1262: A CURIOUS CASE OF SHOCK AFTER A FALL

Abstract

Introduction: Neurogenic shock is a rare presentation that follows spinal cord injuries. Bilello et al argued that up to 31% of cervical spine injury patients typically develop this phenomenon (2). However, the diagnosis remains difficult, as patients typically presents following a major injury and hemorrhagic shock cannot be ruled out. Due to its uniqueness and lack of treatment guidelines, it is important to identify neurogenic shock early. Description: A 70-year-old Caucasian female with a past medical history of dementia, recurrent falls, recurrent UTI’s, and well controlled seizures presented to the Emergency Department following an unwitnessed fall. Labs including CBC, lactic acid, BUN/Cr, troponin, and UA were unremarkable. At presentation the patient was hypotensive and bradycardic which progressed despite receiving 6 liters of intravenous fluids and atropine. This prompted an admission to the ICU for IV norepinephrine. Within hours of being on norepinephrine, her blood pressure improved, and she quickly transitioned to oral midodrine. Nonetheless, the bradycardia persisted. Echocardiogram and EKGs were performed and shockingly were without any insight to the persistent bradycardia. CT Head and C-spine, chest X-ray, and MRI-brain w/o contrast were all unremarkable. An MRI of the C-Spine showed cord compression of C3/C4 and C4/C5. It was at this point that neurosurgery was consulted to evaluate the patient for surgery. Discussion: Our case is unique in that the etiology of the shock is unclear. Neurogenic shock is understood to be a product of both primary and secondary spinal cord injury; a direct damage to the axons that often leads to vascular insult or edema, leading to loss of sympathetic tone3. Typically, this is seen following major traumatic accidents or repeated falls. While our patient does have an inciting factor, the imaging findings seem to infer that there was a baseline chronic degenerative disease, exacerbated by the fall, that resulted in cord compression. Management of neurogenic shock centers around ample fluid resuscitation followed by vasopressor as needed with MAP goals 85-904 for 7 days. However, guidelines are less clear on the best agents, with most recommending a drug that targets both alpha and beta receptors1.