Systematic Review
In-hospital Cardiac Arrest Following Spinal Cord Injury: A Scoping Review
2025 Volume 28 Issue 1 Pages 68-75
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2025 Volume 28 Issue 1 Pages 68-75
Objectives: This review aimed to examine the characteristics of patients with spinal cord injury (SCI) who experience in-hospital cardiac arrest (IHCA), as well as the timing, circumstances, and interventions associated with these events. Methods: A comprehensive literature search was conducted across multiple databases, including PubMed, Scopus, Cochrane Library, and Igaku Chuo Zasshi Web (in Japanese), for studies published up to 2024. Two independent reviewers screened the literature. Data were extracted from the selected studies regarding the characteristics of patients with SCI who experienced IHCA, the timing of IHCA, the circumstances under which it occurred, and the interventions provided. Results: A total of 56 studies met the inclusion criteria. IHCA most commonly occurs in patients with complete cervical SCI. The time frame for IHCA occurrence ranged from 1 day and 2.5 months post-injury. IHCA frequently occurs during endotracheal suctioning or postural changes. The most commonly reported intervention for IHCA was the use of a pacemaker. Conclusions: In patients with SCI, IHCA is more prevalent among those with severe cervical injuries and is often triggered by procedures such as suctioning or postural adjustments. Physical therapist needs to implement robust risk management strategies. These findings are crucial for both clinical practice and future research.
In-hospital cardiac arrest (IHCA) is a serious cardiovascular complication that can occur following acute spinal cord injury (SCI)1–4), and it is primarily caused by disturbances in the autonomic nervous system5) and is associated with increased mortality in patients with SCI6). Previous studies have shown that patients with SCI who experience IHCA have a significantly higher odds ratio (22.4) for in-hospital mortality compared to those without IHCA6). Therefore, understanding IHCA in patients with SCI is essential for the clinical practice of professionals involved in rehabilitation.
Studies have reported that IHCA occurs in approximately 0.6% of all patients with SCI3) and in 16.0% of those with severe cervical cord injuries1). However, these studies provide limited information on the timing of IHCA onset, the circumstances surrounding it, and the interventions used. This gap in information hinders the ability to predict IHCA in clinical settings and to provide appropriate care.
To address this gap, a scoping review synthesizing existing studies is recommended. This approach allows for a comprehensive assessment of previous findings and offers suggestions regarding the timing, situations, and prevention of IHCA following acute SCI. Using the Population, Concept, Context (PCC) framework, this study aimed to conduct a scoping review of available literature to provide comprehensive and practical suggestions for the management of IHCA in patients with SCI.
This scoping review adopted the methodology outlined by Arksey and O'Malley7) and was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. The review aimed to identify knowledge gaps and understand overall trends, which is why a formal quality assessment of the studies was not performed. No review protocols have been registered for this study.
Identifying the research questionThe PCC framework was used as recommended in scoping reviews. The population consisted of patients diagnosed with SCI. The concept focused on the characteristics of IHCA, including the severity of illness, the timing and circumstances of IHCA, and preventive strategies. The context was defined as the acute care setting, specifically within the first 6 months following hospitalization.
The review aimed to address the following research questions: (1) What is the patient profile for IHCA following SCI?; (2) When does IHCA occur after SCI?; (3) Under what circumstances does IHCA occur in patients with SCI?; and (4) What strategies can prevent IHCA in individuals with SCI?
Information source and search strategyA systematic search was conducted across the following databases: PubMed, Scopus, Cochrane Library, and Igaku Chuo Zasshi (ICHUSHI) Web (in Japanese) on December 6, 2024. The search used a combination of search terms related to SCI and IHCA (Appendix 1). Studies were included based on the following criteria: (1) investigations involving patients with SCI; (2) participants aged 18 years or older; and (3) studies that explicitly described IHCA. For studies that included various neurological conditions or broad age groups, only data specific to patients with SCI aged 18 years and above were considered.
Exclusion criteria included studies involving non-human participants, SCI in the chronic phase (>6 months from injury), individuals under 18 years of age, IHCA occurring during surgery, and articles that were not accessible. Review papers, letters to the editor, bulletins, and conference abstracts were excluded.
The literature review was conducted independently by 2 reviewers (DK and TO), and any disagreements were resolved through discussion. In the event of a disagreement between the 2 reviewers, a third reviewer (MK) was consulted to facilitate the resolution process and finalize the selection of the literature.
