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Annals of B-Pod: Neurogenic Shock

It is important to note that neurogenic shock is distinct from spinal shock, which is the loss of sensation, motor function, and reflexes distal to a spinal cord injury that develops within 24 hours of the initial insult. The name derives from the return of some degree of function over time as the “shock” of acute cellular and metabolic derangements dissipates.

Although no universal objective parameters exist to formally define neurogenic shock, it is generally defined as a cervical or upper thoracic SCI with associated systolic blood pressure less than 90-100 mmHg and a heart rate less than 60-80 beats/minute.

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 Spinal Shock and Neurogenic Shock

“Neurogenic Shock” (Neurogenic Hypotension) refers to a loss of BP regulation (hypotension and bradycardia) following a complete SCI above the T5 level and is due to loss of sympathetic outflow to the systemic vasculature and heart.

 What kind of shock? Spinal shock?

Try not to confuse neurogenic and spinal shock. Many will use the terms interchangeably, most often saying spinal shock when they mean neurogenic, and then you will have to use your frontal lobe to inhibit your impulses and decide whether it’s worth a correction that may be deemed rude or nitpicking. Since my frontal lobe stopped working years ago, I decided to save on-shift time and instead refer folk to this post.

Articles of Interest

A primer on Neurogenic Shock

Neurogenic shock is a form of distributive shock unique to patients with spinal cord injuries. Fewer than 20% of patients with a cervical cord injury have the classic diagnosis of neurogenic shock upon arrival to the emergency department, and it is a relatively uncommon form of shock overall. Patients with injuries at T4 or higher are most likely to be affected by neurogenic shock.

Nuances of Neurogenic Shock

Neurogenic shock is an elusive diagnosis to confidently make, particularly when there is a cloudy ‘mixed-shock’ picture. We must remember to consider it in patients with a suggestive mechanism of injury, and appropriately tailor management when it’s likely to be in play. It’s unpredictable, variable in onset and should be considered in shocked patients with any type of spinal injury, regardless of anatomical level. Awareness of these nuances will improve outcomes.

Resources

CriticalCareNow

The classic clinical presentation of Neurogenic Shock is shock (hypotension) with warm extremities and bradycardia after a trauma causing a Spinal Cord Injury above the level of T6.

StatPearls

Neurogenic shock is a devastating consequence of spinal cord injury (SCI) that can manifest as hypotension, bradyarrhythmia, and temperature dysregulation. It is associated with cervical and high thoracic spine injury.

WikiDoc

The classic presentation of a patient in neurogenic shock is almost the opposite to that found in other shock states. In hypovolaemic shock the patient presents with cold, clammy, and pale or cyanotic peripheries. In neurogenic shock, the extremities may remain pink, warm and well perfused. Due to the loss of sympathetic function, he is unable to initiate the vasoconstriction required to divert blood to the central vital organs; and thus it pools in the peripheral vascular compartments.