
The prognosis for AD is generally good, but only if these things happen:- If you, your caregiver, or your medical team recognize this early.
- If emergency corrective treatment is started quickly.
- If you and/or your caregivers are well-informed about the symptoms and triggers of AD.
- If you, your caregiver, or your medical team take proper precautions to prevent AD.
However, severe AD conditions that are not treated promptly and properly can have serious consequences. For example:- Brain damage due to high blood pressure (Hypertensive Encephalopathy).
- Stroke.
- Cardiac arrest.
- Seizure.
- Death.
Fortunately, deaths from AD are very rare. If you are at risk for AD, what should you do?
You and your loved ones need to be involved in recognizing AD symptoms. As soon as you start to feel the symptoms of AD, sit up and start treatment. You may fall, injure yourself, or lose consciousness, so call for help. If you can’t find a trigger, or if the right treatment doesn’t help, someone should call 119 (or the appropriate emergency number). It’s also important to keep an Emergency Treatment Pack with you, if your doctor has prescribed it, and a leaflet with information about AD. This will help even those who don’t know about AD. If you’ve had AD symptoms before, you should let all your doctors, caregivers, and loved ones know about your condition. So that if it happens again, they’ll know, even if you don’t have time to ask for help. Remember as a summary
Autonomic dysreflexia (AD) is a condition that can be life-threatening. But the good news is that it can be treated – often by removing or modifying the trigger. If you are at risk for developing AD, it is important for you and your loved ones to learn all you can about it. Then you can recognize the symptoms and get treatment for AD quickly. Talk to your medical team about ways to avoid triggers. They are ready to help you. Remember, this is nothing to be afraid of, awareness is the greatest protection!
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