In a 30-year-old who fell from height and now has hypotension, bradycardia, and paralysis of both lower limbs, what is the next best management?

Neurogenic Shock Management in Acute Spinal Cord Injury

Intravenous norepinephrine infusion (Option C) is the next best management for this patient with neurogenic shock from spinal cord injury.

Clinical Presentation Analysis

This patient presents with the classic triad of neurogenic shock:

• Hypotension (80/40 mmHg) from loss of sympathetic vascular tone 1, 2
• Bradycardia (64/min) from unopposed vagal stimulation 3, 4
• Bilateral lower limb paralysis indicating high thoracic or cervical spinal cord injury 5, 3

The combination of hypotension with bradycardia (rather than compensatory tachycardia) distinguishes neurogenic shock from hypovolemic shock and mandates vasopressor therapy 2, 4.

Why Norepinephrine is the Correct Choice

Hemodynamic Rationale

• Norepinephrine is the mandatory first-line vasopressor for all types of shock when fluid resuscitation fails to maintain adequate mean arterial pressure (MAP ≥65 mmHg) 6, 7
• It provides both alpha-adrenergic vasoconstriction to restore vascular tone and modest beta-1 cardiac stimulation to counteract bradycardia 8, 7
• In neurogenic shock specifically, norepinephrine addresses the dual pathophysiology: loss of sympathetic tone below the injury level and unopposed parasympathetic activity 1, 3

Dosing Protocol

• Initial fluid resuscitation: Administer at least 30 mL/kg crystalloid to ensure euvolemia before or concurrent with vasopressor initiation 7, 6, 1
• Starting dose: 0.02–0.05 µg/kg/min via central venous access (or large peripheral vein if central access delayed) 7, 9
• Target MAP: ≥65 mmHg initially; some guidelines recommend MAP 85 mmHg for the first week after acute SCI to optimize spinal cord perfusion 4
• Arterial line placement: Essential for continuous blood pressure monitoring 7, 6

Why Other Options Are Incorrect

Option A: Intravenous Albumin Infusion

• Not indicated as first-line therapy in neurogenic shock 7, 6
• The primary problem is loss of vascular tone, not hypovolemia alone 3, 4
• While fluid resuscitation with crystalloids is necessary, albumin offers no advantage and delays definitive vasopressor therapy 7

Option B: Intravenous Hydrocortisone

• Reserved for refractory shock unresponsive to vasopressors after ≥4 hours of high-dose therapy 7
• No evidence supports corticosteroids as first-line treatment in neurogenic shock 2
• The CRASH trial demonstrated that corticosteroids for acute spinal cord injury increase mortality rather than provide benefit 10

Option D: Urgent Blood Transfusion

• Not indicated without evidence of hemorrhage 10
• This patient's hypotension is due to neurogenic shock (loss of sympathetic tone), not blood loss 2, 3
• Transfusion would not address the underlying pathophysiology of vasodilation and bradycardia 4

Critical Management Algorithm

Immediate Actions (First 30 Minutes)

1. Secure airway and breathing if respiratory compromise present 4
2. Establish large-bore IV access and begin crystalloid resuscitation (30 mL/kg) 7, 1
3. Start norepinephrine at 0.02–0.05 µg/kg/min, targeting MAP ≥65 mmHg (or 85 mmHg per SCI-specific guidelines) 7, 4
4. Place arterial catheter for continuous blood pressure monitoring 7, 6
5. Strict spinal immobilization to prevent secondary injury 2

Escalation Strategy for Refractory Hypotension

• If MAP remains <65 mmHg despite norepinephrine at 0.1–0.25 µg/kg/min, add vasopressin 0.03 units/min (fixed dose) 7
• If bradycardia is severe (<50 bpm with symptoms) and compromising cardiac output, consider atropine or temporary pacing 10, 4
• If hypoperfusion persists despite adequate MAP, add dobutamine 2.5–20 µg/kg/min to improve cardiac output 7, 6

Monitoring Beyond Blood Pressure

Tissue Perfusion Markers (Every 2–4 Hours)

• Lactate clearance: Obtain baseline and repeat within 6 hours; aim for normalization 7
• Urine output: Maintain ≥0.5 mL/kg/h to ensure renal perfusion 7, 4
• Mental status, skin perfusion, and capillary refill: Assess regularly for peripheral hypoperfusion 7
• Neurological examination: Serial assessments to detect secondary deterioration 4

Common Pitfalls to Avoid

Do Not Delay Vasopressors

• Early vasopressor use is appropriate in severe hypotension with critically low diastolic pressure; do not wait for complete fluid resuscitation 7
• Prolonged hypotension worsens spinal cord ischemia and neurological outcomes 4

Avoid Dopamine

• Dopamine is strongly contraindicated as first-line therapy (Grade 1A recommendation) 7
• It is associated with 11% absolute increase in mortality and higher arrhythmia rates compared to norepinephrine 7
• The only acceptable indication is highly selected patients with bradycardia and low arrhythmia risk 7

Do Not Use Phenylephrine as First-Line

• Phenylephrine can worsen bradycardia through reflex baroreceptor activation and may reduce cardiac output despite raising blood pressure 7
• Reserved only for norepinephrine-induced arrhythmias, documented high cardiac output with persistent hypotension, or salvage therapy 7

Monitor for Extravasation

• Norepinephrine is a potent vasoconstrictor; extravasation causes tissue necrosis 9
• If extravasation occurs, immediately infiltrate the site with 5–10 mg phentolamine diluted in 10–15 mL saline 7

Avoid Beta-Blockers

• Do not use beta-blockers in acute neurogenic shock with bradycardia and hypotension 10
• The guideline recommendation to avoid symptomatic bradycardia (heart rate <50 with symptoms) applies to traumatic brain injury, not spinal cord injury with neurogenic shock 10