The AD Dish

The scoop on Autonomic Dysreflexia … what it is and how to manage it

Autonomic Dysreflexia (AD) is a complex serious unrelenting medical condition common in individuals with complete spinal cord injury (SCI) at or above the T6 level. This condition occurs when there is pain below the level of injury or below the point where feeling is lost. Because of the complete SCI, the body’s typical response to pain is changed resulting in specific signs and symptoms, the most common being high blood pressure and pounding headaches. In some cases of severe AD, the blood pressure can be so high that brain hemorrhage and death can occur. However on most occasions, AD can be readily managed at home with knowledge of, monitoring for and diligent management of this condition.

What causes AD?

When a person experiences pain, one of the body’s responses is to constrict the blood vessels causing an increase in blood pressure. Pressure sensors in the aortic arch of the heart and the carotid arteries in the neck sense this increase in blood pressure and relay this information to a part of the brain stem that controls the size of the blood vessels in the body. Messages are then sent directly to the heart to slow it down by way of the vagus nerve and also sent down the spinal cord from the brain stem to tell the blood vessels to open up and lower the blood pressure. Just below the T6 level, a network of nerves come out of the spinal cord at multiple levels to control the majority of the body’s blood vessels. When these messages cannot get to this area of the spinal cord because of damage somewhere in between the brain stem and the T6 level, the blood vessels will not open up and the high blood pressure cannot be controlled. The blood pressure will continue to rise until the pain is relieved.

What are the Signs & Symptoms of AD?

-High blood pressure
-Slow pulse
-Pounding headache
-Blurred or spotty vision
-Nasal congestion
-Feelings of anxiety, apprehension, impending doom
-Cool, clammy skin below level of Injury
-Goosebumps, feeling chilled
-Flushed face, neck, shoulders, upper chest
-Sweating above level of injury

What Triggers AD?

Any uncomfortable, irritating or painful sensation below level of injury can trigger AD. However, over stretching of a hollow organ tends to be the most common cause.

Bladder Triggers

-A full bladder (due to blocks or kinks in catheter tubing, incomplete emptying or delaying/skipping a catheterization)
Urinary tract infection
-Bladder stones
-Severe bladder spasms
-Urethral instrumentation, i.e. cystoscopy

Bowel Triggers    

-Full bowels (too much stool and/or gas collect in the bowel due to incomplete emptying, constipation or impaction or blockage)
Digital stimulation

Skin Triggers      

-Irritations, rashes
-Wounds, pressure sores
-Burns, sunburn
-Insect bites
-Ingrown toenails
-Tight clothing, abdominal binder, condom catheter, seams in clothing
-Sitting on something, such as paper clip, wrinkled clothing or slings

Miscellaneous Triggers       

-Severe stomach problems, such as appendicitis, stomach ulcers or gall bladder disease or stones
-Broken bones
-Sexual intercourse
-Menstrual cramps
-Pregnancy, labor and delivery
-Sitting upon scrotal sack

How is AD Managed? 

The only way to relieve AD is to remove the cause of the pain. Keep in mind that once the cause is removed, there will be a sudden drop in blood pressure and relief of symptoms.


1. Place the person in a sitting position before the search is begun to promote a lowering of blood pressure within the head. Bolt upright is the best position, but if unable to obtain this position, elevate the head as high as possible. Once this is accomplished, seek out the cause and remove it

2. Since bladder over stretching tends to be the most common cause of AD, start the search here by doing the following:

  • If utilizing an Intermittent Catheterization Program, catheterize.  Use anesthetic ointment if available.
  • Check for kinks and blockages in urinary drainage tubes.  Remove kinks and replace drainage tubes.                                                                                                   
  • Check to see if urinary drainage bag is full or placed higher than bladder level. Empty drainage bag or lower it.

3. Check the bowel next and remove any stool. Use anesthetic ointment, if available, prior to inserting a gloved, lubricated finger. If symptoms worsen, stop until symptoms subside and then continue.

4. If neither the bladder nor the bowels are the cause, seek out other possibilities. While investigating bowel/bladder, most clothing has already been loosened or removed. Check for any other restrictive items, such as abdominal binder or Spanx products, and loosen them. Look for objects that may cause irritation or increased pressure to the skin.

5. If none of the above actions have resolved the AD, utilize Nitropaste if available, per physician instructions and travel to the nearest Emergency Department for treatment.  At this point, intravenous medication may be required to manage the blood pressure until the cause can be found.

Prevention is Key

For those who know they are susceptible to AD, prevention of this condition is the best management option. Diligent bowel and bladder management, adherence to skin protection strategies and monitoring of possible triggers can assist in keeping episodes of AD to a minimum. Communication of susceptibility to this condition is the responsibility of the person with SCI. Always keep in mind that some medical practitioners may not be aware of this SCI specific medical condition.

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Sonya Perduta-Fulginiti, RN, MS, CRRN, is the SCI Wellness Program Coordinator at Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center in Phoenix.


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