Data extraction and synthesisTwo researchers initially compiled summaries of essential data from the selected studies, including the first author’s name, publication year, study location (country), study design, cause of injury, and patient characteristics such as injury severity and level. Subsequently, data regarding the incidence of IHCA, timing, setting, and circumstances leading to IHCA onset were extracted. For studies that included patients with both with and without IHCA, only data specific to those who experienced IHCA were considered. Studies that could not determine the time interval between the injury and the onset of IHCA were excluded from the analysis of the number of days. Any disagreements between the 2 researchers were resolved through discussion, with a third researcher (MK) consulted if necessary to resolve any remaining disputes.
We identified 56 articles2,4–6,8–59) that met the inclusion criteria for this review (Fig. 1). The appendix summarizes the study population and design of each article (Appendix 2). Of the 56 articles, 40 were case reports9–17,19,21–27,29,32,34–36,38–45,47–51,53,56–59), 15 were observational studies2,4–6,8,18,20,28,30,31,33,37,46,52,55), and 2 were intervention studies40,54) (There was 1 document that included elements of both a case report and an interventional study). A total of 81 patients were reported to have experienced IHCA following SCI5,8–30,32–59). Table 1 provides detailed information on these cases, including the timing, circumstances, and outcomes of IHCA. Injury severity was documented in 45 patients9–12,14–18,20,22,25,26,28,29,32–37,40,43–45,47,48,50–53,58,59), with 33 classified as complete injuries and 12 as incomplete. Injury levels were recorded for 56 patients9,10,13,14,16–19,21–29,32–51,53,55–59), of whom 43 had cervical, 11 had thoracic, and 3 had lumbar SCI. The time from injury to IHCA ranged from 1 day to 2.5 months9–13,15–17,19,21–23,26,27,29,32,33,35,36,38–45,47,48,50,51,53,56–59). The location of IHCA was reported in 14 articles9,10,22,23,26,27,33,35,42,48,51–53,56), with 9 incidents occurring in intensive care units, 4 in non-intensive care settings, and 1 in both settings56). In 32 cases, descriptions of the situations surrounding IHCA were not provided. Among the remaining cases, IHCA was most commonly associated with suctioning13,17,25,36,37,40,56) and postural changes9,10,13,25,42). Other situations included anesthesia administration35,38,39,54), tracheostomy9,40), urinary catheterization29), manual muscle testing43), transportation44,57), bronchoscopy48), extubation18), manual abdominal compression17), recruitment maneuver,56) and defecation56). Interventions for IHCA included pharmacological treatments, surgical interventions, and other measures. Medications administered included atropine17,29,36,37,40,44–46,56), epinephrine9,25,36), ephedrine50), dopamine9,11), catecholamines59), droxidopa56), heparin15,57,59), rivaroxaban57), theophylline11), alteplase15), probanthine36), midodrine9), isoproterenol45), cilostazol9), aminophylline51), lidocaine58), and magnesium sulfate58). Surgical interventions included pacemaker10,11,13,16,17,19,28,33,42,44–47,50–52,56), embolectomy15), thrombectomy57,59), and inferior vena cava filter placement15,19). Additional measures included mechanical ventilation57), percutaneous cardiopulmonary support59), antithrombin III replacement therapy59), anti-hyperthermia59), oxygen inhalation36,37), and avoidance of succinylcholine38).
