VERTEX INSTITUTE OF SCIENCE AND TECHNOLOGY

ABBOTTABAD
DEPARTMENT OF NURSING
“NEUROGENIC SHOCK”
SUBMITTED BY: HAMZA ISHTIAQ
PROGRAM: GENERIC-BSN-SEMESTER-7
SUBJECT: CRITICAL CARE NURSING
DATE: 09-MAY-2020
SUBMITTED TO: SIR NASIR
NEUROGENIC SHOCK
Shock is the state of insufficient blood flow to the tissue of the body as a result of
problems with the circulatory system.There are several types of shock: septic
shock caused by bacteria, anaphylactic shock caused by hypersensitivity or allergic
reaction, cardiogenic shock from heart damage, hypovolemic shock from blood or
fluid loss, and neurogenic shock from spinal cord trauma.[1]

Neurogenic Shock: In neurogenic shock, vasodilation occurs as a result of a loss of

balance between parasympathetic and sympathetic stimulation.It is a type of shock (a
life-threatening medical condition in which there is insufficient blood flow throughout
the body) that is caused by the sudden loss of signals from the sympathetic nervous
system that maintain the normal muscle tone in blood vessel walls.The inability of
the sympathetic nervous system to stimulate nerve impulses, which
causes hemodynamic problems. This leads to a decrease in tissue perfusion where the
cells that make up our organs and tissue don’t receive enough oxygen. Hence, signs
and symptoms of shock occur.Neurogenic shock is a type of distributive
shock ( anaphylactic and septic shock are the other types of distributive shock). This
means that the vessels that deliver blood flow to the cells have an issue
with distributing that blood flow.In neurogenic shock, it’s due to massive vasodilation
because the sympathetic nervous system has lost the ability to stimulate nerves that
control vessel vasomotor tone.[2]

CAUSES

Neurogenic shock is often a result of injury or trauma to the spinal cord. As a result,
your body loses function and stimulation of the sympathetic nervous system. Your
sympathetic nervous system maintains bodily functions during physical activity. That
includes strengthening your heart beat, raising your blood pressure, and opening your
airways to improve breathing.If your sympathetic nervous system doesn’t function
well, your blood pressure could drop and can affect your brain, tissues, and spinal
cord.Neurogenic shock could be occur by the following:

Spinal cord injury: Spinal cord injury is recognized to cause hypotension and

bradycardia (neurogenic shock).
Spinal anesthesia: Spinal anesthesia—injection of an anesthetic into the space
surrounding the spinal cord—or severance of the spinal cord results in a fall in blood
pressure because of dilation of the blood vessels in the lower portion of the body and
a resultant diminution of venous return to the heart.
Depressant action of medications: Depressant action of medications and lack
of glucose could also cause neurogenic shock.[3]

PATHOPHYSIOLOGY

Neurogenic shock is the clinical state manifested from primary and secondary spinal
cord injury. Hemodynamic changes are seen with an injury to the spinal cord above
the level of T6. The descending sympathetic tracts are disrupted most commonly from
associated fracture or dislocation of vertebrae in the cervical or upper thoracic spine.
Primary spinal cord injury occurs within minutes of the initial insult. Primary injury is
direct damage to the axons and neural membranes in the , lateral grey mater, and
anterior root that lead to disrupted sympathetic tone. Secondary spinal cord injury
occurs hours to days after the initial insult. Secondary injury is a result of vascular
insult, electrolyte shifts, and edema that lead to progressive central hemorrhagic
necrosis of grey matter at the injury site. At a cellular level, improper homeostasis of
electrolytes, and reperfusion injury which all lead to controlled and uncontrolled
apoptosis(cell death). Neurogenic shock is a combination of both primary and
secondary injuries that lead to loss of sympathetic tone and thus unopposed
parasympathetic response driven by the vagus nerve. Consequently, patients suffer
from instability in blood pressure, heart rate, and temperature regulation.[4]

Clinical manifestations

The clinical manifestations of neurogenic shock are signs of parasympathetic

stimulation that are Dry, warm skin. Instead of cool, moist skin, the patient
experiences dry, warm skin due to vasodilation and inability to vasoconstrict.

Hypotension. Hypotension occurs due to sudden, massive dilation.

Bradycardia. Instead of getting tachycardic, the patient experience bradycardia.

Diaphragmatic breathing: If the injury is below the 5th cervical vertebra, the patient
will exhibit diaphragmatic breathing due to loss of nervous control of the intercostal
muscles (which are required for thoracic breathing).

