12

, 4 5 2013, ,

, 01 2013

-
, 01 2013

 >6

shock shock

Silver JR. Early autonomic dysreexia. Spinal Cord. 2000; 38(4):22933 Krassioukov AV, Furlan JC, Fehlings MG. Autonomic dysreexia in acute spinal cord injury: An under-recog- nized clinical entity. J Neurotrauma. 2003;20(8):70716.
, 01 2013



shock

50-90%

(>6)

(paroxysmal hypertension Thompson and Witham, 1948) (paroxysmal neurogenic hypertension - Mathias et al.,1976) (sympathetic hyperreexia - Young, 1993) (autonomic spasticity McGuire and Kumar, 1986)

Corbett et al.,1975; Lindan et al.,1980; Mathias and Frankel,1993; Lee et al.,1995; Giannantoni et al., 1998;Vaidyanathan et al., 1998; Karlsson, 1999; Krassioukov et al., 2003
, 01 2013

Bladder distention Urinary tract infection Cystoscopy Urodynamics Detrusor-sphincter dyssynergia[5] Epididymitis or scrotal compression Bowel distention Bowel impaction Gallstones Gastric ulcers or gastritis Invasive testing Hemorrhoids Gastrocolic irritation Appendicitis or other abdominal pathology trauma Menstruation Pregnancy - Especially labor and delivery Vaginitis Sexual intercourse Ejaculation Deep vein thrombosis Pulmonary emboli Pressure ulcers Ingrown toenail Burns or sunburn Blisters Insect bites Contact with hard or sharp objects Temperature fluctuations Constrictive clothing, shoes, or appliances Heterotopic bone Fractures or other trauma Surgical or diagnostic procedures Pain

- (;) , - -

The great Windmill Street School of Anatomy. Spinal Cord (2011) 49, 323

, 01 2013

( >20mmHg) ( 90-110mmHg)
15mm Hg

The great Windmill Street School of Anatomy. Spinal Cord (2011) 49, 323

, 01 2013

silent

( ): silent

autonomic dysreexia

The great Windmill Street School of Anatomy. Spinal Cord (2011) 49, 323

, 01 2013

Hypotension

Operational definition: Sustained decrease in BP >20 mmHg systolic or >10 mmHg diastolic occurring within 3 min when individual moves fro supine to upright posture. Severity: Symptomatic (dizziness, headache, fatigue) or asymptomatic.

Dysreflexia

Operational definition: Constellation of signs/symptoms in SCI above T5 in response to noxious or nonnoxious stimuli below injury level, including Report of the committee ASIAbaseline, and the ISCoS concerning increase injoint BP >20 mmHgof above and may include the one or more o development of assessment for general autonomic function testing following: headache, criteria flushing and sweating above lesion level, vasoconstri following spinal cord injury (SCI). below lesion level, or dysrhythmias. May or may not be symptomatic and occur at any time following SCI. Severity: Mild/partial, BP increase <40 mmHg; Moderate, SBP rise >40 mmHg, but SBP <180 mmHg; Severe, SBP >180 mmHg. Associated symptoms: piloerection, stuffy nose, other.

Dysregulation

Elevation or decrease of body temperature without signs of infection. M Andrei V. Krassioukov,et al. J of Rehabilitation Research & Development, Vol 44 (1), 2007 result from exposure to environmental temperature change.

sturbances osis

sis
, 01 2013

Nonphysiological sweating over portion of body in response to noxious nonnoxious stimuli, positioning, etc. Lack of sweating in denervated areas in response to rise in temperature.

The great Windmill Street School of Anatomy. Spinal Cord (2011) 49, 323

-
:

( <60). ( , , )

The great Windmill Street School of Anatomy. Spinal Cord (2011) 49, 323

, 01 2013

-
:

The great Windmill Street School of Anatomy. Spinal Cord (2011) 49, 323

, : (, , ), ushing :

, 01 2013

91% motor-complete SCI (ASIA A or ASIA B) % (1-6 ) 27% (ASIA C,D) ,

The great Windmill Street School of Anatomy. Spinal Cord (2011) 49, 323

, 01 2013

 Malignant autonomic dysreexia

.

