Neurogenic shock: Difference between revisions
 
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==Background==
==Background==
*Do not confuse with [[Spinal Shock]]
*Do not confuse with [[spinal shock]]
*Diagnosis of exclusion
*Diagnosis of exclusion
**Never presume hypotension in trauma patient is due to neurogenic shock
**Never presume hypotension in trauma patient is due to neurogenic shock
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**T1-L3:  Partial sympathetic denervation
**T1-L3:  Partial sympathetic denervation
**Below L4:  no sympathetic denervation
**Below L4:  no sympathetic denervation
*Lasts 1-3 wk
*Lasts 1-3 week


==Evaluation==
==Clinical Features==
*[[Hypotension]]
*[[Hypotension]]
*[[Bradycardia]]
*[[Bradycardia]]
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==Differential Diagnosis==
==Differential Diagnosis==
{{Shock DDX}}
{{Shock DDX}}
{{Blunt neck trauma DDX}}
==Evaluation==
===Workup===
*Standard [[trauma|ATLS]] workup
===Diagnosis===
*Diagnosis of exclusion after ruling out other causes of hypotension (principally hemorrhagic shock in the setting of trauma)


==Management==
==Management==
#Exclude other causes of shock
===Neurogenic Shock Management===
#Supplemental [[O2]] to perfuse injured spinal cord
''Exclude other causes of shock!''
#Mechanical ventilation and oxygenation if spinal perfusion is compromised
*Judicious [[IVF]] with normal saline, with UOP >30 cc/hr
##Manual in-line stabilization reduces cervical movement better than C-collar, but be careful of tracheal pressures inadvertently applied which can worsen laryngeal visualization<ref>The effect of laryngoscopy of different cervical spine immobilisation techniques. Heath KJ. Anaesthesia. 1994 Oct; 49(10):843-5.</ref><ref>Manual in-line stabilization increases pressures applied by the laryngoscope blade during direct laryngoscopy and orotracheal intubation. Santoni BG, Hindman BJ, Puttlitz CM, Weeks JB, Johnson N, Maktabi MA, Todd MM. Anesthesiology. 2009 Jan; 110(1):24-31.</ref>
**Hypotonic fluids such as D5W and 0.45% NS '''are contraindicated'''
##Direct laryngoscopy causes C-spine extension at atlanto-occipital junction, C1-C2, and C4-C7 in order from most to least
**Albumin is relatively contraindicated as compared to NS<ref>A comparison of albumin and saline for fluid resuscitation in the intensive care unit. Finfer S, Bellomo R, Boyce N, French J, Myburgh J, Norton R, SAFE Study Investigators. N Engl J Med. 2004 May 27; 350(22):2247-56.</ref>
##Consider video laryngoscopy with hyperangulated stylet or bougie assisted DL to intubate higher-grade laryngoscopy views of vocal cords without C-spine overextension<ref>Cervical spinal motion during intubation: efficacy of stabilization maneuvers in the setting of complete segmental instability. Lennarson PJ, Smith DW, Sawin PD, Todd MM, Sato Y, Traynelis VC. J Neurosurg. 2001 Apr; 94(2 Suppl):265-70.</ref>
*[[Norepinephrine]] first line, with '''MAP goal of 85-90 for the first 5-7 days after spinal cord injury'''<ref>Blood pressure management after acute spinal cord injury. Hadley MN, Walters BC, Grabb PA, Oyesiku NM, Przybylski GJ, Resnick DK, Ryken TC. Neurosurgery. 2002 Mar; 50(3 Suppl):S58-62.</ref>
##Post-intubation sedation takes into consideration hemodynamics and potential intraoperative EMG and evoked potential monitoring by anesthesia
**Consider '''adding''' [[phenylephrine]] if BP refractory to first line agent
##*[[Opioids]] do not impact evoked potential monitoring
**[[Phenylephrine]] alone without beta-1 stimulation will cause reflex bradycardia
##*[[Ketamine]] may enhance evoked potential monitoring<ref>Improvement of motor-evoked potentials by ketamine and spatial facilitation during spinal surgery in a young child. Erb TO, Ryhult SE, Duitmann E, Hasler C, Luetschg J, Frei FJ. Anesth Analg. 2005 Jun; 100(6):1634-6.</ref>
**[[Atropine]] if needed, keeping HR 60-100 bpm in NSR
##*Consider [[dexmedetomidine]] as a [[Propofol]] sparing medication in TIVA<ref>Effects of dexmedetomidine on intraoperative motor and somatosensory evoked potential monitoring during spinal surgery in adolescents. Tobias JD, Goble TJ, Bates G, Anderson JT, Hoernschemeyer DG. Paediatr Anaesth. 2008 Nov; 18(11):1082-8.</ref>
**May titrate down on norepinephrine and atropine, to favor more phenylephrine α agonism in ICU setting
#Prevent hypothermia - consider temperature probe Foley
 
