What type of shock is a patient experiencing with hypotension, bradycardia, and peripheral vasodilation after a fall, with a medical history of hypertension (high blood pressure) and hyperlipidemia (elevated levels of lipids in the blood)?

Neurogenic Shock

This patient is experiencing neurogenic shock (Answer B), characterized by the classic triad of hypotension (BP 80/40 mmHg), bradycardia (HR 50 bpm), and peripheral vasodilation following a cervical spinal cord injury from a fall.

Clinical Presentation Analysis

The patient's presentation is pathognomonic for neurogenic shock:

• Hypotension with bradycardia is the hallmark hemodynamic pattern that distinguishes neurogenic shock from other shock types 1, 2
• Bilateral upper extremity neurological deficits (numbness, tingling, weakness) with intact lower extremity function suggests a cervical spinal cord injury, the most common anatomical location for neurogenic shock 2, 3
• Mechanism of injury (fall from standing in a frail elderly patient) is consistent with cervical spine trauma 4

Hemodynamic Differentiation from Other Shock Types

Why Not Cardiogenic Shock (Answer C)?

• Cardiogenic shock presents with elevated systemic vascular resistance (SVR) as a compensatory mechanism, not the peripheral vasodilation seen here 5
• Cardiogenic shock typically shows tachycardia (not bradycardia) as the body attempts to maintain cardiac output 6, 5
• The hemodynamic profile would include elevated central venous pressure and pulmonary capillary wedge pressure, which are not suggested by this clinical picture 5

Why Not Obstructive Shock (Answer D)?

• While the incidental subsegmental PE could theoretically cause obstructive shock, a subsegmental PE is too small to produce hemodynamic compromise 7
• Obstructive shock from PE would present with tachycardia and elevated jugular venous pressure, not bradycardia 5
• The patient's oxygen saturation of 92% and respiratory rate of 12 breaths/min argue against clinically significant PE 7

Why Not Septic Shock (Answer A)?

• Septic shock is a form of distributive shock that presents with tachycardia and warm extremities in early stages, not bradycardia 8
• There are no clinical indicators of infection (normal temperature, no mention of infectious source) 8
• The temporal relationship to trauma and neurological findings point away from sepsis 8

Pathophysiology of Neurogenic Shock

• Loss of sympathetic outflow below the level of spinal cord injury causes unopposed parasympathetic tone, resulting in bradycardia and peripheral vasodilation 1, 4
• The hemodynamic profile shows decreased systemic vascular resistance (distributive pattern) combined with bradycardia, distinguishing it from other distributive shock states 9
• Neurogenic shock represents a spectrum of hemodynamic profiles, with decreased peripheral vascular resistance being the most common mechanism (33% of cases), though mixed patterns occur 9

Clinical Epidemiology

• Neurogenic shock occurs in approximately 19% of cervical cord injuries upon emergency department arrival, though this percentage increases over time as the condition evolves 2
• High cervical injuries (C1-C5) require cardiovascular intervention in 24% of cases, compared to only 5% for lower cervical injuries (C6-C7) 3
• The incidence is significantly lower in thoracic (7%) and lumbar (3%) cord injuries 2

Management Priorities

• Vasopressors are first-line treatment for neurogenic shock after spinal immobilization, with norepinephrine being the preferred agent for distributive shock patterns 6, 7, 8, 1
• Fluid resuscitation should accompany vasopressor therapy, though the primary problem is pathological vasodilation rather than volume depletion 7, 1
• Target mean arterial pressure ≥65 mmHg to maintain spinal cord perfusion 7, 8

Critical Pitfalls

• Do not attribute hypotension solely to the incidental PE—the bradycardia and neurological findings mandate consideration of neurogenic shock 2
• Neurogenic shock may evolve over hours—only 19% of cervical cord injury patients show classic findings immediately, so ongoing monitoring is essential 2
• Steroids are not recommended for traumatic spinal cord injury with neurogenic shock 1