30min , /

(;) ( )

S Elliott, and A Krassioukov, Spinal Cord (2006) 44, 386392

, 01 2013

2009,
- - (somatomotoric) - (somatosensoric) REVIEW - (visceromotoric) International standards to document remaining autonomic - (viscerosensoric) Appendix function after spinal cord injury
& 2009 International Spinal Cord Society All rights reserved 1362-4393/09 $32.00
www.nature.com/sc
6 7 Autonomic Standard MS Alexander1, F Biering-Sorensen2, D Bodner3, NL Brackett4, D Cardenas4, S Charlifue5, G Creasey , V Dietz , Assesment Form 8 11 9 10 11 12 4 1 J Ditunno , W Donovan , SL Elliott , I Estores , DE Graves , B Green , A Gousse , AB Jackson , M Kennelly13, A-K Karlsson14, A Krassioukov9, K Krogh15, T Linsenmeyer16, R Marino8, CJ Mathias17, I Perkash6, 9 AW Name Sheel , G Shilero18, B Schurch7, J Sonksen19, S Stiens20, J Wecht18, LA Wuermser21 and J-J Wyndaele22 Patient ____________________________________
Examiner Name __________________________________ Date/Time of Exam___________________ 1 2

Spinal Cord (2009) 47, 3643

International standards to document autonomic function MS Alexander et al

University of Alabama, Birmingham, AL, USA; Rigshospitalet and University of Copenhagen, Copenhagen, Denmark; 3Case Western Reserve University, Cleveland, OH, USA; 4University of Miami, Miami, FL, USA; 5Craig Hospital, Englewood, CO, USA; STANDARD NEUROLOGICAL 6 7 CLASSIFICATION 8 Stanford University, Palo Alto, CA, USA; University OF SPINAL CORD INJURY Hospital Balgrist, Zurich, Switzerland; Thomas Jefferson University, 9 Philadelphia, PA, USA; International Collaboration On Repair Discoveries (ICORD), University of British Columbia and Vancouver Coastal Health, Vancouver, British Columbia, Canada; 10James A Haley VA Hospital, Tampa, FL, USA; 11Baylor College of Medicine, Houston, TX, USA; 12Shepherd Center, Atlanta, GA, USA; 13McKay Urology, Carolinas Healthcare, Charlotte, NC, USA; 14 Sahlgrenska University Hospital, Gothenburg, Sweden; 15Aarhus University Hospital, Aarhus, Denmark; 16Kessler Institute for (distal phalanx ofNJ, middle finger) Rehabilitation, West Orange, USA; 17Imperial College, St Marys Hospital, London, UK; 18James J Peters Veterans Affairs Medical (little finger) 19 Center, Bronx, NY, USA; Herlev Hospital, University of Copenhagen, Copenhagen, Denmark; 20Veterans Affairs Puget Sound Health Care, Seattle, WA, USA; 21Mayo Clinic, Rochester, MS, USA and 22University Hospital Antwerp, University Antwerp, Antwerp, Belgium
(scoring on reverse side)

Comments:

Study design: Experts opinions consensus. Objective: To develop a common strategy to document remaining autonomic neurologic function following spinal cord injury (SCI). Background and Rationale: The impact of a specific SCI on a persons neurologic function is generally described through use of the International Standards for the Neurological Classification of SCI. These standards document the remaining motor and sensory function that a person may have; however, they do not provide information about the status of a persons autonomic function. Methods: Based on this deficiency, the American Spinal Injury Association (ASIA) and the International Spinal Cord Society (ISCoS) commissioned a group of international experts to develop a common strategy to document the remaining autonomic neurologic function. Results: Four subgroups were commissioned: bladder, bowel, sexual function and general autonomic function. On-line communication was followed by numerous face to face meetings. The information was then presented in a summary format at a course on Measurement in Spinal Cord Injury, held on June 24, 2006. Subsequent to this it was revised online by the committee members, posted on the websites of both ASIA and ISCoS for comment and re-revised through webcasts. Topics include an overview of autonomic anatomy, classification of cardiovascular, respiratory, sudomotor and thermoregulatory function, bladder, bowel and sexual function. Conclusion: This document describes a new system to document the impact of SCI on autonomic function. Based upon current knowledge of the neuroanatomy of autonomic function this paper provides a framework with which to communicate the effects of specific spinal cord injuries on cardiovascular, broncho-pulmonary, sudomotor, bladder, bowel and sexual function.
REV 03/06

Spinal Cord (2009) 47, 3643; doi:10.1038/sc.2008.121; published online 28 October 2008 , 01 2013

