View source for Neurogenic shock

==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==
*[[Hypotension]]
*[[Bradycardia]]
*Peripherally vasodilated, warm extremities
**However, this leads to [[hypothermia]]
**Ensure monitoring of core temperatures and warming of patient

==Differential Diagnosis==
{{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==
===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<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>
*[[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>
**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 spinal cord injury treatment}}

===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==
*[[Spinal cord injury]]
*[[Spinal cord compression (non-traumatic)]]
*[[Autonomic dysreflexia]]
*[[Spinal shock]]

==External Links==

==References==
<references/>

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