Respiratory arrest: If the injury is above the 3rd cervical vertebra, the patient will go
into respiratory arrest immediately following the injury, due to loss of nervous control
of the diaphragm.

Diagnostic Findings: Diagnosis of neurogenic shock is possible through the

following tests:

Computerized tomography (CT) scan: A CT scan may provide a better look at

abnormalities seen on an X-ray.

X-rays: Medical personnel typically order these tests on people who are suspected of
having a spinal cord injury after trauma.

Magnetic resonance imaging (MRI): MRI uses a strong magnetic field and radio
waves to produce computer-generated images.

Medical Management

Treatment of neurogenic shock involves:

Restoring sympathetic tone. It would be either through the stabilization of a spinal

cord injury or, in the instance of spinal anesthesia, by positioning the patient
appropriately.

Immobilization. If the patient has a suspected case of spinal cord injury, a traction
may be needed to stabilize the spine to bring it to proper alignment.

IV fluids. Administration of IV fluids is done to stabilize the patient’s blood pressure.

[5]
Pharmacologic Therapy

Drugs administered to a patient undergoing neurogenic shock are:

Inotropic agents. Inotropic agents such as dopamine may be infused for fluid

resuscitation.

Atropine. Atropine is given intravenously to manage severe bradycardia.

Steroids. Patient with obvious neurological deficit can be given I.V. steroids, such
as methylpredenisolone in high dose, within 8 hours of commencement of neurogenic
shock.

Heparin. Administration of heparin or low molecular-weight heparin as prescribed

may prevent thrombus formation.

Prognosis: The overall prognosis depends on the extent of spinal cord injury and
response to treatment. Those associated with neurological deficits tend to have poor
outcomes.

CASE STUDY

Saeed Hussain and his friends went partying on a Friday night. His friend was in
stress, drove them home. As they were crossing an intersection, their car was hit by a
ten-wheeler truck. Saeed Hussain sustained a spinal cord injury. Upon arrival at the
emergency department, her BP was 80/40, she had warm, dry skin, and her pulse is 44
beats per minute. Saeed Hussain is progressing towards neurogenic shock due to
spinal shock injury.
Past Medical History: Asthma Induced by Exercise and Left leg Fracture 3 years
ago.

Social History: Saeed Hussain is a Full-time student studying Nursing in his 4

year at Vertex college of nursing . He is right hand dominant. He is a music lover
and plays the rabab. Saeed Hussain also plays on the college Cricket Team, and in
his spare time enjoys Mountain Biking and Running. He has a part-time job at the
Private Hospital in Abbottabad.He currently lives in a two-storey house with 3
other college students during the College year and spends his College Holidays at
home where he lives with his parents, one older brother and two younger sisters .

Initial Medical Assessment: Blood Pressure 80/40, Heart Rate 44, Respiratory
Rate 32 with shallow breathing, Oral Temperature 35.1 Degrees Celsius, Color
Pale, Drowsy

Nursing Assessment: Assessment of a patient with neurogenic shock should involve:

ABC assessment: The per-hospital provider should follow the

basic airway, breathing, circulation approach to the trauma patient while protecting
the spine from any extra movement. Neurologic assessment:Neurologic deficits and
a general level at which abnormalities began should be identified.

Nursing Diagnose: Based on the assessment data, the nursing diagnoses for a patient
with neurogenic shock are: Risk for impaired : breathing pattern related to
impairment of innervation of diaphragm (lesions at or above C-5) and Risk for
trauma related to temporary weakness/instability of spinal column.Acute pain
related to pooling of the blood secondary to thrombus formation

Nursing Care Planning and Goals

The major goals for the patient include:

 Maintain adequate ventilation as evidenced by absence of respiratory distress and ABGs

within acceptable limits
 Demonstrate appropriate behaviors to support the respiratory effort.
 Maintain proper alignment of spine without further spinal cord damage.
 Maintain position of function as evidenced by absence of contractures, foot drop.
 Increase strength of unaffected/compensatory body parts.
 Demonstrate techniques/behaviors that enable resumption of activity.
 Recognize sensory impairments.
 Identify behaviors to compensate for deficits.
 Verbalize awareness of sensory needs and potential for deprivation/overload.

NURSING INTERVENTIONS

Nursing interventions are directed towards supporting cardiovascular and neurologic

function until the usually transient episode of neurogenic shock resolves.

Elevate head of bed: Elevation of the head helps prevent the spread of the anesthetic
agent up the spinal cord when a patient receives spinal or epidural anesthesia.