, 01 2013

CONCISE GUIDANCE TO GOOD PRACTICE

A series of evidence-based guidelines for clinical management

Symptoms or signs of AD (eg pound i ng h e ad ach e, f l ush i ng, swe at i ng or b lotch i ng ski n above i n j ur y l e ve l ; p al e, cold, goose bumps be low)

NUMBER 9

Chronic spinal cord injur y: management of patients in acute hospital settings

NATIONAL GUIDELINES

Check blood pressure Con f irm d iagnosis (b lood pressure gre ater t h a n 200/100 or 2040 mmHg h igh er t h a n norm al)

Sit the patient up avoid lying down

Fe bru ar y 2008

BASCIS

For patients with catheter: e mpty l eg b ag a nd note vol ume ch eck t ub i ng not b locke d/ ki n ke d i f cat h eter b locke d re move a nd re-cat h eterise usi ng l ubrica n t con t ai n i ng lidocai n e

For patients without catheter: i f b ladder d iste nde d a nd p at i e n t un ab l e to p ass uri n e i nsert cat h eter usi ng l ubrica n t con t ai n i ng lidocai n e

If bladder distension excluded gently examine per rectum For f a ecal m ass i n rect um: ge n t ly i nsert glove d f i nger covere d i n lidocai n e j e lly i n to rect um a nd re move f a ecal m ass

If symptoms persist or cause is unknown Give n i f e d ip i n e or glycer yl tri n trate (GTN). In adu l ts, p lace sub li ngu ally: t h e con te n ts of a 10 mg sub li ngu al n i f e d ip i n e capsu l e or 12 GTN t ab l ets. Re pe at dose ca n be give n a f ter 20 m i nu tes, i f symptoms persist .

If blood pressure remains high, then an IV hypotensive may be required: hydralazi n e 20 mg iv slowly or d iazoxide 20 mg bol us. Con t i nu e to se arch for ca use a nd mon i tor b lood pressure . May require management on high dependency unit if problem persists. Contact a spinal cord injur y centre for further advice (see Appe nd ix 4).

, 01 2013



, (McGillivray et al, 2006). , . , .

, 01 2013

cated as grade of recommendationB/C). In situcare. The resulting rankings were provided to the ations where no Date published literature existed, panel members during the writing and deliberation Autonomic Dysreexia Guideline Development Panel: Released of2006) the panel members and outside process. If the literature supporting 1997 a guideline Feb (updated 2001 consensus Jul; reviewed expert reviewers was used to develop the guideline recommendation came from two or more levels, Guideline Developer(s) Acute Management recommendation and the grade of recommendathe level of each study is reported (e.g., inSpinal the Cord Medicine Consortium for - Nonprot Organization of Autonomic Dysreflexia: tion is indicated as expert consensus. case of a guideline recommendation that was supParalyzed Veterans of America Nonprot Organization ported by two studies, one a level III, the other a level V , the scientific evidence was indicated as EFLEXIA TA B L E 2 III/V). Categories of the Strength of Evidence Next, each of the guideline recommendations Associated with the Recommendation was classified, according to the level of scientific Category Description TA B L E 1 evidence used in the development of the recomA The guideline recommendation is supported by Hierarchy of the Levels of Scientific Evidence onmendation. The schema used by the panel is one or more level I studies shown in table 2. It should be emphasized that 4 Level Description B The guideline recommendation is supported by these ratings, like those just described, ned I Large randomized trials with clear-cut represent results (and one or more level II studies the strength of the supporting evidence, not the low risk of error) C The guideline recommendation is supported only strength of the recommendation itself. The II Small randomized trials with uncertain results by level III, IV, or V studies strength of the recommendation is indicated by the (and moderate to high risk of error) language describing the rationale. Sources: Sackett, D.L., Rules of evidence and clinical recommendations on Category A requires thatconcurrent the guideline recomIII Nonrandomized trials with or contemthe use of antithrombotic agents, Chest 95 (2 Supp) (1989): 2S-4S; and U.S. poraneous controls he mendation be supported by scientific evidence Preventive Health Services Task Force, Guide to Clinical Preventive Services: An Assessment of the Effectiveness of 169 Interventions, 2nd from at least one properly designed and impleIV Nonrandomized trials with historical controls C LINIC AL PRA CTICE GUIDELINES Edition (Baltimore: Williams and Wilkins, 1996). mented randomized, controlled trial, providing staU.S. V Case series with controls support the tistical results thatno consistently preguideline statement. Category B requires that the TA B L E 3 Strength of Panel Opinion guideline recommendation be supported by scienSources: Sackett, D.L., Rules of evidence and clinical recommendations on Levels of Panel Agreement with the Guideline the use of antithrombotic agents, Chest 95 (2 Supp) (1989): 2S-4S; and U.S. After deliberation and discussion of each Recommendation udy Preventive Health Services Task Force, Guide to Clinical Preventive guideline recommendation the supporting eviServices: An Assessment of the Effectivenessand of 169 Interventions , 2nd Level Mean Agreement Score s Edition (Baltimore: Williams and Wilkins, 1996). dence, the level of expert panel agreement with nd Low 1.0 to less than 2.33 the recommendation was assessed as either low, riteModerate 2.33 to less than 3.67 moderate, or strong. In this assessment, each tificpanel evidence from at least one small randomized zamember was asked to indicate his or her Strong 3.67 to 5.0 trial with uncertain results; this category also may level of agreement on a 5-point scale, with 1 corinclude small randomized certain results finiresponding to neutrality trials and 5with representing maxiwhere statistical power is members low. Category recommum agreement. Panel couldC abstain 2013 mendations supported by nonrandomd , 01 from this are voting process either for a variety of reasons,
CLINICAL PRACTICE GUIDELINES AUTONOMIC DYSREFLEXIA

