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Neuroanaesthesia · Core11 / 14
Acute cervical cord injury with neurogenic shock22-year-old man, 76 kg, dived into shallow water 6 hours ago; complete C5 cord injury
Acute cervical cord injury: neck-safe airway, neurogenic shock and bradycardia
From memory: the diagnosis and the notes are hidden. Answer each question aloud, then press Show.
Know this first
Neurogenic shock: hypotension with bradycardia from loss of cardiac sympathetic supply; lasts 1–3 weeks.
MAP target 85–90 mmHg through the first week.
Suxamethonium is safe only early after injury.
C3, C4 and C5 supply the diaphragm.
No compelling evidence for methylprednisolone.
The patient
22-year-old man, 76 kg, dived into shallow water 6 hours ago; complete C5 cord injury.
Diaphragmatic breathing, weak cough; vital capacity 1.1 L; in a hard collar.
For urgent anterior cervical decompression and fixation today.
Vitals: BP 82/44, HR 48, SpO2 94% on 6 L/min, RR 26, temperature 35.9 °C. FAST negative.
The examiner asks
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Consider
What are your concerns?
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A 22-year-old, 6 hours after a complete C5 cord injury, for urgent decompression. Patient
xABCDE: no exsanguinating bleed, and FAST is negative, so bleeding is less likely.
Low pressure with a slow heart points to neurogenic, not haemorrhagic, shock. Disease
C5 injury: partial diaphragm, no intercostals; ventilatory failure is coming.
Unstable neck: every airway move risks more cord damage. Airway
He can't hold his heat below the lesion; he's already 35.9. Disease
Prepare
How will you prepare?
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Arterial line before induction; MAP 85–90 with fluid and a vasopressor. Disease
Noradrenaline running: he needs both vasoconstriction and rate.
Atropine drawn up; oxygenate before every suction, which can arrest him. Crisis
At 6 hours suxamethonium is still safe; rocuronium is the alternative. Airway
No steroids: no compelling evidence for methylprednisolone. Disease
Warm fluids, forced-air warming and a warm theatre.
Plan
How will you secure his airway?
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If he can cooperate, awake fibreoptic intubation; it moves his neck least. Airway
Otherwise RSI with manual inline stabilisation and a videolaryngoscope.
Collar front opened during MILS; no traction, no extension.
He'll likely stay intubated afterwards given his vital capacity. After surgery
Pressure areas padded; he can't feel or shift.
ICU afterwards, holding his MAP at 85–90 for a week.
Crisis
Just after intubation, the trachea is suctioned; HR falls to 25, then asystole. What do you do?
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Adult arrest algorithm: asystole from suction, with his vagal tone unopposed. Crisis
Stop suction, start CPR, 100% oxygen.
Rhythm isn't shockable, so adrenaline 1 mg IV every 3–5 minutes.
His likely causes: hypoxia from suction, hypothermia, tube position.
If a slow rhythm returns: atropine 1 mg, maximum 3 mg, then adrenaline 2–10 mcg/min.
Afterwards: preoxygenate and keep atropine at hand for every suction. After surgery
Crisis
After positioning, BP is 70/38 and HR 50 despite a litre of crystalloid. What do you do?
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Neurogenic shock, worsened by induction, positive pressure and positioning. (Crisis)
Exclude bleeding: Hb, repeat FAST, look at the wound.
More fluid won't fix it and can cause pulmonary oedema.
Noradrenaline or dopamine for constriction and rate; not dobutamine.
Atropine 1 mg for his bradycardia.
MAP back to 85–90 to protect his cord.
Fatal mistakes
Suxamethonium after the early window.
Fluids alone for neurogenic shock.
Neck extension at laryngoscopy.
Checked against: Miller 10e · Stoelting 8e · Barash 9e
Mark Got it only if you said every point. Again brings the case back tomorrow; Got it brings it back in 3, then 7, 14 and 30 days.
