How to manage hyperthermia and hypotension in a patient with acute cervical spinal cord injury?

Management of Hyperthermia and Hypotension in Acute Cervical Spinal Cord Injury

In acute cervical spinal cord injury, aggressively prevent and treat hypothermia (not hyperthermia) by removing wet clothing, forced air warming, and warm fluid therapy to maintain normothermia (36-37°C), while managing hypotension with cautious fluid resuscitation targeting systolic blood pressure 80-100 mmHg, using norepinephrine only transiently if life-threatening hypotension persists after volume correction. 1

Critical Temperature Management Priority

The question asks about hyperthermia, but the primary temperature concern in acute cervical SCI is actually hypothermia prevention, which is life-threatening and increases mortality. 1, 2

Preventing Hypothermia (The Real Threat)

• Remove wet clothing immediately and cover the patient to prevent additional heat loss 1
• Increase ambient temperature in the treatment area 1
• Apply forced air warming devices as first-line active warming 1
• Administer warm intravenous fluids (not cold fluids which worsen hypothermia) 1, 2
• Target normothermia: core temperature 36-37°C to optimize coagulation and prevent the lethal triad 1
• Each 1°C drop below normal reduces coagulation factor function by 10%, and temperatures below 34°C severely compromise blood coagulation 1, 2

If True Hyperthermia Occurs (Neurogenic Fever)

While less common acutely, neurogenic fever can occur in cervical SCI patients:

• Neurogenic fever is defined as core temperature >37.5°C without infection or inflammation, and should be diagnosed only after ruling out infectious causes 3
• Obtain chest radiograph, blood cultures (two sets, 60 mL total), and consider CT imaging before attributing fever to neurogenic causes 3
• Treat with antipyretic medications rather than physical cooling methods if symptomatic relief is desired 3
• For severe refractory hyperthermia (>40°C), endovascular cooling may be considered as a last resort, though this carries risk of deep vein thrombosis in SCI patients 4

Hypotension Management Algorithm

Step 1: Volume Resuscitation First

Blood volume depletion must always be corrected as fully as possible before any vasopressor is administered. 5

• Hypotension in cervical SCI is often multifactorial: neurogenic shock (loss of sympathetic tone), hypovolemia from trauma, and hypothermia-induced cardiac dysfunction 1
• Target systolic blood pressure 80-100 mmHg during initial resuscitation 5
• Administer warm crystalloid or blood products as indicated, avoiding cold fluids that worsen hypothermia 1, 2

Step 2: Vasopressor Use (If Necessary)

Only use vasopressors transiently if life-threatening hypotension persists despite adequate volume resuscitation. 1, 5

• Norepinephrine is the vasopressor of choice: Initial dose 2-3 mL/minute (8-12 mcg/minute) of a 4 mcg/mL solution, titrated to maintain systolic BP 80-100 mmHg 5
• Early vasopressor use before adequate volume resuscitation may be deleterious and should be used cautiously 1
• Assess cardiac function with ultrasound before escalating vasopressors, as myocardial dysfunction from cardiac contusion or hypothermia may require inotropic support instead 1
• Vasopressors increase cardiac afterload and can worsen outcomes if left ventricular function is impaired 1

Step 3: Monitor for Complications

• Central venous pressure monitoring is helpful for detecting occult blood volume depletion in patients requiring ongoing vasopressor support 5
• Hypothermia causes cold diuresis, leading to hypovolemia that must be corrected before escalating vasopressors 6
• Gradually reduce vasopressor infusions once adequate blood pressure and tissue perfusion are maintained, avoiding abrupt withdrawal 5

Common Pitfalls to Avoid

• Do not assume hyperthermia is the problem—hypothermia is far more dangerous and common in acute cervical SCI 1, 2
• Do not administer cold intravenous fluids, which significantly worsen hypothermia and increase cardiac arrest risk 2
• Do not use vasopressors before correcting hypovolemia, as this worsens outcomes in hemorrhagic shock 1
• Do not diagnose neurogenic fever without ruling out infection first, particularly pneumonia which is common in cervical SCI 3
• Do not use therapeutic hypothermia in acute cervical SCI—while studied in research settings, the 2013 AANS/CNS guidelines explicitly state evidence is too sparse to recommend it, and preventing spontaneous hypothermia takes priority 1, 7, 8, 9