From the Guidelines
Neurogenic shock is a life-threatening condition characterized by the loss of sympathetic tone, resulting in hypotension, bradycardia, and peripheral vasodilation, typically occurring after spinal cord injury above the T6 level. This condition is distinct from other forms of shock due to its pathophysiology, which involves disruption of autonomic pathways rather than hypovolemia or cardiac dysfunction 1. The clinical presentation of neurogenic shock includes hypotension, bradycardia, and warm, dry skin below the level of injury, which contrasts with the typical tachycardic response seen in other shock states.
Key Characteristics
- Hypotension due to decreased vascular resistance
- Bradycardia resulting from unopposed parasympathetic tone
- Peripheral vasodilation leading to decreased blood pressure
- Typically occurs after spinal cord injury above the T6 level
Treatment Considerations
- Aggressive fluid resuscitation with crystalloids (e.g., normal saline or lactated Ringer's solution) to maintain adequate blood pressure
- Vasopressors (e.g., norepinephrine or phenylephrine) may be necessary to restore vascular tone if fluids are insufficient
- Atropine may be required for significant bradycardia
- Spinal immobilization and surgical decompression may be necessary depending on the underlying cause of the spinal cord injury
It is crucial to recognize neurogenic shock promptly and initiate appropriate management to prevent morbidity and mortality, as the condition can lead to severe complications if not addressed promptly 1.
From the Research
Definition and Characteristics of Neurogenic Shock
- Neurogenic shock is a life-threatening emergency associated with spinal cord injuries, characterized by bradycardia and hypotension caused by a medullary trauma 2, 3.
- It is a rare but serious complication of spinal cord injury, which can aggravate the neurological deficit and is life-threatening for the patient 2.
- Early recognition and treatment of neurogenic shock are essential to prevent hypoperfusion-related injuries and death 3.
Treatment and Management of Neurogenic Shock
- Initial treatment requires vasopressors associated with fluid resuscitation, and steroids are not recommended 2.
- Early decompression is recommended for incomplete deficit seen in the first 6 hours 2.
- Vasopressors and inotropes are vasoactive medications that are vital in increasing systemic vascular resistance and cardiac contractility, respectively, in patients presenting with shock 4.
- Current guidelines target mean arterial pressure (MAP) above 85-90 mmHg to maintain cord perfusion and reduce ischemia/secondary injury in managing neurogenic shock following acute traumatic spinal cord injury (SCI) 5.
Importance of Early Intervention and Immobilization
- Early cervical spine immobilization to reduce the risk of neurogenic shock is imperative 3.
- Strict immobilization and a quick assessment of the gravity of cord injury are necessary as soon as prehospital care has begun 2.
- Early initiated noradrenaline compared to fluid therapy may improve blood pressure goals and reduce the need for ICU admittance, although more research is needed to investigate the optimal initiation time 6.