# Situation: A 30-year-old man is in the intensive care unit after a motorcycle crash caused a severe traumatic brain injury (TBI) and a spinal cord injury at the level of the sixth cervical vertebra (C6). He is intubated and sedated, his cervical spine is immobilized, and an intraventricular catheter monitors his intracranial pressure (ICP). The unit's targets are ICP 22 mmHg or lower and cerebral perfusion pressure (CPP) 60–70 mmHg. On day 2 the nurse suctions his endotracheal tube after preoxygenating him. Oxygen saturation stays at 98%. Readings are shown. Before suctioning — heart rate 62 beats/min; blood pressure 104/60 mmHg; ICP 14 mmHg During suctioning — heart rate 38 beats/min; blood pressure 96/54 mmHg; ICP 16 mmHg One minute after — heart rate 60 beats/min; blood pressure 102/58 mmHg; ICP 14 mmHg What is the MOST likely cause of the change during suctioning?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630031  
> language: ko  
> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: A 30-year-old man is in the intensive care unit after a motorcycle crash caused a severe traumatic brain injury (TBI) and a spinal cord injury at the level of the sixth cervical vertebra (C6). He is intubated and sedated, his cervical spine is immobilized, and an intraventricular catheter monitors his intracranial pressure (ICP). The unit's targets are ICP 22 mmHg or lower and cerebral perfusion pressure (CPP) 60–70 mmHg.

On day 2 the nurse suctions his endotracheal tube after preoxygenating him. Oxygen saturation stays at 98%. Readings are shown.
Before suctioning — heart rate 62 beats/min; blood pressure 104/60 mmHg; ICP 14 mmHg
During suctioning — heart rate 38 beats/min; blood pressure 96/54 mmHg; ICP 16 mmHg
One minute after — heart rate 60 beats/min; blood pressure 102/58 mmHg; ICP 14 mmHg
What is the MOST likely cause of the change during suctioning?

## 보기

1. Unopposed vagal stimulation after cervical cord injury **✔ 정답**
2. Reduced venous return from raised pressure in the chest
3. Cushing response to a rise in intracranial pressure
4. Autonomic dysreflexia triggered by the suction catheter

**정답: 1**

## 해설

A cervical cord injury cuts sympathetic outflow to the heart, so vagal stimulation from suctioning or turning is unopposed and can cause marked bradycardia or even asystole. ICP barely changed and blood pressure fell rather than rose, which rules out a Cushing response and autonomic dysreflexia. Brief suction passes, preoxygenation, and atropine at the bedside are used.

## 심화 해설

Core mechanism — A complete cervical cord injury at C6 interrupts descending sympathetic fibers that normally accelerate the heart and maintain vascular tone. The vagus nerve, however, arises from the brainstem and travels outside the injured cord, so parasympathetic input to the sinoatrial node remains intact. When tracheal suctioning mechanically stimulates the airway, vagal afferents fire and the heart receives unopposed parasympathetic drive. The result is abrupt bradycardia, and in severe cases, asystole. The heart rate drop from 62 to 38 beats/min during suctioning, with recovery to 60 beats/min one minute later, is the classic vagal-mediated response seen in tetraplegic patients.

Why the other options do not fit — The ICP rose only from 14 to 16 mmHg, which is a minimal change and well below the treatment threshold of 22 mmHg. A Cushing response requires a substantial rise in ICP that triggers hypertension, bradycardia, and irregular respirations; here the blood pressure fell from 104/60 to 96/54 mmHg, which is the opposite of the hypertensive phase. Autonomic dysreflexia is a sympathetic surge below the level of injury that produces severe hypertension, headache, and flushing; it does not present with hypotension and isolated bradycardia during a brief suction pass. Reduced venous return from raised intrathoracic pressure can lower cardiac output, but the dominant hemodynamic signature would be hypotension with a compensatory tachycardia, not the marked bradycardia observed here.

