eMedicine Specialties > Physical Medicine and Rehabilitation > Spinal Cord Injury

Cardiovascular Concerns in Spinal Cord Injury: Follow-up

Author: William McKinley, MD, Director of Spinal Cord Injury Medicine, Professor and Residency Program Director, Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University Medical Center
Coauthor(s): Susan V Garstang, MD, Assistant Professor, Residency Program Director, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey; Attending Medical Staff, Director of Spinal Cord Injury Program, Department of Physical Medicine and Rehabilitation, University Hospital; Houman Danesh, Virginia Commonwealth University School of Medicine (Medical College of Virginia)
Contributor Information and Disclosures

Updated: Feb 15, 2008

Follow-up

Further Inpatient Care

  • As discussed previously, hypotension and bradycardia typically improve within days to weeks, and the patient can be weaned off medications.
  • Patients with complete cervical injuries often have relatively low resting pulse rates and blood pressures.
  • Discontinue conservative measures only after medications have been stopped and the patient is doing well.
  • Patients frequently continue to need an abdominal binder and anti-embolism stockings (eg, TED hose) for orthostasis and to control lower-extremity edema after discharge.
  • Many patients need to use a wheelchair with a reclining or tilt-in-space mechanism to allow for quick achievement of a supine posture if they become dizzy or light-headed.

Complications

  • Weight gain and obesity after SCI are not uncommon.36
  • Physical inactivity, decreased energy expenditure, and the secondary effects of muscle paralysis decrease muscle and lean body mass, increase the percentage of body fat, increase insulin resistance, and increase the risk for CHD.21
  • Dietary guidelines suggest that reductions be made in the patient's intake of calories, fat (<30% of calories), and cholesterol (<300 mg).25 However, some have noted that dietary intervention has shown limited effectiveness because of the concomitant depression of HDL-C concentrations with TC levels.

Patient Education

  • The education of patients, their families, and staff members is extremely important for the recognition and management of cardiovascular complications (eg, low blood pressure, orthostasis, bradycardia, autonomic dysreflexia, DVT, CHD).
    • Teach patients to recognize the clinical symptoms and to report them immediately.
    • For orthostatic hypotension, family and staff members must respond quickly by reclining the patient and elevating his/her legs.
    • Staff and family must understand that patients should never be left unattended after being placed in a sitting position, because their blood pressure may drop and cause syncope before they can call for help. This precaution is particularly applicable to patients with tetraplegia who may not have access to a bedside call button.
    • Education about the reasons for medications, abdominal binders, anti-embolism stockings (eg, TED hose), and elastic bandages (ACE wraps) is important to ensure compliance.
  • Education of the respiratory and nursing staff is important to prevent bradycardia resulting from increased vagal tone; this is particularly the case in patients with a tracheostomy, during endotracheal suctioning.18,3 If necessary, hyperventilate patients and administer atropine before suctioning.

Miscellaneous

Medicolegal Pitfalls

  • Immediately after acute SCI, differentiate neurogenic shock from hypovolemic shock. In the absence of other injuries, patients with low blood pressure resulting from SCI do not need aggressive fluid resuscitation. In fact, patients with tetraplegia commonly develop pulmonary edema if given too much volume. The etiology of this phenomenon is not clear, but it may be related to decreased pulmonary vascular resistance and/or a lack of sympathetic innervation to the lungs. Therefore, following resuscitation with about 2 L, start pressors to maintain blood pressure after hypovolemia due to other trauma has been ruled out.
  • Monitor patients with acute cervical SCI for cardiac arrhythmias, because bradycardia and tachyarrhythmias are common. As mentioned previously, hypoxia and vagal stimulation can cause bradycardia, leading to asystole. Therefore, close observation, repeat medication with atropine, and hyperventilation may be necessary when endotracheal suctioning procedures are performed.
  • Never leave a patient alone in a sitting position until after his/her blood pressure has stabilized, because the individual may become hypotensive and syncopic before being able to call for help.
 