Same topic, another patient
Run these after the main case when you have time. Same skills, a different patient or setting.
Another patient · ICU and trauma. Cervical cord injury in ankylosing spondylitis. Same cord injury in a rigid ankylosed neck: no extension
Know this first
C3–5 supply the diaphragm; a C5 lesion leaves partial diaphragm function only.
Neurogenic shock: hypotension with bradycardia; MAP 85–90 for 5–7 days.
Suxamethonium is safe within 24 hours of cord injury; avoid it after.
Suctioning in cervical cord injury can cause bradycardia and arrest.
The patient
76-year-old man, 70 kg; ankylosing spondylitis; fell from standing; C5–6 fracture-dislocation with cord injury.
Weak arms, no leg movement; weak cough, RR 30, vital capacity falling; fixed chin-on-chest kyphosis.
Drugs: naproxen. Needs his airway secured in the emergency department before posterior fixation.
Vitals: BP 84/46, HR 48, SpO2 91% on a 15 L mask, temperature 35.9 °C.
The examiner asks
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Consider
What are your considerations?
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A 76-year-old with AS and an acute C5–6 cord injury, needing his airway secured before fixation. Patient
Elderly trauma: frail with little reserve; I still run xABCDE and look for other injuries.
AS spines are rigid but brittle: a minor fall can break the neck. Disease
A C5 injury leaves part of his diaphragm and no intercostals; he's tiring.
BP 84 with HR 48 looks neurogenic, but I exclude bleeding first.
His fixed flexion means no neck extension and no sniffing position. Airway
Prepare
How do you assess and plan his airway?
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Any cervical fracture is a difficult airway; his kyphosis makes it worse. Airway
Awake fibreoptic: he keeps breathing, and I can check his neurology before and after.
Topicalise thoroughly; coughing on the scope could extend his cord injury.
Head supported in its own flexed shape on pillows, never forced flat.
Videolaryngoscope as backup; front-of-neck kit open.
Atropine 1 mg drawn up; his heart rate is already 48. Disease
Plan
Once he is intubated, how do you manage him?
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Bleeding excluded first: eFAST, pelvis, long bones and Hb. Disease
Neurogenic shock: fluid first, then vasopressor, to MAP 85–90 for 5–7 days.
Suxamethonium only within 24 hours of injury; rocuronium after that. Airway
Fully oxygenate before every suction pass; the vagal surge can stop his heart. Disease
Prone for fixation: head kept in its flexed shape, pressure points padded. Surgery
ICU after: ventilated, with an early tracheostomy discussion. After surgery
Crisis
During tracheal suction his heart rate falls to 32 with BP 58/30, then the ECG shows asystole. What do you do?
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HR 32 then asystole: adult arrest algorithm, CPR now, head held in its flexed position. Crisis
Suction stopped; ventilate with 100% oxygen through his tube.
Adrenaline 1 mg every 3–5 minutes; asystole is not shockable.
Cause in him: a vagal reflex from suction in a high cord injury, made worse by hypoxia.
After ROSC: fully oxygenated before each suction, atropine drawn up, pads on. After surgery
Crisis
The next day in theatre, prone, BP 70/38, HR 52, Hb steady at 12.4 g/dL. What do you do?
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Stable Hb and no source: neurogenic shock from lost sympathetic tone. (Crisis)
Fluid bolus, then noradrenaline to bring his MAP back to 85–90.
Slow rate limits his output: dopamine 2–10 mcg/kg/min adds rate and pressure.
Check the prone position: abdomen free, nothing pressing on the eyes.
Warm him; his injury has taken away temperature control.
Fatal mistakes
Extending a rigid AS neck to intubate.
Assuming neurogenic shock without excluding bleeding.
Suxamethonium after the first 24 hours.
Checked against: Miller 10e · Faust · Stoelting 8e · AHA guidelines: adult advanced life support (2025)