What is the initial treatment for neurogenic shock after a fall and fractures?

Management of Neurogenic Shock After Falling and Fractures

IV fluid resuscitation should be initiated immediately in patients with neurogenic shock following trauma, as it is the first-line treatment to restore blood pressure and tissue perfusion. 1

Pathophysiology and Recognition

Neurogenic shock is a distributive type of circulatory shock that occurs after spinal cord injury, characterized by:

• Hypotension
• Bradycardia
• Loss of sympathetic tone below the level of injury

Initial Management Algorithm

1. IV Fluid Resuscitation (First-Line)

   • Begin immediately with crystalloid solutions 2, 1
   • Use isotonic crystalloids (normal saline preferred over Ringer's lactate in cases with potential traumatic brain injury) 2
   • Initial bolus of 20 mL/kg 2
   • Target systolic blood pressure of 80-100 mmHg until major bleeding is controlled 2, 1

2. Vasopressor Support (If fluids inadequate)

   • Add norepinephrine if fluid resuscitation fails to restore adequate blood pressure 3
   • Initial dosing: 2-4 mcg/min, titrated to response 3
   • Central venous access preferred for administration 3

3. Avoid These Common Pitfalls:

   • Do NOT use IV corticosteroids (not recommended for neurogenic shock) 4
   • Do NOT perform celiotomy unless there is evidence of intra-abdominal bleeding 2
   • Do NOT use hypotonic solutions in patients with traumatic brain injury 2
   • Avoid excessive fluid administration which can worsen bleeding and dilute coagulation factors 1

Special Considerations

• Spinal Immobilization: Maintain strict immobilization to prevent further spinal cord damage 4
• Monitoring: Continuous monitoring of vital signs, especially heart rate and blood pressure 1
• Adjunctive Therapy: Consider pseudoephedrine as adjunctive therapy for persistent bradycardia and hypotension 5
• Blood Transfusion: Consider if hemoglobin drops below 70-90 g/L 2

Evidence-Based Rationale

The European guidelines for management of major bleeding and coagulopathy following trauma strongly recommend immediate fluid therapy for hypotensive trauma patients (Grade 1A) 2. Crystalloids are the initial fluid of choice (Grade 1B) 2. While neurogenic shock has specific characteristics that differentiate it from hemorrhagic shock, the initial approach to hypotension remains similar - restore intravascular volume with IV fluids 1, 4.

Research shows that in neurogenic shock, the combination of vasopressors and fluid therapy is most effective for reversing hypotension 6. Corticosteroids were previously used but are no longer recommended based on current evidence 4.