Spinal Shock

17 Nov

Definition – Spinal cord injury (SCI) that leads to loss of sympathetic tone below level of the injury.  Hypotension, bradycardia are key clinical signs s/p recent trauma.

 

Pathophysiology/Mechanism

  • Fracture of spinal element
  • Dislocation
  • Ligamentous Rupture
  • Disc herniation
  • GSW indirectly (Kinetic energy)

 

Clinical Signs/Symptoms

  • Paralysis
  • Anesthesia
  • Hypotension
  • Bradycardia (Unopposed Vagal activity).
  • Absent bowel and bladder control

 

Phases of spinal shock

Phase Time Physical exam finding Underlying physiological event
1 0–1d Areflexia/Hyporeflexia Loss of descending facilitation
2 1–3d Initial reflex return Denervation supersensitivity
3 1–4w Hyperreflexia (initial) Axon-supported synapse growth
4 1–12m Hyperreflexia, Spasticity Soma-supported synapse growth

 

Emergency Management

  • A/B: patient with a high cervical cord injury may breathe poorly and may require airway suction or intubation.
  • C: Hypotension may occur due to blood loss from other injuries or due to blood pooling in the extremities lacking sympathetic tone because of the disruption of the autonomic nervous system (neurogenic shock).
    • Vasopressors are usually required. Levophed has been used widely amongst patient’s with TSCI with hypotension and bradycardia. Phenylephrine is theoretically taught as 1st line treatment but studies recommend goal of MAP > 85 – 90 (4,5). 
    • Elevation of the legs, the head-dependent position, blood replacement, and/or vasoactive agents may be required (1).
  • Secondary: check for bladder distension by palpation or ultrasound. A urinary catheter should be inserted as soon as possible.

 

Further Management

  • Cardiovascular complications— Neurogenic shock refers to hypotension, usually with bradycardia, attributed to interruption of autonomic pathways in the spinal cord causing decreased vascular resistance. Patients with TSCI may also suffer from hemodynamic shock related to blood loss and other complications.
    • An adequate blood pressure is believed to be critical in maintaining adequate perfusion to the injured spinal cord and thereby limiting secondary ischemic injury (goal MAP > 85 – 90 mmHg).
  • Respiratory complications – Weakness of the diaphragm and chest wall muscles leads to impaired clearance of secretions, ineffective cough, atelectasis, and hypoventilation.

Glucocorticoids — Methylprednisolone is the only treatment that has been suggested in clinical trials to improve neurologic outcomes — however, the evidence is limited, and its use is debated.  Methylprednisolone is contraindicated in patients with moderate to severe traumatic brain injury.

Surgery — Goals for surgical intervention in TSCI include stabilization of the spine, as well as reduction of dislocations and decompression of neural elements.

 

Submitted by Christina Brown.

 

References:

  1. http://www.uptodate.com/contents/acute-traumatic-spinal-cord-injury?source=search_result&search=neurogenic+shock&selectedTitle=2%7E17
  2. Jia X, Kowalski RG, Sciubba DM, Geocadin RG. Critical care of traumatic spinal cord injury. J Intensive Care Med 2013; 28:12.
  3. Vale FL, Burns J, Jackson AB, Hadley MN. Combined medical and surgical treatment after acute spinal cord injury: results of a prospective pilot study to assess the merits of aggressive medical resuscitation and blood pressure management. J Neurosurg 1997; 87:239.
  4. Blood pressure management after acute spinal cord injury. Neurosurgery 2002; 50:S58.
  5. Levi L, Wolf A, Belzberg H. Hemodynamic parameters in patients with acute cervical cord trauma: description, intervention, and prediction of outcome. Neurosurgery 1993; 33:1007.
  6. Stevens RD, Bhardwaj A, Kirsch JR, Mirski MA. Critical care and perioperative management in traumatic spinal cord injury. J Neurosurg Anesthesiol 2003; 15:215.
  7. Breslin K, Agrawal D. The use of methylprednisolone in acute spinal cord injury: a review of the evidence, controversies, and recommendations. Pediatr Emerg Care 2012; 28:1238.
  8. Breslin K, Agrawal D. The use of methylprednisolone in acute spinal cord injury: a review of the evidence, controversies, and recommendations. Pediatr Emerg Care 2012; 28:1238.
  9. TABLE: http://www.nature.com/sc/journal/v42/n7/full/3101603a.html
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