Neurogenic shock

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  • 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


  • Hypotension (well tolerated)
  • Bradycardia
  • Peripherally vasodilated (warm extremities)
    • May lead to hypothermia

Differential Diagnosis



  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]
    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


  1. Coplin WM. Traumatic Spinal Cord Injury. 2013 Neurocritical Care Society Practice Update.

See Also