SPINAL

CORD

MEDICINE

Individuals with Spinal Cord Injury Presenting to Health-Care Facilities 2nd Edition

Administrative and financial support provided by Paralyzed Veterans of America Printing provided by Eastern Paralyzed Veterans Association

AUTONOMIC DYSREFLEXIA

SPINAL

CORD

MEDICINE

CLINICAL PRACTICE GUIDELINES

Acute Management of Autonomic Dysreflexia:

Individuals with Spinal Cord Injury Presenting to Health-Care Facilities 2nd Edition

Autonomic Dysreexia Guideline Development Panel: Date Released 1997 Feb (updated 2001 Jul; reviewed 2006) Guideline Developer(s) Consortium for Spinal Cord Medicine - Nonprot Organization Paralyzed Veterans of America - Nonprot Organization

Administrative and financial support provided by Paralyzed Veterans of America Printing provided by Eastern Paralyzed Veterans Association

Recognize the signs and symptoms of autonomic dysreexia, including: Elevated blood pressure. Pounding headache. Bradycardia (may be a relative slowing so that the heart rate is still within the normal range). Profuse sweating above the level of the lesion, especially in the face, neck, and shoulders, or possibly below the level of the lesion. Piloerection or goose bumps above or possibly below the level of the lesion. Cardiac arrhythmias, atrial brillation, premature ventricular contractions, and atrioventricular conduction abnormalities. Flushing of the skin above the level of the lesion, especially in the face, neck, and shoulders, or possibly below the level of lesion. Blurred vision. Appearance of spots in the patients visual elds. Nasal congestion. Feelings of apprehension or anxiety over an impending physical problem. Minimal or no symptoms, despite a signicantly elevated blood pressure (silent autonomic dysreexia).

Scientic evidenceNone; Grade of recommendation Expert consensus; Strength of panel opinionStrong

, 01 2013

AUTONOMIC DYSREFLEXIA

SPINAL

CORD

MEDICINE

CLINICAL PRACTICE GUIDELINES

Acute Management of Autonomic Dysreflexia:

Individuals with Spinal Cord Injury Presenting to Health-Care Facilities 2nd Edition

Autonomic Dysreexia Guideline Development Panel: Date Released 1997 Feb (updated 2001 Jul; reviewed 2006) Guideline Developer(s) Consortium for Spinal Cord Medicine - Nonprot Organization Paralyzed Veterans of America - Nonprot Organization

Administrative and financial support provided by Paralyzed Veterans of America Printing provided by Eastern Paralyzed Veterans Association

Check the individuals blood pressure: A sudden, signicant increase in both the systolic and diastolic blood pressure above their usual levels, frequently associated with bradycardia. An in- dividual with SCI above T6 often has a normal systolic blood pressure in the 90110 mm Hg range. Therefore, a blood pressure of 20 mm to 40 mm Hg above baseline may be a sign of autonomic dysreexia. Systolic blood pressure elevations more than 1520 mm Hg above baseline in adolescents with SCI or more than 15 mm Hg above baseline in children with SCI may be a sign of AD.