Lower extremity interventions: Applying anti-embolism stockings and elevating the

foot of the bed may help minimize pooling of the blood in the legs and prevent
thrombus formation.

Exercise: Passive range of motion of the immobile extremities helps promote

circulation.

Airway patency: Maintain patent airway: keep head in neutral position, elevate head
of bed slightly if tolerated, use airway adjuncts as indicated.

Oxygen: Administer oxygen by appropriate method (nasal prongs, mask, intubation,

ventilator).

Activities: Plan activities to provide uninterrupted rest periods and encourage

involvement within individual tolerance and ability.

BP monitoring: Measure and monitor BP before and after activity in acute phases or
until stable.

Reduce anxiety: Assist patient to recognize and compensate for alterations in

sensation.

Evaluation

Expected patient outcomes are:

  Maintained adequate ventilation.
 Demonstrated appropriate behaviors to support the respiratory effort.
 Maintained proper alignment of spine without further spinal cord damage.
 Maintained position of function.
 Increased strength of unaffected/compensatory body parts.
 Demonstrated techniques/behaviors that enable resumption of activity.
 Recognized sensory impairments.
 Identified behaviors to compensate for deficits.
 Verbalized awareness of sensory needs and potential for
deprivation/overload.

Documentation Guidelines

Documentation is used to assess nursing interventions and evaluate client outcomes,

identify care and documentation issues and advance evidence-based
practice. Nurses are required to make and keep records of their professional practice,
the focus of documentation are:

 Relevant history of problem.

 Respiratory pattern, breath sounds, use of accessory muscles.
 Laboratory values.
 Past and recent history of injuries, awareness of safety needs.
 Use of safety equipment or procedures.
 Environmental concerns, safety issues.
 Level of function, ability to participate in specific or desired activities.
 Client’s description of response to pain, specifics of pain inventory,
expectations of pain management, and acceptable level of pain.
 Prior medication use.
 Plan of care, specific interventions, and who is involved in the planning.
 Teaching plan.
  Response to interventions, teaching, actions performed, and treatment
regimen.
 Attainment or progress towards desired outcomes.
 Modifications to the plan of care.
CONCLUSION
Patient safety experts agree that communication and teamwork skills are essential for
providing quality health care. When all clinical and nonclinical staff collaborate
effectively, health care teams can improve patient outcomes, prevent medical
errors, improve efficiency and increase patient satisfaction.

The diagnosis and management of neurogenic shock are not easy, thus, the condition
is best managed by an interprofessional team that includes the emergency department
physician, neurologist, neurosurgeon, orthopedic surgeon, trauma specialist, and the
intensivist. These patients are usually monitored by neuro intensive care unit nurses.
While fluid resuscitation is the initial treatment, one should use vasopressors
cautiously, since they may exacerbate any vasoconstriction. Most patients have other
concomitant injuries that also require attention. Nurses should ensure that patients
have deep vein thrombosis prophylaxis, pressure sore protection, and a foley catheter.
These patients may develop a range of complications including aspiration pneumonia,
stress ulcer, and deep vein thrombosis. Close monitoring of the patient is critical and
all team members should communicate the treatment plan with each other to ensure
that the patient is receiving optimal care.

The outlook for these patients depends on the severity of the injury, presence of
neurological deficits at the time of presentation, age, concomitant other organ injuries,
and a low Glasgow Coma Scale score.[6]

REFERENCES
1. International Trauma Life Support for Emergency Care Providers(8 ed.). Pearson
Education Limited. 2018. pp. 172–173. ISBN 978-1292-17084-8.
2. Stein DM, Knight WA. Emergency Neurological Life Support: Traumatic Spine
Injury. Neurocrit Care. 2017 Sep;27(Suppl 1):170-180.
3. Taylor MP, Wrenn P, O'Donnell AD. Presentation of neurogenic shock within the
emergency department. Emerg Med J. 2017 Mar;34(3):157-162.
4. Kowalski A, Brandis D. StatPearls [Internet]. StatPearls Publishing; Treasure
Island (FL): Nov 12, 2019. Shock Resuscitation,
5. NJ Abbott, AA Patabendige, DE Dolman, et al.Structure and function of the
blood-brain barrierNeurobiol Dis, 37 (2010), pp. 13-25
6. Yue JK, Tsolinas RE, Burke JF, Deng H, Upadhyayula PS, Robinson CK, Lee
YM, Chan AK, Winkler EA, Dhall SS. Vasopressor support in managing acute
spinal cord injury: current knowledge. J Neurosurg Sci. 2019 Jun;63(3):308-317.