Difference between revisions of "Neurogenic shock"

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#Prevent hypothermia
 
#Prevent hypothermia
 
#Judicious IVF, with UOP > 30 cc/hr
 
#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'''<ref>Coplin WM. Traumatic Spinal Cord Injury. 2013 Neurocritical Care Society Practice Update. http://www.neurocriticalcare.org/sites/default/files/pdfs/09.SCI.final.pdf.</ref>
+
#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
 
##Consider '''adding''' phenylephrine if BP refractory to first line agent
 
##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 alpha agonism in ICU setting
 
##May titrate down on norepinephrine and atropine, to favor more phenylephrine alpha 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
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##Low dose SC heparin at 500 units q8hrs plus SCDs may be alternative
  
 
==Source ==
 
==Source ==

Revision as of 07:14, 11 February 2016

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

Diagnosis

  • 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

Treatment

  1. Exclude other causes of shock
  2. Supplemental O2 to perfuse injured spinal cord
  3. Mechanical ventilation and oxygenation if spinal perfusion is compromised
  4. Prevent hypothermia
  5. Judicious IVF, with UOP > 30 cc/hr
  6. Norepinephrine first line, with MAP goal of 85-90 for the first 7 days after spinal cord injury
    1. Consider adding phenylephrine if BP refractory to first line agent
    2. Phenylephrine alone without beta-1 stimulation will cause reflex bradycardia
    3. Atropine if needed, keeping HR 60-100 bpm in NSR
    4. May titrate down on norepinephrine and atropine, to favor more phenylephrine alpha agonism in ICU setting
  7. High risk of VTE in paraparesis or tetraparesis
    1. Up to 40% in non-prophylaxed
    2. Must weigh benefits of VTE prophylaxis and risk of bleed from LMWH
    3. Low dose SC heparin at 500 units q8hrs plus SCDs may be alternative

Source


See Also