#Judicious [[IVF]] with normal saline, with UOP > 30 cc/hr
{{Acute spinal cord injury treatment}}
##Hypotonic fluids such as D5W and 0.45% NS '''are contraindicated'''
 
##Albumin is relatively contraindicated as compared to NS<ref>A comparison of albumin and saline for fluid resuscitation in the intensive care unit. Finfer S, Bellomo R, Boyce N, French J, Myburgh J, Norton R, SAFE Study Investigators. N Engl J Med. 2004 May 27; 350(22):2247-56.</ref>
===Additional Considerations===
#[[Norepinephrine]] first line, with '''MAP goal of 85-90 for the first 5-7 days after spinal cord injury'''<ref>Blood pressure management after acute spinal cord injury. Hadley MN, Walters BC, Grabb PA, Oyesiku NM, Przybylski GJ, Resnick DK, Ryken TC. Neurosurgery. 2002 Mar; 50(3 Suppl):S58-62.</ref>
*Prevent [[hypothermia]] - consider temperature probe Foley
##Consider '''adding''' [[phenylephrine]] if BP refractory to first line agent
*High risk of [[VTE]] in paraparesis or tetraparesis
##Phenylephrine alone without beta-1 stimulation will cause reflex bradycardia
**Up to 40% in non-prophylaxed
##[[Atropine]] if needed, keeping HR 60-100 bpm in NSR
**Must weigh benefits of VTE prophylaxis and risk of bleed from LMWH
##May titrate down on norepinephrine and atropine, to favor more phenylephrine α agonism in ICU setting
**Low dose SC [[heparin]] at 500 units q8hrs plus SCDs may be alternative
#High risk of [[VTE]] in paraparesis or tetraparesis
 
##Up to 40% in non-prophylaxed
==See Also==
##Must weigh benefits of VTE prophylaxis and risk of bleed from LMWH
*[[Spinal cord injury]]
##Low dose SC heparin at 500 units q8hrs plus SCDs may be alternative
*[[Spinal cord compression (non-traumatic)]]
#[[Corticosteroid]] use is controversial, but consider usage in consultation with spine specialist
*[[Autonomic dysreflexia]]
##2006 survey of ~300 US neurosurgeons revealed ~90% will use them for nonpenetrating traumatic spinal cord injury within 8 hours despite modest evidence<ref>Questionnaire survey of spine surgeons on the use of methylprednisolone for acute spinal cord injury. Eck JC, Nachtigall D, Humphreys SC, Hodges SD. Spine (Phila Pa 1976). 2006 Apr 20; 31(9):E250-3.</ref>
*[[Spinal shock]]
##However, treatment is not guideline mandated, per the American Association of Neurological Surgeons which lists [[methylprednisolone]] as a ''treatment option'' and not standard of care
 
##[[Methylprednisolone]] bolus 30 mg/kg over 1 hour, then infusion of 5.4 mg/kg/hr for 23 hours, given within 3-8 hours following injury<ref>Steroids for acute spinal cord injury. Bracken MB. Cochrane Database Syst Rev. 2002; (3):CD001046.</ref>
==External Links==


==References==
==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.
<references/>
<references/>
*Orlando Regional Medical Center. Vasopressor and Inotrope Usage in Shock. 4/19/2011. http://www.surgicalcriticalcare.net/Guidelines/Vasopressors%20and%20Inotropes%20in%20Shock.pdf.
==See Also==
*[[Spinal Cord Trauma]]
*[[Spinal Cord Compression (Non-Traumatic)]]
*[[Autonomic Dysreflexia]]
*[[Spinal Shock]]


[[Category:Neurology]]
[[Category:Neurology]]
[[Category:Trauma]]
[[Category:Trauma]]
[[Category:Critical Care]]
[[Category:Critical Care]]

Latest revision as of 00:26, 11 February 2021

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 week

Clinical Features

Differential Diagnosis

Shock

Neck Trauma

Evaluation

Workup

  • Standard ATLS workup

Diagnosis

  • Diagnosis of exclusion after ruling out other causes of hypotension (principally hemorrhagic shock in the setting of trauma)

Management

Neurogenic Shock Management

Exclude other causes of shock!