SCI, spinal cord injury
| First author | Patients with IHCA n (%) |
The severity of patients with IHCA |
Injury level of patients with IHCA |
Timing | Situation | Treatments | Patients outcome |
|---|---|---|---|---|---|---|---|
| Okuda A | 7 (16.7) | NR | NR | NR | NR | NR | NR |
| Hachiya S | 1 (100) | Complete = 1 | C3 = 1 | Day 26 | Postural change | Pharmacotherapy Epinephrine Dopamine Midodrine Cilostazol |
Transfer = 1 |
| Murakami T | 1 (100) | Incomplete = 1 | C3–5 = 1 | Days 29 and 32 | Postural change | Pacemaker | Transfer = 1 |
| Miura N | 1 (100) | Complete = 1 | NR | Days 11 and 22 | NR | Pharmacotherapy Dopamine Theophylline Pacemaker |
Transfer = 1 |
| Inoue S | 1 (100) | Incomplete = 1 | NR | Day 1 | Tracheostomy | NR | Home = 1 |
| Onuki T | 1 (100) | NR | C3–4 = 1 | Day 16 | Postural change Suctioning |
Pacemaker | NR |
| Saruyama M | 1 (100) | Complete = 1 | C6 = 1 | Postoperative 6 weeks (42 days) |
NR | NR | Death = 1 |
| Kiuchi S | 1 (100) | Incomplete = 1 | NR | Day 44 | Transfer (To bed from wheelchair) |
Pharmacotherapy Unfractionated Heparin Alteplase Embolectomy Inferior vena cava filter |
NR |
| Yamada Y | 1 (100) | Complete = 1 | C5 = 1 | Days 5, 13, and 21 | NR | Temporary pacing Pacemaker | NR |
| Lee J | 2 (100) | Complete = 1 Incomplete = 1 |
C6 = 2 | Case 1 = Day 27 Case 2 = Day 30 |
Suctioning Abdominal compression |
Pharmacotherapy Atropine sulfate Pacemaker |
Transfer = 2 |
| Nagayama M | 1 (2.3) | Complete = 1 | C6 = 1 | NR | Extubation | NR | Death = 1 |
| Meredith A | 2 (50) | NR | C3–4 = 1 C5–6 = 1 |
Case 1 = Day 2 Case 2 = Day 23 |
NR | Pacemaker | Home = 1 Death = 1 |
| Ull C | 6 (10.0) | Complete = 6 | NR | NR | NR | NR | NR |
| Lee SY | 1 (100) | NR | C3–4 = 1 | Day 9 | NR | NR | Death = 1 |
| Benton JA | 1 (100) | Complete = 1 | C4 = 1 | Day 25 | NR | NR | Death = 1 |
| Marion TE | NR | NR | NR | NR | NR | NR | NR |
| Ijmkers S | 1 (100) | NR | C1–2 = 1 | Day 3 | NR | Pharmacotherapy Inotropic drug |
Death = 1 |
| Riley K | 1 (100) | NR | C5–6 = 1 | NR | NR | NR | Death = 1 |
| Oh Y-M | 1 (100) | Complete = 1 | T4 = 1 | Postoperative 2 day | Postural change Suctioning |
Pharmacotherapy Epinephrine (Before postural change and suctioning) |
Home = 1 |
| Wu Y-S | 1 (100) | Complete = 1 | C4–5 = 1 | Day 1 | NR | NR | Death = 1 |
| Efeoglu M | 1 (100) | NR | C2–7 = 1 | Day 1 | NR | NR | Death = 1 |
| Bartholdy K | 3 (10.0) | Complete = 3 | C1–2 = 3 | NR | NR | Pacemaker | NR |
| Jain A | 1 (100) | Complete = 1 | T9 = 1 | 2 weeks (14 days) | Urinary catheterization | Pharmacotherapy Atropine |
Death = 1 |
| Dididze M | 2 (5.7) | NR | NR | NR | NR | NR | NR |
| Babu R | NR | NR | NR | NR | NR | NR | NR |
| Angthong C | 1 (100) | Incomplete = 1 | C6 = 1 | Day 15 | NR | NR | Death = 1 |
| Ruiz-Arango AF | 2 (2.7) | Complete = 2 | C4–5 = 1 C3–5 = 1 |
Case 1 = Days 5, 26, 27, and 63 Case 2 = Day 8 |
NR | Pacemaker | Death = 1 NR = 1 |
| Chen D | NR (0.7) | NR | NR | NR | NR | NR | NR |
| van den Bout AH | 1 (100) | Complete = 1 | C4 = 1 | NR | NR | NR | Death = 1 |
| Brooke MM | 3 (100) | Incomplete = 1 NR = 2 |
T11 = 2 L2 = 1 |
Case 1 = 6 weeks (42 days) Case 2 = 2.5 months Case 3 = 7 weeks (49 days) and 9 weeks (63 days) |
Succinylcholine injection Intubation |
NR | NR |
| Mathias CJ | 2 (50) | Complete = 2 | C3–4 = 1 C4 = 1 |
Case 1 = Days 39, 40, 41, and 44 Case 2 = Day 2 |
