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Fatal cerebral hemorrhage in a tetraplegic patient due to autonomic dysreflexia triggered by delay in emptying urinary bladder after unsuccessful intermittent catheterization by carer: lessons learned

Authors Vaidyanathan S, Soni BM, Hughes PL, Oo T

Received 2 June 2017

Accepted for publication 15 July 2017

Published 7 March 2018 Volume 2018:11 Pages 53—58


Checked for plagiarism Yes

Review by Single-blind

Peer reviewers approved by Dr Amy Norman

Peer reviewer comments 2

Editor who approved publication: Professor Ronald Prineas

Subramanian Vaidyanathan,1 Bakulesh M Soni,1 Peter L Hughes,2 Tun Oo1

1Regional Spinal Injuries Centre, 2Department of Radiology, Southport and Formby District General Hospital, Town Lane, Southport, UK

Introduction: Over-distension of urinary bladder in a high spinal cord injury patient is a triggering factor for autonomic dysreflexia. Removing triggering factors is vital to prevent autonomic dysreflexia.
Case presentation: A 36-year-old tetraplegic patient, who was managed by intermittent catheterizations performed by caregivers, developed recurrent autonomic dysreflexia during a week due to: 1) carers not performing intermittent catheterizations every night; 2) infrequent catheterizations during the day, leading to distension of urinary bladder. A day before his demise, carer attempted routine catheterization; but was unable to insert the catheter; blood pressure rose to 192/109 mmHg. Nifedipine 10 mg was administered. Thirty minutes later, blood pressure was 181/113 mmHg; second dose of Nifedipine was not given. Forty minutes elapsed before a senior carer came and catheterized successfully. Meanwhile, patient developed pounding headache; became drowsy; was talking incoherently. Four and half hours after unsuccessful catheterization, carers contacted emergency services and the patient was taken to Accident and Emergency; CT of head revealed very large acute intracranial hemorrhage in the right frontal and parietal lobes. The patient expired a day later. The Coroner’s verdict: “Patient died of massive intracranial hemorrhage caused by autonomic dysreflexia, a known complication of high spinal cord injury. Emergency protocols to manage autonomic dysreflexia were not followed in the days leading up to his death.”
Conclusion: Failed urethral catheterization is a potentially life-threatening emergency; every patient should have a care plan explicitly describing what should be done when catheterization is not successful. Preventive measures rather than episodic treatment of autonomic dysreflexia should be the guiding principle.

Keywords: spinal cord injury, autonomic dysreflexia, brain hemorrhage, tetraplegia, intermittent catheterization

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