  • Judicious IVF with normal saline, with UOP >30 cc/hr
    • Hypotonic fluids such as D5W and 0.45% NS are contraindicated
    • Albumin is relatively contraindicated as compared to NS[1]
  • Norepinephrine first line, with MAP goal of 85-90 for the first 5-7 days after spinal cord injury[2]
    • 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

Acute Management of Spinal Cord Injury

  • Neurogenic shock management
  • Consider intubation injuries at C5 or above
    • Manual in-line stabilization reduces cervical movement better than C-collar, but be careful of tracheal pressures inadvertently applied which can worsen laryngeal visualization[3][4]
    • Direct laryngoscopy causes C-spine extension at atlanto-occipital junction, C1-C2, and C4-C7 in order from most to least
    • Consider video laryngoscopy with hyperangulated stylet or bougie assisted DL to intubate higher-grade laryngoscopy views of vocal cords without C-spine overextension[5]
    • Post-intubation sedation takes into consideration hemodynamics and potential intraoperative EMG and evoked potential monitoring by anesthesia
  • Consider surgical intervention for:
  • Steroids are no longer recommended
    • Administration of methylprednisolone (MP) for the treatment of acute spinal cord injury (SCI) is not recommended. Clinicians considering MP therapy should bear in mind that the drug is NOT approved by the FDA for this indication. There is no Class I or Class II medical evidence supporting the clinical benefit of MP in the treatment of acute SCI. Scattered reports of Class III evidence claim inconsistent effects likely related to random chance or selection bias. However, Class I, II, and III evidence exists that high-dose steroids are associated with harmful side effects including death.[8]
    • See EBQ:High Dose Steroids in Cord Injury for further discussion

Additional Considerations

  • Prevent hypothermia - consider temperature probe Foley
  • 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

See Also

External Links

References

  1. ↑ A comparison of albumin and saline for fluid resuscitation in the intensive care unit. Finfer S, Bellomo R, Boyce N, French J, Myburgh J, Norton R, SAFE Study Investigators. N Engl J Med. 2004 May 27; 350(22):2247-56.
  2. ↑ Blood pressure management after acute spinal cord injury. Hadley MN, Walters BC, Grabb PA, Oyesiku NM, Przybylski GJ, Resnick DK, Ryken TC. Neurosurgery. 2002 Mar; 50(3 Suppl):S58-62.
  3. ↑ The effect of laryngoscopy of different cervical spine immobilisation techniques. Heath KJ. Anaesthesia. 1994 Oct; 49(10):843-5.
  4. ↑ Manual in-line stabilization increases pressures applied by the laryngoscope blade during direct laryngoscopy and orotracheal intubation. Santoni BG, Hindman BJ, Puttlitz CM, Weeks JB, Johnson N, Maktabi MA, Todd MM. Anesthesiology. 2009 Jan; 110(1):24-31.
  5. ↑ Cervical spinal motion during intubation: efficacy of stabilization maneuvers in the setting of complete segmental instability. Lennarson PJ, Smith DW, Sawin PD, Todd MM, Sato Y, Traynelis VC. J Neurosurg. 2001 Apr; 94(2 Suppl):265-70.
  6. ↑ Improvement of motor-evoked potentials by ketamine and spatial facilitation during spinal surgery in a young child. Erb TO, Ryhult SE, Duitmann E, Hasler C, Luetschg J, Frei FJ. Anesth Analg. 2005 Jun; 100(6):1634-6.
  7. ↑ Effects of dexmedetomidine on intraoperative motor and somatosensory evoked potential monitoring during spinal surgery in adolescents. Tobias JD, Goble TJ, Bates G, Anderson JT, Hoernschemeyer DG. Paediatr Anaesth. 2008 Nov; 18(11):1082-8.
  8. ↑ Hurlbert RJ et al. Pharmacological therapy for acute spinal cord injury. Neurosurgery. 2013 Mar;72 Suppl 2:93-105 http://www.ncbi.nlm.nih.gov/pubmed/23417182
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