What kind of shock? Spinal shock?

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Okay this one isn’t quite as “nails-on-a-chalkboard” for me as a “dissecting aortic aneurysm,” but it comes up often.

There’s a patient with multiple injuries who’s hypotensive and has had significant direct trauma to the back. “Oh, maybe he’s in spinal shock.” Well, maybe. But I have no idea yet what you’re talking about:

Are you talking about a cause for his low blood pressure? In that case, what you mean is that you’re concerned for neurogenic shock. Granted, this pt. has a much higher likelihood of being in hemorrhagic shock, but it’s good to think broadly. Neurogenic shock is the entity that the textbook says will present with hypotension and bradycardia, and that responds well to norepinephrine (a predominantly alpha agonist agent, with a bit of beta agonist activity that may improve the HR). So can our patient have neurogenic shock, even if he has tachycardia? Yes, absolutely he can, and he may even have two things.

But what he does NOT have is spinal shock. Now, if he also presented with low extremity paralysis, loss of sensation and loss of reflexes, then we would certainly be concerned about this. Neurogenic shock can be considered as a subset or complication of spinal shock, especially with trauma above the T6 level. The autonomic dysfunction when both are present is typically not as profound as in isolated neurogenic shock, and so may not require pressor therapy. It also can improve over hours to weeks.

To be clear, these two syndromes can present clinically separately- a pt. with abnormal VS and no focal neurologic signs (neurogenic shock) vs. a pt. with normal VS with paralysis and a sensory level (spinal shock). When they overlap, the pt. has spinal shock with dysautonomia, or neurogenic shock AS A RESULT OF spinal shock.

So your trauma pt. has a back injury and paralysis below the injury? How do you know if you’re dealing with a transected cord or a spinal shock patient? Well, you want to pay attention to your rectal exam. If there is no rectal tone or bulbocavernosus reflex then it is impossible to tell: spinal shock patients lose reflexes below the level of their cord injury. However, if there IS bulbocavernous, then that’s terrible. It means that this pt. does not have spinal shock, likely has direct cord injury, and cannot be expected to improve over the coming days. It is one of the few times that the absence of reflex is a worse prognostic sign than its presence.

SO: 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.

 

For more, check out:

[/et_pb_text][/et_pb_column][et_pb_column type=”1_4″][et_pb_team_member admin_label=”Person” saved_tabs=”all” name=”Pinaki Mukherji, MD, FACEP, FAAEM” position=”Program Director, Emergency Medicine, LIJ Medical Center” image_url=”http://theempulse.org/wp-content/uploads/2015/09/dr-pinaki-mukherji-md-11313705.jpg” animation=”off” background_layout=”light” twitter_url=”https://twitter.com/ercowboy” use_border_color=”off” border_color=”#ffffff” border_style=”solid”]

Dr. Mukherji is the Residency Director at LIJ Medical Center in New Hyde Park, NY.  He spends most of his time confusing residents and trying to convince doctors that they overestimate the benefits of treatment and underestimate the harms. He has a passion for education and trying not to do things wrong.

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