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Acute cervical spinal cord injury frequently results in bradydysrhythmia, which may lead to hypotension and asystole. Such symptoms are more common in the first 2 weeks after the injury. Treatment modalities include atropine, epinephrine, aminophylline, and pacemaker insertion. The criteria for pacemaker use in this population are not well defined. We describe characteristics of 3 patients who required permanent, transvenous pacemaker implantation for recurrent symptoms. In 2 of the 3 patients, transcutaneous pacing failed to provide adequate protection. Transcutaneous pacemakers are not reliable, as was the case of these patients, and early consideration for transvenous pacemaker insertion may be indicated, especially in hemodynamically unstable patients. In this report, all 3 patients required permanent pacemaker implantation.