Clinical evidence from the cited studies — Mathias (1976) directly observed tracheal suction-induced bradycardia in four recently injured tetraplegics with physiologically complete cervical cord transections at C3–C5. In that series, two patients progressed to cardiac arrest during suctioning. The bradycardia was most pronounced when patients were hypoxic, and it was prevented by adding oxygen to inspired air or by administering atropine. Garner and colleagues (1985) reinforced this mechanism, describing profound bradycardia in the early posttraumatic period after cervical cord damage as resulting from temporary sympathetic inactivity combined with unopposed vagal dominance because the vagus nerve is spared. They also noted that hypoxia, underventilation, and tracheal suctioning intensify the bradycardia.

Applying this to the bedside — In this scenario, the nurse preoxygenated the patient, and oxygen saturation remained at 98%, which likely prevented a more severe vagal response. Watch out! Even with adequate oxygenation, the mechanical stimulation of the suction catheter can still trigger vagal bradycardia because the airway reflex arc is intact. Key point! For a patient with a cervical cord injury, suctioning should be brief, preoxygenation is essential, and atropine must be immediately available at the bedside. The recovery of heart rate to 60 beats/min within one minute confirms that this was a transient vagal episode rather than a progressive neurologic deterioration.

Differentiating vagal bradycardia from other bradycardic states

| Feature | Vagal response in cervical cord injury | Cushing response | Autonomic dysreflexia |
| --- | --- | --- | --- |
| Heart rate | Marked bradycardia, may progress to asystole | Bradycardia late, after hypertension | Bradycardia may occur as reflex, but hypertension dominates |
| Blood pressure | Normal or decreased | Increased (widening pulse pressure) | Severely increased |
| ICP | Minimal change | Markedly elevated | Not directly related to ICP |
| Trigger | Airway suctioning, turning, hypoxia | Rising ICP from mass lesion or edema | Noxious stimuli below injury level (bladder, bowel, skin) |
| Key intervention | Preoxygenation, brief suction, atropine at bedside | Lower ICP, maintain CPP | Remove stimulus, control blood pressure |

Why CPP matters here — The unit target for CPP is 60–70 mmHg. During suctioning, the mean arterial pressure fell slightly, but the ICP remained stable, so CPP was not critically compromised. The primary concern during suctioning in this patient is not cerebral hypoperfusion but the risk of vagal-induced asystole. Maintaining oxygenation and having atropine ready are the immediate safety measures.

## 임상 시나리오

Suctioning the Patient with Cervical Cord InjuryPreventing vagal-mediated bradycardia in tetraplegia
In a patient with C6 complete cord injury, sympathetic outflow to the heart is interrupted while vagal input remains intact. Airway suctioning triggers unopposed parasympathetic drive, causing abrupt bradycardia or even asystole. Heart rate may drop from 62 to 38 beats/min and recover within 1 minute after suctioning stops.

Preventive measures include preoxygenation before suctioning, keeping suction passes brief, and having atropine readily available at the bedside. Monitor ICP and CPP closely; a minimal ICP rise from 14 to 16 mmHg does not indicate a Cushing response.

CautionDo not mistake suction-induced bradycardia for autonomic dysreflexia or Cushing response. Both present with hypertension, whereas vagal-mediated bradycardia shows hypotension with minimal ICP change. If severe bradycardia occurs, stop suctioning immediately and prepare to administer atropine.

## 핵심 개념

- **unopposed vagal stimulation** — Parasympathetic drive to the heart without sympathetic counterbalance after cervical cord injury, causing bradycardia or asystole during airway stimulation
- **cerebral perfusion pressure** — Mean arterial pressure minus intracranial pressure; target 60-70 mmHg in severe TBI
- **Cushing response** — Physiologic response to elevated ICP characterized by hypertension, bradycardia, and irregular respirations
- **autonomic dysreflexia** — Sympathetic surge below spinal cord injury level causing severe hypertension, headache, and flushing, typically triggered by noxious stimuli below injury
- **tetraplegia** — Paralysis of all four limbs resulting from cervical spinal cord injury

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