Neurogenic shock after cervical cord injury — FFICM MCQ

Correct answer: E — Neurogenic shock

The correct answer is E, neurogenic shock. A C5 fracture-dislocation causes a high cervical cord lesion that abolishes sympathetic outflow (T1 to L2) while leaving unopposed vagal tone intact, producing the classic triad of hypotension with bradycardia rather than reflex tachycardia. Warm peripheries reflect loss of vasomotor tone causing vasodilatation, and priapism results from unopposed parasympathetic (sacral) outflow to the corpora cavernosa, both pointing away from hypovolaemia. The negative FAST scan, stable haemoglobin, and a well-filled, hyperdynamic left ventricle on echo exclude occult haemorrhage and instead show a low systemic vascular resistance state with preserved or increased contractility, the haemodynamic signature of distributive (neurogenic) shock following acute spinal cord injury. Why the other options are wrong: B. Haemorrhagic shock: this produces compensatory tachycardia, cool clammy peripheries and an underfilled ventricle, all of which are contradicted by the bradycardia, warm skin and hyperdynamic, well-filled LV seen here, and haemoglobin is stable with negative FAST. C. Cardiac tamponade: causes muffled heart sounds, raised JVP and a small, poorly filling ventricle with tachycardia (Beck triad), the opposite of the hyperdynamic well-filled LV described. A. Tension pneumothorax: causes obstructive shock with tachycardia, distended neck veins and reduced venous return, not a hyperdynamic, well-filled ventricle with bradycardia. D. Septic shock: is a distributive shock but has no temporal or clinical link to an acute traumatic fall, and priapism plus a discrete cord-level injury make a cord-mediated cause far more likely than infection. Key point: hypotension with bradycardia (not tachycardia), warm peripheries and priapism after a high cervical cord injury is the hallmark of neurogenic shock from acute sympathetic denervation.

Reference: NICE guideline NG41, Spinal injury: assessment and initial management (2016, updated 2023), section on recognising and managing neurogenic shock and haemodynamic instability after traumatic spinal cord injury, nice.org.uk/guidance/ng41