Neurogenic Shock for Certified Emergency Nursing (CEN)
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Outline
Neurogenic Shock
Definition/Etiology:
- Shock is circulatory collapse, and inadequate tissue perfusion/oxygenation.
- Neurogenic shock is a diagnosis of exclusion in trauma, and hypovolemic shock should be considered and ruled out first.
- 8,000-10,000 traumatic spinal cord injuries occur each year in the United States.
- 19% of cervical spine injuries result in neurogenic shock.
- 7% of thoracic spine injuries result in neurogenic shock.
- Neurogenic shock occurs in 25-50% of brain/spinal cord injury patients, and usually in the first 5 weeks after injury.
- In neurogenic shock, sympathetic input is lost, and parasympathetic input is unopposed.
- Vasodilation occurs, and a distributive shock results due to pooling of blood in the periphery.
- The body is unable to compensate for the hypotension by increasing heart rate because sympathetic response is disrupted, This results in uncompensated hypotension with bradycardia.
- Sympathetic control is from T1-L2 (fight or flight)
- Parasympathetic control is from mostly cranial nerves and a little bit from S4 (rest and digest)
- When cervical or thoracic injury occurs, only the sympathetic system is interrupted
Pathophysiology:
Spinal cord injury or brain injury produces neurogenic shock:
- Vertebral fracture
- T6 or above
- Dislocation of vertebra
- Torn vertebral ligament
- Disruption or herniation of intravertebral disc
- Loss of sympathetic nervous system input
Clinical Presentation:
Vasodilation:
- Hypotension
- Warm, flushed skin
- Priapism
- Good urine output
Unable to compensate for hypotension:
- Normal heart rate or bradycardia
- Altered mental status
Euvolemic:
- Normal skin turgor
- Moist mucous membranes
- No edema
- No jugular venous distention
Neuro deficits distal to injury:
- Loss of motor
- Loss of sensation
- Loss of reflexes
Collaborative Management:
Labs: CBC, CMP, lactate, ABG, coags, type and cross
Imaging:
- FAST exam to rule out concomitant hypovolemic shock
- MRI or CT spine/brain
- Vasopressors to keep MAP 85-90 mmHg to minimize secondary spinal injury from hypotension. Norepinephrine is the preferred vasopressor. If profoundly bradycardic, Dopamine or Atropine may be of benefit.
- Monitor fluid status and avoid excess IV fluids because edema in the injured spinal column worsens the injury.
- Get a good history. If on beta blockers, calcium channel blockers, or digoxin, then they could be clouding the picture by suppressing compensatory tachycardia.
Evaluation | Patient Monitoring | Education:
- Continuous cardiac and SaO2 monitoring
- Central venous catheter if vasopressors are needed
- Frequent NIBP vs arterial line
- Foley catheter to monitor urine output
- Neuro ICU admission
Linchpins: (Key Points)
- Early identification/treatment can prevent secondary injury.
- Rule out hypovolemic shock first.
- Neurogenic shock is a diagnosis of exclusion.
- Suspect neurogenic shock with T6 injury or above.
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Transcript
For more great CEN prep, got to the link below to purchase the “Emergency Nursing Examination Review” book by Dr. Laura Gasparis Vonfrolio RN, PHD
https://greatnurses.com/
References:
- Colwell, C. (2022, September 30). Approach to shock in the adult trauma patient. UpToDate. https://www.uptodate.com/contents/approach-to-shock-in-the-adult-trauma-patient
- Gaieski, D. F. (2022, March 22). Definition, classification, etiology, and pathophysiology of shock in adults. UpToDate. https://www.uptodate.com/contents/definition-classification-etiology-and-pathophysiology-of-shock-in-adults
