Neurogenic shock: Difference between revisions
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##Phenylephrine alone without beta-1 stimulation will cause reflex bradycardia | ##Phenylephrine alone without beta-1 stimulation will cause reflex bradycardia | ||
##Atropine if needed, keeping HR 60-100 bpm in NSR | ##Atropine if needed, keeping HR 60-100 bpm in NSR | ||
##May titrate down on norepinephrine and atropine, to favor more phenylephrine | ##May titrate down on norepinephrine and atropine, to favor more phenylephrine α agonism in ICU setting | ||
#High risk of VTE in paraparesis or tetraparesis | #High risk of VTE in paraparesis or tetraparesis | ||
##Up to 40% in non-prophylaxed | ##Up to 40% in non-prophylaxed | ||
Revision as of 01:13, 24 July 2017
Background
- Do not confuse with Spinal Shock
- Diagnosis of exclusion
- Never presume hypotension in trauma patient is due to neurogenic shock
- Injury to cervical or thoracic vertebrae causes peripheral sympathetic denervation
- Above T1: full sympathetic denervation
- T1-L3: Partial sympathetic denervation
- Below L4: no sympathetic denervation
- Lasts 1-3 wk
Evaluation
- Hypotension(well tolerated)
- Bradycardia
- Peripherally vasodilated (warm extremities)
- However, this leads to hypothermia
- Ensure monitoring of core temperatures and warming of patient
Differential Diagnosis
Shock
- Cardiogenic
- Acute valvular Regurgitation/VSD
- CHF
- Dysrhythmia
- ACS
- Myocardial Contusion
- Myocarditis
- Drug toxicity (e.g. beta blocker, CCB, or bupropion OD)
- Obstructive
- Distributive
- Hypovolemic
- Severe dehydration
- Hemorrhagic shock (traumatic and non-traumatic)
Management
- Exclude other causes of shock
- Supplemental O2 to perfuse injured spinal cord
- Mechanical ventilation and oxygenation if spinal perfusion is compromised
- Prevent hypothermia
- Judicious IVF, with UOP > 30 cc/hr
- Norepinephrine first line, with MAP goal of 85-90 for the first 7 days after spinal cord injury
- Consider adding phenylephrine if BP refractory to first line agent
- Phenylephrine alone without beta-1 stimulation will cause reflex bradycardia
- Atropine if needed, keeping HR 60-100 bpm in NSR
- May titrate down on norepinephrine and atropine, to favor more phenylephrine α agonism in ICU setting
- High risk of VTE in paraparesis or tetraparesis
- Up to 40% in non-prophylaxed
- Must weigh benefits of VTE prophylaxis and risk of bleed from LMWH
- Low dose SC heparin at 500 units q8hrs plus SCDs may be alternative
References
- Chin LS et al. Spinal Cord Injuries Treatment & Management. Jul 7, 2015. http://emedicine.medscape.com/article/793582-treatment#showall.
- Coplin WM. Traumatic Spinal Cord Injury. 2013 Neurocritical Care Society Practice Update. http://www.neurocriticalcare.org/sites/default/files/pdfs/09.SCI.final.pdf.
- Orlando Regional Medical Center. Vasopressor and Inotrope Usage in Shock. 4/19/2011. http://www.surgicalcriticalcare.net/Guidelines/Vasopressors%20and%20Inotropes%20in%20Shock.pdf.