From the Guidelines
The initial management of neurogenic shock focuses on stabilizing the patient through fluid resuscitation and vasopressor support, with the goal of maintaining mean arterial pressure (MAP) at 85-90 mmHg to optimize spinal cord perfusion. Begin with rapid administration of isotonic crystalloids (typically normal saline or Lactated Ringer's) at 1-2 L boluses while monitoring response. If hypotension persists despite adequate volume resuscitation, initiate vasopressors, with norepinephrine (starting at 0.1-0.5 mcg/kg/min) as the first-line agent due to its combined alpha and beta effects, as recommended by studies such as 1. Phenylephrine (40-180 mcg/min) may be used as an alternative, particularly when tachycardia is a concern. For bradycardia, administer atropine 0.5 mg IV, repeating every 3-5 minutes as needed up to a maximum of 3 mg.
Some key points to consider in the management of neurogenic shock include:
- Immobilizing the spine to prevent further injury
- Performing a thorough neurological assessment to determine the level and severity of injury
- Maintaining adequate fluid resuscitation and vasopressor support to optimize spinal cord perfusion
- Monitoring for signs of organ perfusion and adjusting treatment as needed
Neurogenic shock results from disruption of sympathetic pathways in the spinal cord, typically with injuries above T6, causing loss of vasomotor tone and unopposed vagal activity. This leads to the classic triad of hypotension, bradycardia, and peripheral vasodilation with warm, dry skin—distinguishing it from hypovolemic shock where tachycardia is typically present. The use of norepinephrine as a vasopressor is supported by studies such as 1 and 1, which highlight its effectiveness in maintaining blood pressure and perfusion in shock states.
Overall, the management of neurogenic shock requires a comprehensive approach that includes fluid resuscitation, vasopressor support, and careful monitoring of the patient's hemodynamic and neurological status, as emphasized by recent studies such as 1.
From the Research
Initial Management of Neurogenic Shock
The initial management of neurogenic shock involves several key steps:
- Strict immobilization and quick assessment of the gravity of cord injury are necessary as soon as prehospital care has begun 2
- Initial treatment requires vasopressors associated with fluid resuscitation 2
- Steroids are not recommended 2
- Early decompression is recommended for incomplete deficit seen in the first 6 hours 2
Fluid Management and Vasopressor Therapy
- Fluid management is not currently an integral aspect of clinical management, with all persons being treated at a net fluid intake ≤ zero 3
- Vasopressors such as arginine vasopressin (AVP) or phenylephrine (PE) may be used to maintain mean arterial pressure > 60mmHg 4
- The use of pressors plus fluid is superior to either fluid alone or pressor alone in correcting vasodilatory shock after traumatic brain injury 4
Treatment of Neurogenic Shock
- A combined transfusion of dopamine and normal saline may be effective in treating neurogenic shock due to acute intracranial hypertension, but not blood transfusion 5
- In the absence of hypovolemia, neurogenic shock should be treated with a combined transfusion of dopamine and normal saline 5
- Crystalloid solutions and blood transfusion are the mainstays of pre-hospital and in-hospital treatment of hemorrhagic shock, but may not be directly applicable to neurogenic shock 6