- Gaieski, D. F. (2022, May 9). Evaluation of and initial approach to the adult patient with undifferentiated hypotension and shock. UpToDate. https://www.uptodate.com/contents/evaluation-of-and-initial-approach-to-the-adult-patient-with-undifferentiated-hypotension-and-shock
- Hansebout, R. R. (2018, July 18). Acute traumatic spinal cord injury. UpToDate. https://www.uptodate.com/contents/acute-traumatic-spinal-cord-injury
- Kaji, A. (2021, October 4). Evaluation and initial management of cervical spinal column injuries in adults. UpToDate. https://www.uptodate.com/contents/evaluation-and-initial-management-of-cervical-spinal-column-injuries-in-adults
- Sagar, D. (2022, February 10). Neurogenic shock. Stat Pearls. https://www.ncbi.nlm.nih.gov/books/NBK459361/
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Med surg 2 (Endocrine, Gastro, Neuro and musculoskeletal)
Concepts Covered:
- Disorders of the Posterior Pituitary Gland
- Disorders of the Thyroid & Parathyroid Glands
- Disorders of Pancreas
- Prenatal Concepts
- Tissues and Glands
- Pregnancy Risks
- Health & Stress
- Emergency Care of the Cardiac Patient
- Vascular Disorders
- Terminology
- Studying
- Female Reproductive Disorders
- Disorders of the Adrenal Gland
- Endocrine System
- Oncology Disorders
- Eating Disorders
- Substance Abuse Disorders
- Shock
- Respiratory Disorders
- Male Reproductive Disorders
- Gastrointestinal Disorders
- Upper GI Disorders
- Liver & Gallbladder Disorders
- Digestive System
- Newborn Complications
- Neurologic and Cognitive Disorders
- Emergency Care of the Trauma Patient
- Disorders of Thermoregulation
- Hematologic Disorders
- Lower GI Disorders
- Immunological Disorders
- Anxiety Disorders
- Endocrine and Metabolic Disorders
- Urinary Disorders
- Cardiac Disorders
- Central Nervous System Disorders – Brain
- Nervous System
- Intraoperative Nursing
- Medication Administration
- Urinary System
- Musculoskeletal Trauma
- Cognitive Disorders
- Acute & Chronic Renal Disorders
- Noninfectious Respiratory Disorder
- Somatoform Disorders
- Microbiology
- Adult
- Multisystem
- Neurological
- Emergency Care of the Neurological Patient
- Peripheral Nervous System Disorders
- Neurological Trauma
- Central Nervous System Disorders – Spinal Cord
- Neurological Emergencies
- Musculoskeletal Disorders
- Preoperative Nursing
- Skeletal System
- Musculoskeletal Disorders
- Communication
- Learning Pharmacology
Study Plan Lessons
03.05 Endocrine Practice Questions for CCRN Review
Diabetes Mellitus for Progressive Care Certified Nurse (PCCN)
Factors That Can Put a Pregnancy at Risk Nursing Mnemonic (RIBCAGE)
Glands
Glucose Tolerance Test (GTT) Lab Values
Health & Stress
Hypertension (Uncontrolled) and Hypertensive Crisis for Progressive Care Certified Nurse (PCCN)
Hypoglycemia for Progressive Care Certified Nurse (PCCN)
Metabolic & Endocrine Module Intro
Metabolic & Endocrine Terminology
Metabolic/Endocrine Course Introduction
Mnemonic for Organ Systems (MR DICE RUNS)
Nursing Care and Pathophysiology for Menopause
Nursing Care Plan (NCP) for Addison’s Disease (Primary Adrenal Insufficiency)
Nursing Care Plan (NCP) for Hyperthyroidism
Nursing Care Plan (NCP) for Osteoporosis
Nutritional Requirements
Pancreas
Pharmacology Terminology
Pituitary Adenoma
Potassium-K (Hyperkalemia, Hypokalemia)
Thyroid Cancer
Urinalysis (UA)
Anti-Infective – Carbapenems
Anti-Infective – Macrolides
Anti-Infective – Sulfonamides
Appendicitis
Bariatric Surgeries
Celiac Disease
Cirrhosis for Certified Emergency Nursing (CEN)
Colonoscopy
Colorectal Cancer (colon rectal cancer)
Constipation and Encopresis (Incontinence)
Cystic Fibrosis (CF)
Digestion & Absorption
Digestive Terminology
Discomforts of Pregnancy
Endoscopy & EGD
Erythroblastosis Fetalis
Famotidine (Pepcid) Nursing Considerations
Gastritis
Gastrointestinal (GI) Bleed Concept Map