More on Cardiovascular Concerns in Spinal Cord Injury

Overview: Cardiovascular Concerns in Spinal Cord Injury
Differential Diagnoses & Workup: Cardiovascular Concerns in Spinal Cord Injury
Treatment & Medication: Cardiovascular Concerns in Spinal Cord Injury
Follow-up: Cardiovascular Concerns in Spinal Cord Injury
References
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References

  1. Eidelberg EE. Cardiovascular response to experimental spinal cord compression. J Neurosurg. Mar 1973;38(3):326-31. [Medline].

  2. Meinecke FW, Rosenkranz KA, Kurek CM. Regulation of the cardiovascular system in patients with fresh injuries to the spinal cord--preliminary report. Paraplegia. Nov 1971;9(3):109-12. [Medline].

  3. Piepmeier JM, Lehmann KB, Lane JG. Cardiovascular instability following acute cervical spinal cord trauma. Cent Nerv Syst Trauma. 1985;2(3):153-60. [Medline].

  4. Laird AS, Finch AM, Waite PM, et al. Peripheral changes above and below injury level lead to prolonged vascular responses following high spinal cord injury. Am J Physiol Heart Circ Physiol. Nov 30 2007;[Medline].

  5. Evans DE, Kobrine AI, Rizzoli HV. Cardiac arrhythmias accompanying acute compression of the spinal cord. J Neurosurg. Jan 1980;52(1):52-9. [Medline].

  6. Gondim FA, Lopes AC, Oliveira GR. Cardiovascular control after spinal cord injury. Curr Vasc Pharmacol. Jan 2004;2(1):71-9. [Medline].

  7. Greenhoot JH, Shiel FO, Mauck HP Jr. Experimental spinal cord injury. Electrocardiographic abnormalities and fuchsinophilic myocardial degeneration. Arch Neurol. Jun 1972;26(6):524-9. [Medline].

  8. Teasell RW, Arnold JM, Krassioukov A, et al. Cardiovascular consequences of loss of supraspinal control of the sympathetic nervous system after spinal cord injury. Arch Phys Med Rehabil. Apr 2000;81(4):506-16. [Medline].

  9. Young W, DeCrescito V, Tomasula JJ, et al. The role of the sympathetic nervous system in pressor responses induced by spinal injury. J Neurosurg. Apr 1980;52(4):473-81. [Medline].

  10. Lehmann KG, Lane JG, Piepmeier JM, et al. Cardiovascular abnormalities accompanying acute spinal cord injury in humans: incidence, time course and severity. J Am Coll Cardiol. Jul 1987;10(1):46-52. [Medline].

  11. Frisbie JH. Microvascular instability in tetraplegic patients: preliminary observations. Spinal Cord. May 2004;42(5):290-3. [Medline].

  12. Mathias CJ, Christensen NJ, Frankel HL, et al. Cardiovascular control in recently injured tetraplegics in spinal shock. Q J Med. Apr 1979;48(190):273-87. [Medline].

  13. Mathias CJ, Frankel HL. Clinical manifestations of malfunctioning sympathetic mechanisms in tetraplegia. J Auton Nerv Syst. Mar-Apr 1983;7(3-4):303-12. [Medline].

  14. McLeod JG, Tuck RR. Disorders of the autonomic nervous system: Part 1. Pathophysiology and clinical features. Ann Neurol. May 1987;21(5):419-30. [Medline].

  15. Wecht JM, Weir JP, Krothe AH, et al. Normalization of supine blood pressure after nitric oxide synthase inhibition in persons with tetraplegia. J Spinal Cord Med. 2007;30(1):5-9. [Medline]. [Full Text].

  16. Claydon VE, Steeves JD, Krassioukov A. Orthostatic hypotension following spinal cord injury: understanding clinical pathophysiology. Spinal Cord. Jun 2006;44(6):341-51. [Medline].

  17. De Groot PC, Van Kuppevelt DH, Pons C, et al. Time course of arterial vascular adaptations to inactivity and paralyses in humans. Med Sci Sports Exerc. Dec 2003;35(12):1977-85.

  18. Mathias CJ. Bradycardia and cardiac arrest during tracheal suction--mechanisms in tetraplegic patients. Eur J Intensive Care Med. 1976;2(4):147-56. [Medline].

