Neurogenic Shock Flashcards
Patients with Traumatic Spinal Cord Injury can be at exceptionally high risk for loss of airway due to a combination of what? (ENLS Traumatic Spinal Cord Injury Protocol)
• Airway edema
• Loss of diaphragmatic innervation (C3, C4, and C5 innervate the diaphragm)
• Failure to ventilate
• Loss of chest and abdominal wall strength
All patients with a complete cervical TSI C1-C4 should be considered for early, elective intubation and mechanical ventilation.
Patients with incomplete or lower TSI will have a high degree of variability in their ability to maintain adequate oxygenation and ventilation. General parameters for urgent intubation include what? (ENLS Traumatic Spinal Cord Injury Protocol)
• Complaint of “shortness of breath”, inability to “catch my breath” or breathlessness
• Vital Capacity < 10 ml/kg or decreasing vital capacity
• Appearance of “quad breathing” (abdomen goes out sharply with inspiration). When in doubt, it is better to intubate a patient with a cervical TSI electively rather than wait until it needs to be done
emergently. Patients will typically develop worsening of their primary injury shortly after admission due to cord edema and progressive loss of muscle strength. Patients with very high (above C3) complete TSI will almost invariably suffer a respiratory arrest in the field and, if not intubated by prehospital providers, typically present in cardiac arrest.
Appearance of “quad breathing” (abdomen goes out sharply with inspiration). When in doubt, it is better to intubate a patient with a cervical TSI electively rather than wait until it needs to be done
emergently. Patients will typically develop worsening of their primary injury shortly after admission due to cord edema and progressive loss of muscle strength. Patients with very high (above C3) complete TSI will almost invariably suffer a respiratory arrest in the field and, if not intubated by Paramedics, typically present in cardiac arrest.
Patients with TSI are at high risk of inadequate oxygenation and ventilation. This is due to a combination of what factors? (ENLS Traumatic Spinal Cord Injury Protocol)
• Loss of diaphragmatic function
• Loss of ability to cough and deep breathe due to loss of chest wall and abdominal musculature function
• Aspiration
• Retention of secretions
• Atelectasis
• Concomitant injuries (pulmonary contusions, pneumothorax, rib fractures)
• Supplemental oxygen should be supplied to all patients with cervical TSI if necessary. Hypoxia is extremely detrimental to patients with neurological injury. Noninvasive methods of ventilation should be used with caution as the inability to cough and clear secretions may lead to an increased risk of aspiration.
In TSI, what is your MAP goal for the first 7 days? (ENLS Traumatic Spinal Cord Injury Protocol)
Management of hypotension: maintain MAP 85-90 mm Hg for the first 7 days
First line treatment of neurogenic shock is always fluid resuscitation to maintain euvolemia.
• The loss of sympathetic tone leads to vasodilation and the need for an increase in the circulating blood volume (“filling the tank”)
• Second line therapy includes vasopressors and/or inotropes.
• Norepinephrine - (preferred) has both alpha and some beta activity thereby improving both
blood pressure and bradycardia.
• Phenylephrine - pure alpha agonist. Phenylephrine is commonly used and easily
titrated. Lacks beta activity so does not treat bradycardia and may actually worsen it
through reflexive mechanisms.
• Dopamine - need high doses (> 10 mcg/kg/min) for alpha effect, but does have
significant beta effects at lower doses. May lead to inadvertent diuresis at lower
doses exacerbating relative hypovolemia.
• Epinephrine - an alpha and beta agonist. Epinephrine causes vasoconstriction and
increased cardiac output. High doses are often required leading to inadvertent
mucosal ischemia. Rarely used or needed.
• Dobutamine - beta agonist (inotrope) that can be useful when the loss of
sympathetic tone causes cardiac dysfunction. Caution should be used in patients who are not adequately volume loaded as may cause hypotension.
What is the first line treatment of hypotension in neurogenic shock?
Fluid resuscitation is always the first line treatment to maintain euvolemia due to the loss of sympathetic tone which leads to vasodilation and the need for an increase in the circulating blood volume (“filling the tank”).
Second line therapy for the treatment of hypotension in neurogenic includes vasopressors and/or inotropes. Discuss the pros and cons of the common medications.
• Norepinephrine - (preferred agent) has both alpha and some beta activity thereby improving both blood pressure and bradycardia.
• Phenylephrine - pure alpha agonist; commonly used and easily titrated. Lacks beta activity so does not treat bradycardia and may actually worsen it through reflexive mechanisms.
• Dopamine - need high doses (> 10 mcg/kg/min) for alpha effect, but does have significant beta effects at lower doses; may lead to inadvertent diuresis at lower doses exacerbating relative hypovolemia.
• Epinephrine - an alpha and beta agonist; causes vasoconstriction and increased cardiac output.
High doses are often required leading to inadvertent mucosal ischemia. Rarely used or needed.
• Dobutamine - beta agonist (inotrope) that can be useful when the loss of sympathetic tone causes cardiac dysfunction.
Caution should be used in patients who are not adequately volume loaded as may cause hypotension.
Are steroids recommended in the initial treatment of Traumatic Spinal Cord Injury?
The use of steroids following acute traumatic cervical spinal injury should not be considered the standard of care.
Fifteen medical societies, including the American Association of
Neurological Surgeons and the Congress of Neurological Surgeons do not recommend their use.
Methylprednisolone therapy is not Food and Drug Administration (FDA)
approved for this application. Steroid use is associated with increased complications such as pneumonia and gastrointestinal bleeding, as well as hyperglycemia in diabetic patients.
When should a patient be removed from a backboard?
The patient should be removed as soon as possible from the backboard, ideally at the conclusion of the primary or secondary survey.
Evidence suggests leaving a patient on a backboard can lead to deleterious complications such as skin breakdown.
Thoracic and lumbar immobilization can be accomplished on a stretcher or hospital bed.
