Damage control approach to refractory neurogenic shock: a new proposal to a well-established algorithm / El control de daños en el choque neurogénico refractario: propuesta de un nuevo algoritmo de manejo

Abstract Resuscitative endovascular balloon occlusion of the aorta (REBOA) is commonly used as an adjunct to resuscitation and bridge to definitive control of non-compressible torso hemorrhage in patients with hemorrhagic shock. It has also been performed for patients with neurogenic shock to support the central aortic pressure necessary for cerebral, coronary and spinal cord perfusion. Although volume replacement and vasopressors are the cornerstones of the management of neurogenic shock, we believe that a REBOA can be used as an adjunct in carefully selected cases to prevent prolonged hypotension and the risk of further anoxic spinal cord injury. This manuscript aims to propose a new damage control algorithmic approach to refractory neurogenic shock that includes the use of a REBOA in Zone 3. There are still unanswered questions on spinal cord perfusion and functional outcomes using a REBOA in Zone 3 in trauma patients with refractory neurogenic shock. However, we believe that its use in these case scenarios can be beneficial to the overall outcome of these patients.

Resumen El Balón de Resucitación Endovascular de Oclusión Aórtica (REBOA) se utiliza habitualmente como complemento de la reanimación y como puente para el control definitivo de la hemorragia no compresible del torso en pacientes con shock hemorrágico. También se ha implementado en pacientes con choque neurogénico para mantener la presión aórtica central necesaria para la perfusión cerebral, coronaria y de la médula espinal. Aunque la reanimación hídrica y el uso de vasopresores son los pilares en el manejo del choque neurogénico, el REBOA puede utilizarse como complemento en casos cuidadosamente seleccionados para evitar la hipotensión prolongada y el riesgo de una lesión medular anóxica mayor. El objetivo de este artículo es proponer un algoritmo para el abordaje y manejo del choque neurogénico refractario que incluye el uso del REBOA en Zona III como estrategia para el control de daños. Todavía existen interrogantes respecto a la perfusión de la médula espinal y aún se cuestionan los resultados funcionales con el uso del REBOA en pacientes con trauma y choque neurogénico refractario. No obstante, se cree que el uso adecuado del REBOA en determinados escenarios puede mejorar los resultados globales de estos pacientes.

Neurogenic Shock: Clinical Management and Particularities in an Emergency Room

Neurogenic shock has a strong impact in traumatology. It is an important condition, associated with lesions in the neuraxis and can be medullar and/or cerebral. In the last years, its pathophysiology has been better understood, allowing a reduction in the morbimortality with more precise and efficacious interventions taking place in the emergency room. In this review article, the author presents the current aspects of the management of neurogenic shock, highlighting the neuroprotective measures that improve the outcome. Many pharmacologic interventions are still questionable and need more prospective studies to accurately assess their real value. The best moment for neurosurgical intervention is also debatable. Quite clearly, the initial proceedings in the emergency room are fundamental to guarantee the adequate conditions for neuroplasticity and neuronal rehabilitation.

A Case of Neurogenic Shock from Intussuception Secondary to a Small Bowel Lipoma / 대한소아신경학회지

For neurologic symptoms such as mental changes, the etiologies should be thoroughly looked for. Neurologic problems are primarily assessed by medical history, physical and neurologic examination, electroencephalogram, neuroimaging studies. Furthermore, cardiovascular disorders, metabolic diseases, toxic materials and psychologic problems are also evaluated. In some cases that are difficult to find the causes of mental change despite the thorough evaluation and rarely, neurologic shock caused by severe pain can bring about alterness of consiousness. The causes of leading points are discovered frequently in the intussusception in late childhood and lipoma in the small bowel can be one of leading points but it rarely occurs. We report a case of neurologic shock with mental changes from intussusception secondary to a small bowel lipoma in a 13 year-old boy.