  19. Ruiz-Arango AF, Robinson VJ, Sharma GK. Characteristics of patients with cervical spinal injury requiring permanent pacemaker implantation. Cardiol Rev. Jul-Aug 2006;14(4):e8-e11.

  20. Winslow EB, Lesch M, Talano JV, et al. Spinal cord injuries associated with cardiopulmonary complications. Spine. Oct 1986;11(8):809-12. [Medline].

  21. Myers J, Lee M, Kiratli J. Cardiovascular disease in spinal cord injury: an overview of prevalence, risk, evaluation, and management. Am J Phys Med Rehabil. Feb 2007;86(2):142-52. [Medline].

  22. Manns PJ, McCubbin JA, Williams DP. Fitness, inflammation, and the metabolic syndrome in men with paraplegia. Arch Phys Med Rehabil. Jun 2005;86(6):1176-81. [Medline].

  23. Maruyama Y, Mizuguchi M, Yaginuma T, et al. Serum leptin, abdominal obesity and the metabolic syndrome in individuals with chronic spinal cord injury. Spinal Cord. Jan 22 2008;[Medline].

  24. Liang H, Mojtahedi MC, Chen D, et al. Elevated C-reactive protein associated with decreased high-density lipoprotein cholesterol in men with spinal cord injury. Arch Phys Med Rehabil. Jan 2008;89(1):36-41. [Medline].

  25. Szlachcic Y, Adkins RH, Adal T, et al. The effect of dietary intervention on lipid profiles in individuals with spinal cord injury. J Spinal Cord Med. 2001;24(1):26-9. [Medline].

  26. Nash MS, Jacobs PL, Mendez AJ, et al. Circuit resistance training improves the atherogenic lipid profiles of persons with chronic paraplegia. J Spinal Cord Med. 2001;24(1):2-9. [Medline].

  27. Dela F, Mohr T, Jensen CM, et al. Cardiovascular control during exercise: insights from spinal cord-injured humans. Circulation. Apr 29 2003;107(16):2127-33. [Medline]. [Full Text].

  28. Ditor DS, Macdonald MJ, Kamath MV, et al. The effects of body-weight supported treadmill training on cardiovascular regulation in individuals with motor-complete SCI. Spinal Cord. Nov 2005;43(11):664-73. [Medline].

  29. Thijssen DH, Ellenkamp R, Smits P, et al. Rapid vascular adaptations to training and detraining in persons with spinal cord injury. Arch Phys Med Rehabil. Apr 2006;87(4):474-81. [Medline].

  30. Spinal Cord Injury Information Network. Spinal Cord Injury. Facts and Figures at a Glance. 2006;[Full Text].

  31. McKinley W, Santos K, Meade M, et al. Incidence and outcomes of spinal cord injury clinical syndromes. J Spinal Cord Med. 2007;30(3):215-24. [Medline]. [Full Text].

  32. Wirth B, van Hedel HJ, Kometer B, et al. Changes in activity after a complete spinal cord injury as measured by the Spinal Cord Independence Measure II (SCIM II). Neurorehabil Neural Repair. Aug 30 2007;[Medline].

  33. Szlachcic Y, Carrothers L, Adkins R, et al. Clinical significance of abnormal electrocardiographic findings in individuals aging with spinal injury and abnormal lipid profiles. J Spinal Cord Med. 2007;30(5):473-6. [Medline].

  34. Jacobs P, Beekhuizen K. Appraisal of Physiological Fitness in Persons with Spinal Cord Injury. Top Spinal Cord Injur Rehabil. 2005;10(4):32-50.

  35. Tuli S, Tuli J, Coleman WP, et al. Hemodynamic parameters and timing of surgical decompression in acute cervical spinal cord injury. J Spinal Cord Med. 2007;30(5):482-90. [Medline].

  36. Spungen AM, Adkins RH, Stewart CA, et al. Factors influencing body composition in persons with spinal cord injury: a cross-sectional study. J Appl Physiol. Dec 2003;95(6):2398-407. [Medline]. [Full Text].