Gastrointestinal (GI) Course Introduction
Gastrointestinal Trauma for Certified Emergency Nursing (CEN)
Hemorrhagic Fevers for Certified Emergency Nursing (CEN)
Hyperbilirubinemia (Jaundice)
Imperforate Anus
Intussusception
Iron (Fe) Lab Values
Liver Function Tests
Lower Gastrointestinal (GI) Module Intro
Nursing Care Plan (NCP) for Abdominal Pain
Nursing Care Plan (NCP) for Acquired Immune Deficiency Syndrome (AIDS)
Nursing Care Plan (NCP) for Addison’s Disease (Primary Adrenal Insufficiency)
Nursing Care Plan (NCP) for Anemia
Nursing Care Plan (NCP) for Anxiety
Nursing Care Plan (NCP) for Appendicitis
Nursing Care Plan (NCP) for Bowel Obstruction
Nursing Care Plan (NCP) for Cholecystitis
Nursing Care Plan (NCP) for Colorectal Cancer (Colon Cancer)
Nursing Care Plan (NCP) for Constipation / Encopresis
Nursing Care Plan (NCP) for Cystic Fibrosis
Nursing Care Plan (NCP) for Dehydration & Fever
Nursing Care Plan (NCP) for Diverticulosis / Diverticulitis
Nursing Care Plan (NCP) for GI (Gastrointestinal) Bleed
Nursing Care Plan (NCP) for Hyperemesis Gravidarum
Nursing Care Plan (NCP) for Imperforate Anus
Nursing Care Plan (NCP) for Inflammatory Bowel Disease (Ulcerative Colitis / Crohn’s Disease)
Nursing Care Plan (NCP) for Intussusception
Nursing Care Plan (NCP) for Nutrition Imbalance
Nursing Care Plan (NCP) for Ovarian Cancer
Nursing Care Plan (NCP) for Pancreatitis
Nursing Care Plan (NCP) for Peptic Ulcer Disease (PUD)
Nursing Care Plan (NCP) for Sepsis
Nursing Care Plan (NCP) for Stomach Cancer (Gastric Cancer)
Nursing Care Plan (NCP) for Urinary Tract Infection (UTI)
Nursing Care Plan for Hiatal Hernia
Nursing Care Plan for Liver Cancer
Nursing Care Plan for Scleroderma
Nursing Case Study for Colon Cancer
Nutrition (Diet) in Disease
Omphalocele
Pediatric Gastrointestinal Dysfunction – Diarrhea
Pharmacology Terminology
Physiological Changes
Thromboembolic Disease- Deep Vein Thrombosis (DVT) for Certified Emergency Nursing (CEN)
Total Bilirubin (T. Billi) Lab Values
Umbilical Hernia
Upper Gastrointestinal (GI) Module Intro
Nursing Care Plan (NCP) for Eating Disorders (Anorexia Nervosa, Bulimia Nervosa, Binge-Eating Disorder)
Nursing Care Plan (NCP) for Hashimoto’s Thyroiditis
Nursing Care Plan (NCP) for Hyperparathyroidism
Nutrition Assessments
Alcohol Withdrawal (Addiction)
Altered Mental Status Nursing Mnemonic (AEIOU TIPS)
Ammonia (NH3) Lab Values
Autonomic Nervous System (ANS)
Barbiturates
Bowel Perforation for Certified Emergency Nursing (CEN)
Calcium and Magnesium Imbalance for Certified Emergency Nursing (CEN)
Chemotherapy Patients
Complications of Immobility
Day in the Life of a Med-surg Nurse
Dementia Nursing Mnemonic (DEMENTIA)
Fibromyalgia
Head to Toe Nursing Assessment (Physical Exam)
Meds for Alzheimers
Nuclear Medicine
Nursing Care and Pathophysiology for Hypothyroidism
Nursing Care and Pathophysiology of Chronic Kidney (Renal) Disease (CKD)
Nursing Care Plan (NCP) for Anaphylaxis
Nursing Care Plan (NCP) for Aspiration
Nursing Care Plan (NCP) for Celiac Disease
Nursing Care Plan (NCP) for Eating Disorders (Anorexia Nervosa, Bulimia Nervosa, Binge-Eating Disorder)
Nursing Care Plan (NCP) for Encephalopathy
Nursing Care Plan (NCP) for Endocarditis
Nursing Care Plan (NCP) for Hashimoto’s Thyroiditis
Nursing Care Plan (NCP) for Hyperparathyroidism
Nursing Care Plan (NCP) for Hypoparathyroidism
Nursing Care Plan (NCP) for Hypothyroidism
Nursing Care Plan (NCP) for Hypovolemic Shock
Nursing Care Plan (NCP) for Omphalocele
Nursing Care Plan (NCP) for Reye’s Syndrome
Nursing Care Plan (NCP) for Somatic Symptom Disorder (SSD)
Nursing Care Plan (NCP) for Vomiting / Diarrhea
Nursing Care Plan (NCP) for West Nile Virus
Nursing Care Plan for Distributive Shock
Nutrition Assessments
