Undifferentiated Shock Possibly Due to Autonomic Dysfunction in Cerebral Palsy Patients

Abstract

INTRODUCTION: Cerebral palsy (CP) is a complex disorder that involves progressive permanent central motor dysfunction. Although patients with CP often survive up to adulthood, it is often not without multiple hospitalization for various different disease processes throughout their lifetime. Patients with CP not only suffer from intellectual disabilities but also their disease manifests in many different organ systems. Although autonomic dysfunction has been associated with CP here we aim to describe a series of cases involving a group of patients from a group home for cerebral palsy patients. Who on numerous occasions are hospitalized in undifferentiated shock from suspected autonomic dysfunction. CASE PRESENTATION:We describe multiple patients with CP from a local group home who are brought to the emergency room multiple times a year with similar symptoms. All initially present with the chief complaint of altered mental status worsening from baseline. The patients are often obtunded on initial presentation and unable to protect their airway requiring mechanical ventilation. All of the patients present with a triad of hypothermia (less than 90 degrees fahrenheit), hypotension requiring vasopressors, and bradycardia with heart rates often less than 40 BPM requiring admission to the intensive care unit (ICU). Throughout their hospitalization these patients are thoroughly assessed for their cause of shock including thyroid dysfunction and adrenal insufficiency. Extensive, imaging, and cultures demonstrate no significant abnormalities or growth. Echocardiograms are interpreted as unremarkable. Ultimately there is no clear source of why the patient presented in shock requiring mechanical ventilation, active rewarming and pressor support. The patients usually require ICU supportive management for a few days before they are back to their baseline. No source of shock is ever isolated.DISCUSSION: According to the CDC, cerebral palsy is the most common motor disability in childhood. These patients do survive into adulthood but not without multiple hospitalizations for various different reasons. Homeostasis dysfunction has been associated with CP possibly related to autonomic dysfunction. However, no data has shown patients in adulthood presenting in undifferentiated shock as a result of autonomic dysfunction. We propose that the patients' shock is possibly part of the autonomic dysfunction that has previously been described in patients with CP, however never fully studied in terms of shock. CONCLUSIONS:Patients with CP who survive to adulthood many times have regression in mobility. These patients also suffer from other comorbid conditions that make it difficult for these patients to live independently. Further research is needed to improve the quality of life for this patient population.