  37. Vale FL, Burns J, Jackson AB, et al. Combined medical and surgical treatment after acute spinal cord injury: results of a prospective pilot study to assess the merits of aggressive medical resuscitation and blood pressure management. J Neurosurg. Aug 1997;87(2):239-46. [Medline].

  38. Bizzarini E, Saccavini M, Lipanje F, et al. Exercise prescription in subjects with spinal cord injuries. Arch Phys Med Rehabil. Jun 2005;86(6):1170-5. [Medline].

  39. Barber DB, Rogers SJ, Fredrickson MD, et al. Midodrine hydrochloride and the treatment of orthostatic hypotension in tetraplegia: two cases and a review of the literature. Spinal Cord. Feb 2000;38(2):109-11. [Medline].

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Further Reading

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Keywords

cardiovascular concerns in spinal cord injury, neurogenic shock, orthostatic hypotension, spinal cord injury, SCI, autonomic nervous system, ANS, autonomic dysreflexia, deep vein thrombosis, DVT, coronary heart disease, CHD, bradycardia

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Contributor Information and Disclosures

Author

William McKinley, MD, Director of Spinal Cord Injury Medicine, Professor and Residency Program Director, Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University Medical Center
William McKinley, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, American Paraplegia Society, American Spinal Injury Association, and Association of Academic Physiatrists
Disclosure: Nothing to disclose.

Coauthor(s)

Susan V Garstang, MD, Assistant Professor, Residency Program Director, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey; Attending Medical Staff, Director of Spinal Cord Injury Program, Department of Physical Medicine and Rehabilitation, University Hospital
Susan V Garstang, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation and Association of Academic Physiatrists
Disclosure: Nothing to disclose.

Houman Danesh, Virginia Commonwealth University School of Medicine (Medical College of Virginia)
Disclosure: Nothing to disclose.

Medical Editor

J Michael Wieting, DO, MEd, Professor of Physical Medicine and Rehabilitation, Professor of Osteopathic Principles and Practices, Director of Sports Medicine, Associate Director of Physician Assistant Training Program, Department of Osteopathic Principles and Practice, Lincoln Memorial University-DeBusk College of Osteopathic Medicine
J Michael Wieting, DO, MEd is a member of the following medical societies: American Academy of Osteopathy, American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American College of Forensic Examiners, American College of Sports Medicine, American Osteopathic Association, American Osteopathic College of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, and International Society of Physical and Rehabilitation Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Patrick M Foye, MD, FAAPMR, FAAEM, Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain Service (Tailbone Pain Service: www.TailboneDoctor.com), University of Medicine and Dentistry of New Jersey, New Jersey Medical School
Patrick M Foye, MD, FAAPMR, FAAEM is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, and International Spine Intervention Society
Disclosure: Nothing to disclose.

CME Editor

Kelly L Allen, MD, Regional Medical Director, IMX-Medical Management Services
Disclosure: Nothing to disclose.

Chief Editor

Denise I Campagnolo, MD, MS, Director of Multiple Sclerosis Clinical Research and Staff Physiatrist, Barrow Neurology Clinics, St Joseph's Hospital and Medical Center; Investigator for Barrow Neurology Clinics; Director, NARCOMS Project for Consortium of MS Centers
Denise I Campagnolo, MD, MS is a member of the following medical societies: Alpha Omega Alpha, American Association of Neuromuscular and Electrodiagnostic Medicine, American Paraplegia Society, Association of Academic Physiatrists, and Consortium of Multiple Sclerosis Centers
Disclosure: Teva Neuroscience Honoraria Speaking and teaching; Serono-Pfizer Honoraria Speaking and teaching; Genzyme Corporation Grant/research funds investigator; Biogen Idec Grant/research funds investigator; Genentech, Inc Grant/research funds investigator; Eli Lilly & Company Grant/research funds Novaritis; Novaritis  Novaritis; MSDx LLC Grant/research funds investigator; BioMS Technology Corp Grant/research funds investigator; Avanir Pharmaceuticals Grant/research funds investigator

 
 
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