Pituitary Gland
Stomach Cancer (Gastric Cancer)
Vomiting
Adrenal Gland
Advanced Cardiovascular Life Support (ACLS)
Anti-Infective – Antifungals
07.01 CVA (Cerebrovascular Accident/Stroke) for CCRN Review
07.10 Neurologic Review questions for CCRN Review
Acute Confusion
Altered Mental Status Nursing Mnemonic (AEIOU TIPS)
Altered Mental Status- Delirium and Dementia for Progressive Care Certified Nurse (PCCN)
Assessment of Guillain-Barre Syndrome Nursing Mnemonic (GBS=PAID)
Blood Brain Barrier (BBB)
Brain Tumors
Brain Tumors
Cerebral Metabolism
Cerebral Palsy (CP)
Cerebral Perfusion Pressure Case Study (60 min)
Electroencephalography (EEG)
Encephalopathies
Encephalopathy Case Study (45 min)
Head and Spinal Cord Trauma for Certified Emergency Nursing (CEN)
Hydrocephalus
Increased Intracranial Pressure
Impulse Transmission
Increased Intracranial Pressure (ICP) for Certified Emergency Nursing (CEN)
Intracranial Hemorrhage
Intracranial Pressure ICP
Levels of Consciousness (LOC)
Mannitol (Osmitrol) Nursing Considerations
Meningitis
Membrane Potentials
Meningitis Assessment Findings Nursing Mnemonic (FAN LIPS)
Meningitis for Certified Emergency Nursing (CEN)
Migraines
Nerve Transmission
Nervous System Anatomy
Neuro A&P Module Intro
Neuro Anatomy
Neuro Assessment
Neuro Assessment Module Intro
Neuro Course Introduction
Neuro Disorders Module Intro
Neuro Terminology
Neuro Trauma Module Intro
Neurogenic Shock for Certified Emergency Nursing (CEN)
Neurological Disorders (Multiple Sclerosis, Myasthenia Gravis, Guillain-Barré Syndrome) for Certified Emergency Nursing (CEN)
Neurological Fractures
Nursing Care Plan (NCP) for Brain Tumors
Nursing Care Plan (NCP) for Encephalopathy
Nursing Care Plan (NCP) for Meningitis
Nursing Care Plan (NCP) for Migraines
Nursing Care Plan (NCP) for Multiple Sclerosis (MS)
Nursing Care Plan (NCP) for Seizures
Nursing Care Plan (NCP) for Spinal Cord Injury
Nursing Care Plan (NCP) for Stroke (CVA)
Nursing Case Study for Head Injury
Parasympatholytics (Anticholinergics) Nursing Considerations
Parasympathomimetics (Cholinergics) Nursing Considerations
Seizure Causes (Epilepsy, Generalized)
Seizure Disorder for Progressive Care Certified Nurse (PCCN)
Seizure Disorders for Certified Emergency Nursing (CEN)
Seizure Management in the ER
Seizures Case Study (45 min)
Spina Bifida – Neural Tube Defect (NTD)
Spinal Cord Injury
Spinal Cord Injury Case Study (60 min)
Stroke (CVA) Management in the ER
Stroke Assessment (CVA)
Stroke Case Study (45 min)
Stroke Concept Map
Stroke for Certified Emergency Nursing (CEN)
Stroke for Progressive Care Certified Nurse (PCCN)
Stroke Nursing Care (CVA)
Casting & Splinting
Complications of Immobility
Head to Toe Nursing Assessment (Physical Exam)
Health & Stress
Intro to Health Assessment
Introduction to Health Assessment
Joints
Marfan Syndrome
Musculoskeletal Assessment
Musculoskeletal Course Introduction
Musculoskeletal Module Intro
Musculoskeletal Terminology
Nursing Care Plan (NCP) for Abdominal Pain
Nursing Care Plan (NCP) for Activity Intolerance
Nursing Care Plan (NCP) for Cerebral Palsy (CP)
Nursing Care Plan (NCP) for Clubfoot
Nursing Care Plan (NCP) for Lyme Disease
Nursing Care Plan (NCP) for Marfan Syndrome
Nursing Care Plan (NCP) for Neural Tube Defect, Spina Bifida
Nursing Care Plan (NCP) for Osteoporosis
Nursing Care Plan (NCP) for Scoliosis
Nursing Care Plan (NCP) for Spinal Cord Injury
Nursing Care Plan (NCP) for Systemic Lupus Erythematosus (SLE)
Nursing Care Plan for Fibromyalgia
Nursing Care Plan for Scleroderma
Nutrition Assessments
Osteosarcoma
Physiological Changes
Positioning (Pressure Injury Prevention and Tourniquet Safety) for Certified Perioperative Nurse (CNOR)
Report For Transferring To a Higher Level of Care
The SOCK Method – O