Scientic evidenceIII/V; Grade of recommendationC; Strength of panel opinionStrong

, 01 2013

AUTONOMIC DYSREFLEXIA

SPINAL

CORD

MEDICINE

CLINICAL PRACTICE GUIDELINES

Acute Management of Autonomic Dysreflexia:

Individuals with Spinal Cord Injury Presenting to Health-Care Facilities 2nd Edition

Autonomic Dysreexia Guideline Development Panel: Date Released 1997 Feb (updated 2001 Jul; reviewed 2006) Guideline Developer(s) Consortium for Spinal Cord Medicine - Nonprot Organization Paralyzed Veterans of America - Nonprot Organization

If a pregnant woman with a spinal cord injury at T6 or above presents with signs and symptoms of autonomic dysreexia, consider referral to an obstetric health-care provider under the following circumstances: Determination of choice of antihypertensive medication. Persistent hypertension after resolution of the acute autonomic dysreexia episode. Persistent symptoms of autonomic dysreexia despite acute care measures. Life-threatening autonomic dysreexia. Autonomic dysreexia episode occurring in the third trimester of pregnancy. Hypotension requiring pharmacological treatment. First episode of autonomic dysreexia during the pregnancy. Presence of vaginal bleeding or suspicion of labor. Decisions to be made about long-term medication use. Unclear about the causes, signs, and symptoms, despite a normal blood pressure.

Administrative and financial support provided by Paralyzed Veterans of America Printing provided by Eastern Paralyzed Veterans Association

Scientic evidenceNone; Grade of recommendation Expert consensus; Strength of panel opinionStrong

, 01 2013

AUTONOMIC DYSREFLEXIA

SPINAL

CORD

MEDICINE

CLINICAL PRACTICE GUIDELINES

Acute Management of Autonomic Dysreflexia:

Individuals with Spinal Cord Injury Presenting to Health-Care Facilities 2nd Edition

Autonomic Dysreexia Guideline Development Panel: Date Released 1997 Feb (updated 2001 Jul; reviewed 2006) Guideline Developer(s) Consortium for Spinal Cord Medicine - Nonprot Organization Paralyzed Veterans of America - Nonprot Organization

Administrative and financial support provided by Paralyzed Veterans of America Printing provided by Eastern Paralyzed Veterans Association

If signs or symptoms of AD are present, but the blood pressure is not elevated and the cause has not been identied, refer the individual to an appropriate consultant depending on symptoms. Other medical problems may be causing the signs and symptoms of autonomic dysreexia. Scientic evidenceNone; Grade of recommendation- Expert consensus; Strength of panel opinionStrong

, 01 2013

AUTONOMIC DYSREFLEXIA

SPINAL

CORD

MEDICINE

CLINICAL PRACTICE GUIDELINES

Acute Management of Autonomic Dysreflexia:

Individuals with Spinal Cord Injury Presenting to Health-Care Facilities 2nd Edition

Autonomic Dysreexia Guideline Development Panel: Date Released 1997 Feb (updated 2001 Jul; reviewed 2006) Guideline Developer(s) Consortium for Spinal Cord Medicine - Nonprot Organization Paralyzed Veterans of America - Nonprot Organization

If the blood pressure is elevated, immediately sit the person up if the

Administrative and financial support provided by Paralyzed Veterans of America Printing provided by Eastern Paralyzed Veterans Association

individual is supine. Scientic evidenceIII/V; Grade of recommendationC; Strength of panel opinionStrong Loosen any clothing or constrictive devices. Scientic evidenceIII/V; Grade of recommendationC; Strength of panel opinionStrong Monitor the blood pressure and pulse frequently. Scientic evidenceIII/V; Grade of recommendationC; Strength of panel opinionStrong Quickly survey the individual for the instigating causes, beginning with the urinary system. Scientic evidenceIII/V; Grade of recommendationC; Strength of panel opinionStrong If an indwelling urinary catheter is not in place, catheterize the individual. Scientic evidenceNone; Grade of recommendationExpert consensus; Strength of panel opinionStrong Prior to inserting the catheter, instill 2 percent lidocaine jelly (if immediately avail- able) into the urethra and wait 2 minutes, if possible. Scientic evidenceNone; Grade of recommendation Expert consensus; Strength of panel opinionStrong

, 01 2013

AUTONOMIC DYSREFLEXIA

SPINAL

CORD

MEDICINE

CLINICAL PRACTICE GUIDELINES

Acute Management of Autonomic Dysreflexia:

