9.16 SFGH pearls – Neurogenic shock

  • Remember to search for an underlying cause in patients who present with vague weakness/fatigue/failure to thrive. FTT is a diagnosis in children under 2, but is a symptom of something else for grown ups
  • Spinal cord injuries above T6 often disturb the descending pathways to the sympathetic trunk, so patients have loss of sympathetic control and loss of parasympathetic inhibition. This can lead to autonomic dysregulation of multiple organ systems, including cardiac, thermoregulatory, pulmonary, urinary and GI systems, with the most worrisome effects being bradycardia and hypotension due to decrease SVR and altered vagal tone
    • LE stasis and edema can develop, and these patients are at high risk for VTE!
  • Management should be focused on stabilizing the spine and minimizing neurologic damage by maintaining good perfusion (MAP goal >85 acutely)
  • Other treatment is primarily supportive aiming for euthermia, euvolemia, PT, and ventilator strategies that can improve diaphragmatic strength
  • Cardiovascular support can be accomplished with pressors, atropine as needed. Pressors may be needed for up to 5 weeks after spinal cord injury (!), and oral pressors like ephedrine can be used for these patients.

Summers, RL et al. Characterization of the spectrum of hemodynamic profiles in trauma patients with acute neurogenic shock. J Crit Care. 2013 Aug;28(4);531.

Tator CH. Update on the pathophysiology and pathology of acute spinal cord injury. Brain Pathol 1995; 5:407.

 

Evernote link here: https://www.evernote.com/shard/s300/sh/cfba436b-655d-475d-a794-2aed1c0ed7d1/3473e280292a81135c1779fdec685ab4

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