Case Presentation: A 52-year-old African-American male was admitted to the hospital with sepsis secondary to urinary tract infection and pneumonia. His past medical history is significant for gunshot wound to C6-C7 region of the spine three months prior, complicated by paraplegia and neurogenic bladder requiring chronic indwelling urinary catheter. The hospital course was complicated by septic shock, acalculous cholecystitis and cardiac arrest. He had several episodes of bradycardia and four episodes of asystole requiring cardiopulmonary resuscitation (CPR). The occurrence of these episodes coincided with weaning trial, bladder/bowel evacuation and re-positioning in bed. The family also reported several episodes of unresponsiveness and spontaneous regaining of consciousness while at home. Also, during this period his sepsis was clinically resolving and was not felt to be a significant contributor. Telemetry was reviewed which showed normal sinus rhythm most of the time with episodes of sinus tachycardia interspersed with sinus bradycardia leading to periods of asystole. 12-lead EKG showed a normal sinus rhythm with possible old anteroseptal infarct. An echocardiogram revealed normal left ventricular function without any valvular abnormalities. Given the profound nature of his hemodynamic instability and multiple episodes of cardiac arrest, a permanent pacemaker was placed. Taking into consideration the entire picture, the diagnosis of autonomic dysreflexia secondary to high spinal cord injury was made.
Discussion: Acute phase of spinal cord injury (SCI) falls under the purview of neurosurgery and other surgical specialties. The chronic complications associated with SCI include recurrent infections and hemodynamic instability, which contribute to significant morbidity are managed by medical subspecialties. Autonomic dysreflexia is a well described phenomenon of SCI (especially involving the cervical and upper thoracic regions) characterized by bradycardia, hypertensive crisis and sometimes life-threatening complications such as cardiac arrest. However, it is not one of the differentials physicians consider when treating these patients. In our patient, we observed a series of cardiac arrests and autonomic instability characterized by bradycardia, hypotension leading to asystole. This was first observed 10 minutes into a weaning trial for extubation. Initially, this was thought to be from respiratory failure leading to circulatory arrest. However, subsequently patient had similar presentations with positional changes, bowel/bladder movements.
Conclusions: Hemodynamic instability manifesting as bradycardia and orthostatic hypotension are well described phenomenon in patients with SCI above T6 level. However, treating physicians should be aware of its more dangerous complications such as one described here and should include autonomic dysreflexia as part of the differential diagnosis of cardiac arrest in patients with SCI. Disruption of sympathetic nervous system coupled with parasympathetic over activity due to the SCI is thought to be the primary mechanism. Increase in vagal reflexes such as those mentioned in this case along with hypoxic events can precipitate this phenomenon.
To cite this abstract:Yelamanchili, S. RECURRENT CARDIAC ARREST – AN UNEXPECTED CAUSE. Abstract published at Hospital Medicine 2018; April 8-11; Orlando, Fla. Abstract 921. https://www.shmabstracts.com/abstract/recurrent-cardiac-arrest-an-unexpected-cause/. Accessed May 24, 2019.