An unconscious 35 y/o male presents from the scene of a motor vehicle versus pedestrian accident. The patient is intubated and hypotensive but there is no source of external bleeding. FAST is negative. Blood products are given with no response. CT imaging shows no evidence of bleeding. What should you consider? (scroll for answer)

Type of Shock:

• Distributive (Neurogenic)

Cause:

• Loss of peripheral sympathetic innervation (T1-L2) ⇒ severe vasodilation ⇒ Hypotension
• Loss of sympathetic innervation to heart (T1-T4) ⇒ leaves unopposed vagal parasympathetic cardiac innervation ⇒ Bradycardia

Clinical Presentation:

• Warm extremities, hypotensive with a relative bradycardia

Management:

• Judicious IV Crystalloid
• Early vasopressors (Norepinephrine 1st line)
• Temperature probe foley due to risk of hypothermia 2/2 vasodilation

Pearl:

• Diagnosis of exclusion in a trauma patient. Hemorrhagic etiology must be ruled out by FAST and CT imaging prior to consideration. Presentation can be mixed with hemorrhagic shock.

Reference:

Mapelli E, Sabhaney V. "Neurogenic Shock."Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8eEds. Judith E. Tintinalli, et al. New York, NY: McGraw-Hill, 2016, pg 1720-1721.