Individuals with Spinal Cord Injury Presenting to Health-Care Facilities 2nd Edition

Autonomic Dysreexia Guideline Development Panel: Date Released 1997 Feb (updated 2001 Jul; reviewed 2006) Guideline Developer(s) Consortium for Spinal Cord Medicine - Nonprot Organization Paralyzed Veterans of America - Nonprot Organization

If fecal impaction is suspected and the elevated blood pressure is less than 150 mm Hg, check the rectum for stool, using the following procedure: With a gloved hand, instill a topical anesthetic agent, such as 2 percent lidocaine jelly, generously into the rectum. Wait 2 minutes if possible for sensation in the area to decrease. Then, with a gloved hand, insert a lubricated nger into the rectum and check for the presence of stool. If present, gently remove, if possible. If autonomic dysreexia becomes worse, stop the manual evacuation. Instill additional topical anesthetic and recheck the rectum for the presence of stool after approximately 20 minutes. Scientic evidenceII/V; Grade of recommendationB/C; Strength of panel opinionStrong

Administrative and financial support provided by Paralyzed Veterans of America Printing provided by Eastern Paralyzed Veterans Association

, 01 2013

AUTONOMIC DYSREFLEXIA

SPINAL

CORD

MEDICINE

CLINICAL PRACTICE GUIDELINES

Acute Management of Autonomic Dysreflexia:

Individuals with Spinal Cord Injury Presenting to Health-Care Facilities 2nd Edition

Autonomic Dysreexia Guideline Development Panel: Date Released 1997 Feb (updated 2001 Jul; reviewed 2006) Guideline Developer(s) Consortium for Spinal Cord Medicine - Nonprot Organization Paralyzed Veterans of America - Nonprot Organization

Administrative and financial support provided by Paralyzed Veterans of America Printing provided by Eastern Paralyzed Veterans Association

Use an antihypertensive agent with rapid onset and short duration while the causes are being investigated & BP a systolic blood pressure >150mmHg 120 mm Hg in infants and younger children (under 5 years old) 130 mm Hg in older children (612 years old) 140 mm Hg in adolescents

Scientic evidenceV; Grade of recommendationC; Strength of panel opinionStrong

Monitor the individual for symptomatic hypotension.

Scientic evidenceNone; Grade of recommendation Expert consensus; Strength of panel opinionStrong

, 01 2013

Therapeutic management of Autonomic Dysreexia

International Collaboration on Repair Discoveries (ICORD), Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia, and GF Strong Rehab Centre,Vancouver, Canada. review of 40 studies (6 RCTs):

Andrei Krassioukov

THERAPEUTIC MANAGEMENT of acute AD Preventative strategies to reduce the episodes of AD caused by common triggers (e.g. urogenital system, surgery) initial acute non-pharmacological management of an episode of AD (i.e.

LEVEL OF EVIDENCE
Level 4 (pre-post studies) Level 5 (observational studies) Level 5 (clinical consensus and physiological data)
Level 2 evidence (nifedipine and prostaglandin E2) Level 5 (nitrates) Level 4 (captopril) Level 1 (prazosin)

positioning the patient upright, loosening tight clothing, and eliminating any precipitating stimulus)

use of antihypertensive drugs in the presence of sustained elevated blood pressure

, 01 2013

AUTONOMIC DYSREFLEXIA

SPINAL

CORD

MEDICINE

CLINICAL PRACTICE GUIDELINES

Acute Management of Autonomic Dysreflexia:

Individuals with Spinal Cord Injury Presenting to Health-Care Facilities 2nd Edition

Autonomic Dysreexia Guideline Development Panel: Date Released 1997 Feb (updated 2001 Jul; reviewed 2006) Guideline Developer(s) Consortium for Spinal Cord Medicine - Nonprot Organization Paralyzed Veterans of America - Nonprot Organization

Administrative and financial support provided by Paralyzed Veterans of America Printing provided by Eastern Paralyzed Veterans Association

Following an episode of autonomic dysreexia, instruct the individual to monitor symptoms and blood pressure for at least 2 hours after resolution of the episode to make sure that it does not reoccur. Educate the individual to seek immediate medical attention if it reoccurs. Monitor inpatients closely for at least 2 hours, as deemed necessary by the health-care provider. Seek the pregnant womans obstetrical- care provider for evaluation. Scientic evidenceNone; Grade of recommendation Expert consensus; Strength of panel opinionStrong