Suctioning | Pharmacotherapy Probanthine Epinephrine Atropine Oxygen inhalation |
NR |
| Welply NC | 2 (28.6) | Complete = 2 | C3–4 = 1 C4 = 1 |
NR | Suctioning | Pharmacotherapy Atropine Oxygen inhalation |
NR |
| Snow JC | 1(100) | NR | L4 = 1 | Day 27 | Succinylcholine injection Intubation |
Avoidance of succinylcholine | Home = 1 |
| Baker BB | 1(100) | NR | L1–4 = 1 | Day 45 | Succinylcholine injection | NR | NR |
| Dollfus P | 1(12.5) | Incomplete = 1 | C4 = 1 | Day 16 | Tracheostomy Suctioning |
Pharmacotherapy Atropine |
Death = 1 |
| Wu Y | 1 (100) | NR | C1–4 = 1 | Day 1 | NR | NR | NR |
| Kim SW | 1 (100) | NR | C4–7 = 1 | Day 22 | Postural change | Pacemaker | NR |
| Malmqvist L | 4 (8.0) | NR | NR | NR | NR | NR | NR |
| Kovindha A | 1 (100) | Incomplete = 1 | T11 = 1 | Day 18 | Manual muscle test | NR | Death = 1 |
| Kumagai N | 1 (100) | Incomplete = 1 | C4–7 = 1 | Day 1 | During transportation | Pharmacotherapy Atropine Pacemaker |
Transfer = 1 |
| Veeravagu A | NR | NR | NR | NR | NR | NR | NR |
| Peyrol M | 1 (100) | Complete = 1 | T2 = 1 | Day 6 | NR | Pharmacotherapy Atropine Isoproterenol Pacemaker |
NR |
| Moerman JR | 2 (1.8) | NR | C2–6 = 1 C5–7 = 1 |
NR | NR | Pharmacotherapy Atropine Pacemaker |
Transfer = 1 Death = 1 |
| Singh A | 1 (100) | Incomplete = 1 | C5–6 = 1 | Day 10 | NR | Pacemaker | NR |
| Sobiech S | 1 (100) | Complete = 1 | C3–4 = 1 | Day 23 | Bronchoscopy | NR | Death = 1 |
| Velnar T | 1 (100) | NR | C3 = 1 | NR | NR | NR | Transfer = 1 |
| Sanghvi AV | 1 (100) | Complete = 1 | C7–T1 = 1 | Days 8, 10, 35, and 62 | NR | Pharmacotherapy Ephedrine Pacemaker |
NR |
| Weant KA | 1 (100) | Complete = 1 | T4 = 1 | Days 21 and 22 | NR | Pharmacotherapy Aminophylline Pacemaker |
Transfer = 1 |
| Franga DL | 2 (16.7) | Complete = 2 | NR | NR | NR | Pacemaker | Death = 2 |
| Bhuiyan MS | 1 (100) | Incomplete = 1 | T4 = 1 | Day 17 | NR | NR | Death = 1 |
| Tobey RE | 1 (25.0) | NR | NR | NR | Succinylcholine injection | NR | NR |
| Gardner BP | 4 (10.0) | NR | C4 = 1 C5 = 2 C6 = 1 |
NR | NR | NR | Death = 2 Home = 2 |
| Yamanaka T | 1 (100) | NR | C4–7 = 1 | Days 7, 15, 16, and 17 | Suctioning Recruitment maneuver During defecation |
Pharmacotherapy Atropine Droxidopa Pacemaker |
Transfer = 1 |
| Chikaishi N | 1 (33.3) | NR | T5/6 =1 | Day 18 | During transportation | Mechanical ventilation Thrombectomy Pharmacotherapy Heparin Rivaroxaban |
NR |
| Funayama T | 1 (100) | Incomplete = 1 | T1 = 1 | Day 4 | NR | Pharmacotherapy Catecholamines Heparinization Percutaneous Cardiopulmonary support Antithrombin III replacement therapy Thrombectomy Inferior vena cava filter Anti-hyperthermia |
Transfer = 1 |
| Mahanta DS | 1 | Complete = 1 | C5–6 = 1 | Day 1 | NR | Pharmacotherapy Lidocaine Magnesium sulfate |
Home = 1 |
SCI, spinal cord injury; IHCA, in-hospital cardiac arrest; NR, not reported
This comprehensive scoping review methodically examined and assessed existing research on IHCA following SCI. Key findings include the following: (1) IHCA was predominantly observed in patients with complete and cervical SCI; (2) IHCA occurred between 1 day and 2.5 months post-injury; (3) IHCA most frequently occurred during endotracheal suctioning, followed by postural changes; and (4) Pacemaker implantation was the most commonly reported intervention for IHCA.
