Neurogenic Shock

1. See Also
   1. Spinal Shock
   2. Hemorrhagic Shock
   3. Severe Head Trauma
   4. Spinal Cord Syndrome
   5. Cervical Spine Injury
   6. Thoracolumbar Trauma
2. Definitions
   1. Neurogenic Shock
      1. Distributive shock from neurogenic vasodilation mediated by loss of sympathetic tone
      2. Follows cerebral or spinal cord injury (above T6) affecting sympathtic nervous system
   2. Spinal Shock
      1. In contrast to Neurogenic Shock, Spinal Shock is not a true shock syndrome
      2. Results in Flaccid Paralysis and Deep Tendon Reflex loss below level of spinal cord injury
3. Pathophysiology
   1. Results from Severe Head Injury or upper spine injury (above T6)
   2. Peripheral Sympathetic Nerve denervation results in ungoverned Parasympathetic Nerve activity
      1. Loss of vasomotor tone (vasodilation) leading to distributive shock
      2. Loss of cardiac Sympathetic Nerve activity, leads to paradoxical Bradycardia
4. Causes
   1. Severe Head Trauma
   2. Cervical Spine Injury
   3. Thoracic Spine Injury (above T6)
5. Signs
   1. Hypotension
      1. Secondary to Bradycardia and vasodilation
      2. Narrow Pulse Pressure is absent
         1. Lack of typical sympathetic response (increased SVR and diastolic BP)
   2. Paradoxical Bradycardia
      1. Expected response is a reflex Tachycardia (a sympathetic response)
   3. Decreased vascular tone (vasodilation)
      1. Warm extremities
6. Associated Conditions
   1. See Severe Head Trauma
   2. See Spinal Cord Syndrome
   3. See Cervical Spine Injury
   4. See Thoracolumbar Trauma
   5. Spinal Shock
      1. Flaccid Paralysis and Deep Tendon Reflex loss below level of spinal cord injury
   6. Diaphragm Paralysis
      1. C3-5 Cervical Spine Injury resulting in phrenic nerve denervation
7. Differential Diagnosis
   1. Hemorrhagic Shock (first priority to manage)
      1. Presents with Tachycardia, Vasoconstriction and cold extremities
      2. In actuality, distinguishing from Neurogenic Shock can be difficult
      3. Hemorrhagic Shock is more common, more immediately deadly and more treatable
         1. Address possible Hemorrhagic Shock first
8. Pitfalls
   1. Fluid Overload (from aggressive fluid Resuscitation)
9. Management
   1. Careful Fluid Replacement
   2. Vasopressors (Norepinephrine is preferred)
   3. Target mean arterial pressure of 85 mmHg or higher (maximizes spinal cord perfusion)
10. Prognosis
    1. Neurogenic Shock if due to critical Head Injury may indicate terminal event
    2. Prognosis is often poor
11. References
    1. (2012) ATLS, ACOS, p. 179-80