, 01 2013

AUTONOMIC DYSREFLEXIA

SPINAL

CORD

MEDICINE

CLINICAL PRACTICE GUIDELINES

Acute Management of Autonomic Dysreflexia:

Individuals with Spinal Cord Injury Presenting to Health-Care Facilities 2nd Edition

Autonomic Dysreexia Guideline Development Panel: Date Released 1997 Feb (updated 2001 Jul; reviewed 2006) Guideline Developer(s) Consortium for Spinal Cord Medicine - Nonprot Organization Paralyzed Veterans of America - Nonprot Organization

Administrative and financial support provided by Paralyzed Veterans of America Printing provided by Eastern Paralyzed Veterans Association

Consider admitting the individual to the hospital for monitoring to maintain pharmacologic control of the blood pressure, and to investigate other causes: If there is poor response to the treatment specied above. If the cause has not been identied. If there is suspicion of an obstetrical complication.

Scientic evidenceV; Grade of recommendationC; Strength of panel opinionStrong

, 01 2013

AUTONOMIC DYSREFLEXIA

SPINAL

CORD

MEDICINE

CLINICAL PRACTICE GUIDELINES

Acute Management of Autonomic Dysreflexia:

Individuals with Spinal Cord Injury Presenting to Health-Care Facilities 2nd Edition

Autonomic Dysreexia Guideline Development Panel: Date Released 1997 Feb (updated 2001 Jul; reviewed 2006) Guideline Developer(s) Consortium for Spinal Cord Medicine - Nonprot Organization Paralyzed Veterans of America - Nonprot Organization

Administrative and financial support provided by Paralyzed Veterans of America Printing provided by Eastern Paralyzed Veterans Association

Schedule detailed evaluations for individuals with recurrent autonomic dysreexia.

a worsening of detrusor sphincter dyssynergia an expanding syrinx

Scientic evidenceNone; Grade of recommendation Expert consensus; Strength of panel opinionStrong

, 01 2013

AUTONOMIC DYSREFLEXIA

SPINAL

CORD

MEDICINE

CLINICAL PRACTICE GUIDELINES

Acute Management of Autonomic Dysreflexia:

Individuals with Spinal Cord Injury Presenting to Health-Care Facilities 2nd Edition

Autonomic Dysreexia Guideline Development Panel: Date Released 1997 Feb (updated 2001 Jul; reviewed 2006) Guideline Developer(s) Consortium for Spinal Cord Medicine - Nonprot Organization Paralyzed Veterans of America - Nonprot Organization

Administrative and financial support provided by Paralyzed Veterans of America Printing provided by Eastern Paralyzed Veterans Association

, , , . , , , , . > T6 , . .

, 01 2013

AUTONOMIC DYSREFLEXIA

SPINAL

CORD

MEDICINE

CLINICAL PRACTICE GUIDELINES

Acute Management of Autonomic Dysreflexia:

Individuals with Spinal Cord Injury Presenting to Health-Care Facilities 2nd Edition

Autonomic Dysreexia Guideline Development Panel: Date Released 1997 Feb (updated 2001 Jul; reviewed 2006) Guideline Developer(s) Consortium for Spinal Cord Medicine - Nonprot Organization Paralyzed Veterans of America - Nonprot Organization

preventive process entails: Adjusting the treatment plan to ensure that future episodes are recognized and treated to prevent a medical crisis or, ideally, are avoided altogether. Discussing autonomic dysreexia during the individuals education program, so that he or she will be able to minimize the risks known to precipitate AD, solve problems, recognize early onset, and obtain help as quickly as possible. Providing the individual with education about the prevention and treatment of autonomic dysreexia at the time of discharge that can be referred to in an emergency. Scientic evidenceNone; Grade of recommendation Expert consensus; Strength of panel opinionStrong

Administrative and financial support provided by Paralyzed Veterans of America Printing provided by Eastern Paralyzed Veterans Association

, 01 2013

Therapeutic management of Autonomic Dysreexia

International Collaboration on Repair Discoveries (ICORD), Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia, and GF Strong Rehab Centre,Vancouver, Canada. review of 40 studies (6 RCTs):

Andrei Krassioukov

THERAPEUTIC MANAGEMENT prevention of AD Education on the causes of AD, appropriate bladder and bowel routines, and pressure ulcer prevention appear to be the most effective measures for pre- vention of AD in control of detrusor hyperreexia & subjects with SCI DSD: anticholinergics, IVES BT-A, augmentation enterocystoplasty use of antihypertensive drugs in the presence of sustained elevated blood pressure

LEVEL OF EVIDENCE

??