Profile for IHCA following SCIPrevious studies have highlighted the correlation between the level of SCI and the incidence of IHCA. In a study involving 71 patients with acute SCI, IHCA was observed only in those with severe cervical injuries, with no cases reported in patients with thoracic SCI1). Furthermore, IHCA was limited to patients with complete motor function loss associated with cervical cord injury1). From these findings, it can be inferred that the severity of injury, particularly complete SCIs, is a more significant factor in the development of IHCA than incomplete injuries. Our pooled results support previous reports that highlight the importance of both cervical cord injury and injury severity as key factors related to IHCA following SCI.
The underlying mechanism through which individuals with complete cervical SCI develop IHCA is posited to originate from dysregulation in the autonomic nervous system. Research analyzing heart rate variability in 13 patients with SCI revealed a diminution in low-frequency power and amplitude among those with cervical SCIs, compared to healthy individuals. Conversely, high-frequency power and amplitude were comparable to those observed in healthy individuals60). Given these findings, incorporating this demographic into future research focusing on IHCA after SCIs is deemed imperative.
Timing of IHCA following SCIPrevious studies have not provided adequate information regarding the timing of IHCA in the acute phase post-SCI1). Although studies involving patients with acute-phase SCI frequently document early cardiovascular abnormalities during hospitalization, they lack specific details regarding the timing of IHCA onset2,4–6,8,18,20,24,28,30,31,34,37,46,49,52,54,55). This review synthesizes data from individual case reports, revealing that IHCA can occur as early as the day of injury and up to 2.5 months post-injury. These findings offer valuable insights for the design of future observational studies concerning IHCA post-SCI. In addition, rehabilitation professionals may need to take into account the potential occurrence of IHCA when planning interventions during the first 2.5 months post-injury.
Occurrence of IHCAThis review highlights that IHCA often occurs during situations such as suctioning and postural change, which are performed as part of respiratory rehabilitation. Therefore, professionals involved in rehabilitation need to be aware of the potential occurrence of IHCA when performing suctioning and postural changes. However, a specific description of the postural change could not be identified. This review also revealed that information regarding the situations of IHCA occurrences was not reported in 31 articles2,4–6,8,11,14,16,19–22,24,26–28,30–34,41,45–47,49–53,55), indicating a lack of information. This suggests a deficiency in crucial information needed for risk management in the acute rehabilitation of SCI patients. Future research should focus on identifying the circumstances under which IHCA occurs.
Intervention to the IHCANo intervention studies were identified for IHCA following SCI. This may be due to the rarity of IHCA in patients with SCI, with previous reports indicating an occurrence rate of 0.6%3). The infrequency of IHCA poses challenges in conducting prospective studies, as rare outcomes require large sample sizes. Additionally, 27 articles in this review did not report any interventions2,4–6,8,12,14,18,20–22,24,26,27,30–32,34,35,39,41,43,48,49,53–55). Among the cases that did, pacemaker implantation was the most commonly cited intervention. Given its effectiveness, pacemaker implantation was frequently mentioned in the studies reviewed. The included case reports also detailed cases where sufficient oxygen therapy effectively prevented bradycardia and cardiac arrest36,37). Therefore, rehabilitation professionals should facilitate interprofessional communication to ensure the appropriate implementation of pharmacological therapies, pacemaker interventions, and oxygen therapy.
Currently, there is a lack of sufficient observational studies with adequate sample sizes to provide a comprehensive understanding of IHCA in patients with acute SCI requiring acute care. Therefore, further observational studies are needed to address this knowledge gap. Additionally, it is important to acknowledge that patients with SCI within the first 2.5 months post-injury are at heightened risk for IHCA. Future studies should consider this timeframe when designing observational studies on this topic.
We wish to acknowledge Masato Kaneko from the Department of Health Data Science at Yokohama City University for serving as the third reviewer and assisting with the literature screening. We are also grateful to the staff at Tokai University Hospital for their valuable advice, and we extend our deepest thanks to all collaborators for their support.
This research was funded by the Kanagawa Physical Therapy Association.
The authors have no conflicts of interest to declare.
Appendix.1 Search strategy (Pubmed); Appendix.2 Characteristics of included studies.
