Neurogenic shock: Difference between revisions
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==Background== | ==Background== | ||
*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 | ||
*Injury to cervical or thoracic vertebrae causes peripheral sympathetic denervation | *Injury to cervical or thoracic vertebrae causes peripheral sympathetic denervation | ||
**Above T1: full | **Above T1: full sympathetic denervation | ||
**T1-L3: Partial | **T1-L3: Partial sympathetic denervation | ||
**Below L4: | **Below L4: no sympathetic denervation | ||
*Lasts 1-3 wk | *Lasts 1-3 wk | ||
== | ==Evaluation== | ||
*Hypotension (well tolerated) | *[[Hypotension]](well tolerated) | ||
*Bradycardia | *Bradycardia | ||
*Peripherally vasodilated (warm extremities) | *Peripherally vasodilated (warm extremities) | ||
** | **However, this leads to hypothermia | ||
**Ensure monitoring of core temperatures and warming of patient | |||
== | ==Differential Diagnosis== | ||
{{Shock DDX}} | |||
==Management== | |||
#Exclude other causes of shock | #Exclude other causes of shock | ||
#IVF | #Supplemental O2 to perfuse injured spinal cord | ||
# | #Mechanical ventilation and oxygenation if spinal perfusion is compromised | ||
#Atropine if needed | #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. | ||
<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: | [[Category:Neurology]] | ||
[[Category:Trauma]] | [[Category:Trauma]] | ||
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.