Skip to content

Neurogenic Shock and Spinal Shock CDI Scenario – November 2021

Topic: Neurogenic Shock and Spinal Shock

H&P: 58 y/o male admitted to ER for a level 1 trauma with accidental fall backwards and hitting back of neck on a step. No LOC reported. Per EMT, patient alert and oriented when they arrived on the scene, but lethargic enroute to ED.

PMH: HTN, CAD

Vitals: 96 F, HR 42, RR 24, SpO2 92%, BP 70/48, CVP 1-2mm Hg, skin appears flushed, patient arousable but lethargic.

PE: skin flushed and warm,AMS, midline spinal tenderness when back of neck palpated. Patient altered and cannot perform neuro assessment. Per EMT notes, on their arrival to the scene, the patient was able to move legs, trunk, and fingers, but unable to fully raise arms above head.

Labs: WBC 11.6. HGB 12.2; repeat HGB 11.8, Cr 1.0, LA 1.1

CT:  C7 facet fracture with soft tissue swelling anterior to the C6 vertebral body. Heterogeneously hyperintense to spinal cord with hypointense foci.

Treatment: Norepinephrine gtt, IVF bolus of 2 L 0.9% NS, atropine IVP x2, c-collar and spinal precautions.

Progress Notes: “Patient unstable overnight with BP 78/54 despite fluid challenge, temp 95F warming blanket applied, continue to monitor, Norepinephrine gtt. Acute C7 fracture with ? spinal cord injury. Neuro checks q2 and c-collar. Con’t with Decadron. Patient with good urine output, appears euvolemic.”

Discharge Summary: “Acute C7 facet fracture. Patient with hypotension noted during the admission, now resolved. Patient with minimal BUE movement and some return of DTR. Patient to remain in c-collar. IP rehab. Repeat imaging with reduction in foci at C7 with improved soft tissue swelling.”

Question: Are there query opportunities based on the scenario stated above?

UASI Recommends:

  • Neurogenic shock and spinal shock are often both thought as a type of distributive shock, however spinal shock is referencing a spinal cord injury and not a systemic response. 
  • Query for neurogenic shock based on C7 injury and lack of alternate etiology for shock (no infection, hemorrhage, hypovolemia, etc.). Along with hypotension that was refractory to fluid resuscitation, the patient had bradycardia and labile temperature which are hallmark findings of neurogenic shock.
  • Query for Spinal shock or spinal cord injury based on the CT findings that suggest a hypointense foci and transient paralysis exhibited by the patient. According to an article in StatPearls, “The term ‘spinal shock’ denotes the acute loss of motor, sensory, and reflex functions below the level of injury and can be associated with neurogenic shock (Dave S, Cho JJ. Neurogenic Shock. In: StatPearls. StatPearls Publishing, Treasure Island (FL); 2020. PMID: 29083597). Spinal shock will become the principal diagnosis and change the DRG.
  • Query to confirm and specify incomplete spinal cord injury in a patient with returning DTR. This will offer a more specific code that indicates an incomplete lesion at C7.

Documentation without Clarification:

  • Principal Diagnosis: S12690A Other displaced fracture of seventh cervical vertebra, initial encounter for closed fracture
  • Secondary Diagnosis: I10 essential HTN, I2510 atherosclerotic heart disease of native coronary artery without angina pectoris, R295 transient paralysis
  • Procedure: none 
  • Working DRG: 552 Medical Back Problems without MCC RW: 0.942    GMLOS: 3.18      SOI/ROM: 2/1

Documentation with Clarification:

  • Principal Diagnosis: S14157A Other incomplete lesion at C7 level of cervical spinal cord
  • Secondary Diagnosis: S12690A Other displaced fracture of seventh cervical vertebra, initial encounter for closed fracture, R578 other shock, I10 essential HTN, I2510 atherosclerotic heart disease of native coronary artery without angina pectoris, R295 transient paralysis
  • Procedure: none 
  • Working DRG: 052 Spinal Disorders and Injuries with CC/MCC RW: 1.8451     GMLOS: 4.2     SOI/ROM: 3/3

CDI Educational Tips:

  • Spinal shock typically results from an injury above T6.
    • Clinical indicators for spinal shock:
      • transient paralysis—patient will have return of reflexes and motor skills (see stages of spinal shock below), so it is important to wait for the appropriate time to query when trying to determine incomplete vs complete lesion.
      • Soft tissue swelling on imaging helps to identify an injury, so it would be an important clinical indicator to include in a query for a possible spinal cord injury.
    • Stages of spinal shock:
      • Phase 1: areflexia/hyporeflexia (0-1 days)
      • Phase 2: initial reflex return (1-3 days)
      • Phase 3: early hyperreflexia (4 days to 1 month)
      • Phase 4: spasticity/hyperreflexia (1-12 months)
      • Ditunno, J., Little, J., Tessler, A. et al. Spinal shock revisited: a four-phase model. Spinal Cord 42, 383–395 (2004). https://doi.org/10.1038/sj.sc.3101603
  • Neurogenic shock develops as a result of imbalance of autonomic control because of loss of sympathetic tone due to disruption in supraspinal control and an intact parasympathetic influence via the vagal nerve. (David W. Cadotte, Michael G Fehlings, in Principles of Neurological Surgery (Third Edition), 2012.)
  • Hallmark findings of neurogenic shock are hypotension that does not respond to fluids, bradycardia, warm and flushed skin, and labile temperatures.

This is a short synopsis of a possible patient record and is not intended to be all inclusive.  This is for educational purposes only and not intended to replace your institutional guidelines.