Terbutaline for Spinal Cord Injury-Induced Bradycardia

Introduction: Spinal cord injury (SCI) is a severe condition that can lead to significant cardiovascular complications, including bradycardia, particularly in higher level injuries. While often transient, pacemaker placement may be required in certain cases. Current oral pharmacologic treatment strategies are limited.


Description: Case 1 involved a 35-year-old male presenting after a pedestrian versus car injury. His injuries included a complete SCI at C4-5. The patient had two brief episodes of asystole during hospital days 1 and 3 and ultimately required transcutaneous pacing. On hospital day 15, terbutaline 5 mg Q8H was initiated and ultimately titrated to 10 mg Q8H allowing the pacer to be removed. Terbutaline was stopped to assess for need after which the patient has two subsequent bradycardia events. The patient transitioned back to terbutaline 10 mg Q8H and had one additional asystole event. While he remained stable over the next few weeks, the rehabilitation facility required a permanent pacemaker for placement.

Case 2 involved a 76-year-old female presenting after a ground-level fall. Her injuries included C4-5 fractures with central canal stenosis, cord impingement, and ligamentous injury, and a T1 spinous fracture. On hospital day 3 she had sustained heart rates in the 30s requiring dopamine. Dopamine was transitioned to pseudoephedrine which was titrated up to 60 mg Q6H. Pseudoephedrine was switched to midodrine due to issues with hypotension, but after a bradycardia event, theophylline was added and titrated up to 100 mg Q8H and midodrine was removed. Sinus bradycardia persisted and dopamine had to be restarted. Dopamine was unable to be weaned despite pseudoephedrine 90 mg Q6H and theophylline 200 mg Q8H, therefore terbutaline was initiated at 5 mg Q8H. Theophylline was stopped after 2 days, and dopamine was stopped 3 days afterwards. Ultimately the patient developed acute renal failure requiring dialysis and the family decided to transition to comfort measures.


Discussion: Bradycardia secondary to SCI can be difficult to manage. We describe two experiences of relative benefit with the use of oral terbutaline.