??

alpha 1 blockers: Level 4 (terazocin- Hytrin) Level 1 (prazosin- Minipress)

, 01 2013



, 01 2013

(push ups, ) /, >15, ,



, 01 2013

CISC: : CISC kit

AUTONOMIC DYSREFLEXIA

SPINAL

CORD

MEDICINE

A G u i d e f o r Pe o p l e w i th
Acute Management of Autonomic Dysreflexia:
Individuals with Spinal Cord Injury Presenting to Health-Care Facilities 2nd Edition

CLINICAL PRACTICE GUIDELINES

AUTONOMIC DYSREFLEXIA:
WHAT YOU SHOULD KNOW

Administrative and financial support provided by Paralyzed Veterans of America Printing provided by Eastern Paralyzed Veterans Association

Consortium for Spinal Cord Medicine

Administrative and financial support pr ovided by Paralyzed Veterans of America

, 01 2013

A G u i d e f o r Pe o p l e w i th

What to Do I f You Think You Have Autonomic Dysreflexia:

Prompt action is essential! If you cant follow these steps yourself, tell a family member, an attendant, or a friend what to do. Its important to do these steps in the order below. 1. Sit up, or raise your head to 90 degrees. If you can lower your legs, do.

Important: You need to stay sitting or upright until your

blood pressure is back to normal.

AUTONOMIC DYSREFLEXIA:
WHAT YOU SHOULD KNOW

2. Loosen or take off anything tight:

! ! !

External catheter tape Clothes Elastic hose or bandages

! ! !

Abdominal binders Shoes or leg braces Leg bag straps

3. If you have a blood pressure kit, take your blood pressure reading about every 5 minutes to see if youre getting better. 4. Check to see if your bladder is draining properly (see page 4, step 4). 5. Call your health-care professional, even if the warning signs go away. Report the symptoms you had and what you did to correct the problem. 6. If the warning signs come back again, repeat these steps. Even if the warning signs go away again, call your health-care professional and go to the emergency room. 7. At the emergency room, make sure you:
!

! ! !

Tell the emergency room staff that you think you may have autonomic dysreflexia and need immediate treatment. Ask to have your blood pressure checked immediately. Request to keep sitting up as long as your blood pressure is high. Ask the emergency room staff to look for causes of the problem. Suggest that they check for causes in this order: (1) bladder, (2) bowel, and (3) other causes. Suggest that your health-care professional instill anesthetic jelly into your rectum before checking your bowel.

Consortium for Spinal Cord Medicine

Administrative and financial support pr ovided by Paralyzed Veterans of America

Important: Inform the emergency room staff that there is a

complete clinical practice guideline available at the website: www.pva.org.

, 01 2013

My Personal Autonomic Dysreflexia Diary

This Personal Diary is intended for you to use to keep a health-care record of your episodes of autonomic dysreflexia. Another copy of the Diary, which you can photocopy for re-use, appears in the back pocket of this Guide. Keep this diary and the Guide with you.

Date of Dysreflexia Episode:

Symptoms
Put a checkmark or "X" next to every symptom you have for each dysreflexia episode.

Name: Address: City Phone Number: ( ) Date of Birth: State: Zip Code:

! ! ! ! ! ! ! !

Pounding headache Heavy sweating Flushed skin Goose bumps Blurry vision Seeing spots Stuffy nose Anxiety or jitters

! !

Tight chest Trouble breathing

Other:

Social Security Number: Date of Dysreflexia Episode:

Cause of Dysreflexia Episode and Comments:

Symptoms
Put a checkmark or "X" next to every symptom you have for each dysreflexia episode.

! ! ! ! ! ! ! !

Pounding headache Heavy sweating Flushed skin Goose bumps Blurry vision Seeing spots Stuffy nose Anxiety or jitters

! !

Tight chest Trouble breathing

Date of Dysreflexia Episode:

Symptoms
Put a checkmark or "X" next to every symptom you have for each dysreflexia episode.

Other:

Cause of Dysreflexia Episode and Comments:

! ! ! ! ! ! ! !

Pounding headache Heavy sweating Flushed skin Goose bumps Blurry vision Seeing spots Stuffy nose Anxiety or jitters

! !

Tight chest Trouble breathing

Other:

Cause of Dysreflexia Episode and Comments:

, 01 2013

11

12