[monkeyman1000]

Hi, my question has to do with SCI's and bradycardia. When do you begin to worry about it? I've had two patient's with SCI's the last few weeks with HR's in the 40's; both had systolic pressure's in the 90's and above and the doc's weren't worried. Just curious. The patient I had Sunday had to go to MRI and his HR kept hitting as low as 29 but with adequate sys pressure (the neuro PA was there and didn't seem concerned so I tried not to be but... ). Thanks in advance

[jax]

Great question - I'd love to hear the answer too.

[gwenith]

Sorry - I am a bit confused and want to make sure I am on the right wave lenght SCI = Spinal Cord Injury - yes?

I ask because Spinal shock is different to Neurogenic shock. (well at least in some texts ). Can you give me a bit more information about the case scenario's - were they young or old?

See if the systolic pressure is holding up it probably is not a classic spinal shock.

[monkeyman1000]

Sorry, Both patient's are in their early 20's. Both C5-C6 fx's. The resource I found stated that neurogenic shock occurs due to loss of sympathetic control resulting in, among other things, bradycardia. It went on to say to use atropine. My question, why would I use atropine if they are making an adequate pressure and in the one case the guy was responsive. Did that make sense (it's not unusual for my questions to not make sense, they say that there are no stupid questions but there are a lot of stupid people asking a lot of questions). Thank you Gwenith

[gwenith]

I don't believe in stupid questions (or didn't till I found an agency nurse standing in the middle of a frantic ICU asking if she could plug an ordinary bit of equipment into the socket on the wall - er yeah! That is why the plug is made to fit the socket)

Anyways - I do see where you are coming from and shock is SOOOOOO confusing with virtually every text treating it a different way (and watch this space in relation to shock the new non-invasive CO monitors threaten to re-write the texts on shock management)

But one thing I have learnt from CCU is that one mans bradycardia is anothers resting pulse rate It ALL depends on the cardiac output - is it adequate to perfuse the organs and especially those organs that are suffering from acute oedema.

I saw on the other thread I did promise to look up Neurogenic shock on UP2DATE and I did but it was no more helpful than the sites I had already found. Oh! Well! I will keep looking and if I have a chance after Easter I will start a resource thread/learning thread on Neurogenic shock.

[dorimar]

Now you said his SBP was ok, but were you able to assess mental status (SCI could also involve TBI that's why i ask)? Now I have lots of experience in ICU, but am new to neuro. In my experience sometimes the only symptom of "symptomatic bracycardia" is mental status changes (ie confusion) even with what appears to be a good BP. I guess if he was truly aysmptomatic, you wouldn't treat. Now on the neruogienic shock thing I am very new. My book says HR's 40-60 are common in neorogneic shock (and of course hypotension). I guess if they are not hypotensive and remain asymptomatic you wouldn't treat, but I would be a little nervous like you said about HR of 29. Maybe others have some good hands on experience with this. The only neurogenic shock patient I've actually dealt with was actually hypotensive ( and slightly bradycardic). Atropine was never necessarry, but fluid bolus' were (and not working).Some residents were saying pressors were contraindicated in neurogenic shock, but my literature states otherwise. Nurses argued back and forth with docs about pressors and finally when they let us start some neo we had acceptable bp. I am really interested to hear about some hands on with this.

Doris

[samad]

thank you for my freind to speak about nerogenic shock due to spinal fx
can i ask about sign and symptome of this shock and how to treat

[JenSICU_CCRN]

We usually don't treat an acute SCI with bradycardia unless it is symptomatic (low BP). Usually these tragic accidents are young adults (probably with low HR's anyway) so is a HR in the 40's really as bradycardic as we think. As long as the pressure is OK then we watch it closely, but if I was taking a pt. for MRI and they had been doing this and holding their pressure, I would take a few amps of atropine just in case. In my experience, the bradycardia usually resolves within 1-2 weeks post injury. I hope this helps you some.

Jenny

[JenSICU_CCRN]

Some residents were saying pressors were contraindicated in neurogenic shock, but my literature states otherwise. Nurses argued back and forth with docs about pressors and finally when they let us start some neo we had acceptable bp. I am really interested to hear about some hands on with this.



Pressors aren't contraindicated in neurogenic shock if they are euvolemic....however, giving a neurogenic shock pt. too much fluid is very risky and can cause cord edema to become worse. I'm glad that the nurses spoke up and did what was right. Good for you all.

Jenny