From the Guidelines
Neurogenic shock treatment in the pre-hospital theater should prioritize spinal immobilization, fluid resuscitation with isotonic crystalloids, and vasopressor support as needed, with the goal of maintaining adequate perfusion and preventing further spinal cord damage. The treatment approach begins with placing the patient in a supine position, as suggested by the 2015 international consensus on first aid science 1, to help maintain blood flow and prevent further injury.
Initial Assessment and Intervention
Key interventions include:
- Spinal immobilization to prevent additional injury
- Fluid resuscitation using isotonic crystalloids like normal saline or Lactated Ringer's solution at 10-20 mL/kg boluses, titrated to maintain systolic blood pressure between 90-100 mmHg
- Vasopressors, such as norepinephrine (starting at 0.1-0.5 mcg/kg/min), when fluids alone are insufficient
- Atropine (0.5-1 mg IV) to address bradycardia if present
- Oxygen administration to maintain saturation above 94%
- Maintaining normothermia to prevent hypothermia, which can worsen outcomes
Ongoing Management
Frequent reassessment of vital signs every 5-10 minutes is crucial, as is careful documentation of neurological status, including motor and sensory function below the injury level. Neurogenic shock results from disruption of sympathetic pathways in the spinal cord, causing vasodilation and loss of vascular tone below the injury level, leading to hypotension without the compensatory tachycardia seen in other shock states. Rapid transport to a trauma center with neurosurgical capabilities should be prioritized while maintaining these interventions. Although hypertonic saline has been evaluated in neurogenic shock 1, the primary approach remains focused on isotonic crystalloids and vasopressor support as needed.
From the FDA Drug Label
Dopamine Hydrochloride in 5% Dextrose Injection, USP is indicated for the correction of hemodynamic imbalances present in shock due to myocardial infarction, trauma, endotoxic septicemia, open heart surgery, renal failure and chronic cardiac decompensation as in refractory congestive failure When indicated, restoration of circulatory volume should be instituted or completed with a suitable plasma expander or whole blood, prior to administration of dopamine hydrochloride. Patients most likely to respond to dopamine are those whose physiological parameters (such as urine flow, myocardial function and blood pressure) have not undergone extreme deterioration Begin infusion of dopamine hydrochloride solution at doses of 2 to 5 mcg/kg/min in adult or pediatric patients who are likely to respond to modest increments of heart force and renal perfusion In more seriously ill patients, begin infusion of dopamine hydrochloride at doses of 5 mcg/kg/min and increase gradually, using 5 to 10 mcg/kg/min increments, up to a rate of 20 to 50 mcg/kg/min as needed.
The treatment of neurogenic shock in the pre-hospital theater with dopamine involves:
- Restoration of circulatory volume with a suitable plasma expander or whole blood prior to administration of dopamine hydrochloride
- Initial infusion rates of 2 to 5 mcg/kg/min for adult or pediatric patients
- Gradual increase in infusion rates, using 5 to 10 mcg/kg/min increments, up to a rate of 20 to 50 mcg/kg/min as needed 2
- Monitoring of the patient's response, including urine flow, myocardial function, and blood pressure, to adjust the dosage accordingly 2
From the Research
Neurogenic Shock Treatment
Definition and Presentation
Neurogenic shock is a condition that occurs due to loss of sympathetic innervation, resulting in a drop in blood pressure (BP) and heart rate (HR) 3. It is a complex and life-threatening condition that can arise from acute circulatory failure, leading to hypoxia, tissue hypoperfusion, and cellular dysfunction 4.
Treatment in Pre-Hospital Theater
There is limited information available on the treatment of neurogenic shock in the pre-hospital theater. However, it is essential to be aware of the condition in all patients with spinal cord injury, regardless of the injury level 3. The treatment of neurogenic shock typically involves fluid resuscitation and vasopressor support to maintain adequate blood pressure and perfusion of vital organs.
Fluid Resuscitation
The choice of fluid for resuscitation in neurogenic shock is not well established. However, a study on hemorrhagic shock suggests that lactated Ringer's solution may have more favorable effects than normal saline on extravascular lung water, pH, and blood pressure 5. The study found that early resuscitation with either normal saline or lactated Ringer's solution had little impact on oxygenation when the resuscitation volume was less than 250 ml/kg.
Key Points to Consider
- Neurogenic shock can present in the pre-hospital environment and without warning in a patient with previously normal vital signs 3.
- The condition is variable and unpredictable, and medical teams should be aware of it in all patients with spinal cord injury, regardless of the injury level 3.
- Fluid resuscitation and vasopressor support are essential components of neurogenic shock treatment, but the optimal choice of fluid is not well established 5.