Neurogenic Shock — FRCA Final MCQ

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ModerateTrauma & Emergency AnaesthesiaNeurogenic ShockFRCA Final

An 18-year-old man sustains a complete C5 spinal cord injury in a diving accident 2 hours ago. He remains hypotensive at 78/45 mmHg with a heart rate of 42 beats min−1 and has warm, dry skin below the clavicles. Haemorrhage has been excluded, and his circulating volume is judged adequate after initial fluid resuscitation. Which drug is the most appropriate first-line continuous vasoactive infusion?

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Correct answer: E — Noradrenaline

This is neurogenic shock following a high cervical cord injury: interruption of sympathetic pathways causes reduced systemic vascular resistance, venous pooling and unopposed vagal activity, producing warm peripheries, hypotension and bradycardia. Noradrenaline is the best option because predominant alpha-adrenoceptor agonism restores vascular tone, while beta-1 activity provides useful cardiac support in marked bradycardia. Phenylephrine and metaraminol are predominantly alpha agonists and may aggravate bradycardia through baroreflex mechanisms. Adrenaline has excessive beta-1 and arrhythmogenic effects for routine first-line use, while dobutamine does not adequately correct vasodilatation. A rigid target of MAP at least 85 mmHg for exactly 7 days is outdated: current guidance suggests approximately 75–80 to 90–95 mmHg for 3–7 days, but acknowledges very-low-quality evidence.

Reference: Vasopressor Use in Acute Spinal Cord Injury: Current Evidence and Clinical Implications, 2025, https://pubmed.ncbi.nlm.nih.gov/39941573/