Introduction

Neurogenic shock is due to disruption of the sympathetic outflow as a result of an injury to the spinal cord. The main clinical signs of a patient in neurogenic shock are:

Hypotension – Due to passive dilatation of the vascular system. This can lead to decreased cardiac output as well as over-infusion of fluid replacement if not recognised.

Bradycardia – Due to unopposed vagal stimulation. Cardiac syncope can occur with trachea-oesophageal stimulation.

Poikilothermia – Due to dilatation of the vascular network. Patient becomes susceptible to their surroundings leading to hypo or hyperthermia if not insulated.

The higher the spinal lesion, the more pronounced the signs. A blood pressure of 60/40mmHg would not be unusual in a cervical spinal cord injury.

It is important that fluid replacement is carefully monitored to ensure patients in neurogenic shock are not over-infused leading to pulmonary oedema and respiratory distress.

A clinical suspicion of neurogenic shock can be made from the key signs such as hypotension, bradycardia, neurological deficit and warm, dry skin.

Immediate management

The initial evaluation and care of the patient with potential neurogenic shock is the same as for all trauma patients, that is, rapid identification and stabilisation of life-threatening injuries.

• Monitor BP, pulse, CVP, mean arterial pressure and urinary output.
• Measure the above every 15 minutes and watch for any trends.
• Massive fluid replacement should be avoided. In the case of polytrauma, fluid replacement should be given carefully whilst monitoring the patient carefully.
• If significant hypotension persists with no evidence of blood loss, consider the use of vasopresser drugs to replace the lost neurogenic vasoconstriction.
• TED stockings should be applied to reduce the risk of DVT but also to help replace some of the lost muscle resistance.
• Avoid rolling the patient on to the left side for a prolonged time as this can cause increase vagal stimulation leading to cardiac syncope.