Neurogenic Shock and Neurological Storming (New for 2025)
3
Neurogenic Triad
Bradycardia hypotension warm dry skin
5
Storming Symptoms
Tachy hypertension tachypnea diaphoresis posturing
1
Key Difference
Neurogenic = loss of sympathetic tone
Neurogenic Shock
the one shock where the heart is slow and the skin is warmSpinal cord injury above T6 disrupts sympathetic outflow
Bradycardia (unopposed vagal tone)
Hypotension (loss of vascular tone, massive vasodilation)
Warm, dry, flushed skin below the level of injury
IV fluids first, then vasopressors (norepinephrine or phenylephrine)
Atropine or transcutaneous pacing for symptomatic bradycardia
Neurogenic shock = low SVR and BRADYCARDIA. Opposite of hypovolemic shock which has HIGH SVR and TACHYCARDIA.
Paroxysmal Sympathetic Hyperactivity (Storming)
Occurs after severe TBI, anoxic brain injury, or brainstem stroke
Episodes of sudden tachycardia, hypertension, and tachypnea
Diaphoresis, hyperthermia, and extensor posturing
Episodes triggered by stimulation (turning, suctioning, noise)
Treatment with beta-blockers, gabapentin, bromocriptine
Minimize environmental stimulation between episodes
Clustering care to reduce triggers
Key Values to Memorize
SCI above T6 = risk
Brady + hypo + warm
Norepinephrine for BP
Storming = PSH
Beta-blockers for storms
Minimize stimulation
neurogenic shock is the shock that breaks all the rules
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Practice CCRN QuestionsExam Traps
Neurogenic shock means bradycardia not tachycardia
Most types of shock cause tachycardia as a compensatory response. Neurogenic shock is the exception. Loss of sympathetic tone below the injury means the heart cannot speed up and vessels cannot constrict. This produces bradycardia plus hypotension plus warm dry skin, the opposite of hypovolemic shock.
Storming requires treatment and trigger minimization
Paroxysmal sympathetic hyperactivity (neurological storming) in TBI patients causes episodic tachycardia, hypertension, tachypnea, diaphoresis, and posturing. Treatment includes beta-blockers, gabapentin, bromocriptine, and minimizing stimulation. These episodes are exhausting and increase ICP.
New for November 2025 test plan
Both neurogenic shock and neurological storming were added to the CCRN test plan for November 2025. Know the pathophysiology of each and understand they are opposite ends of autonomic dysfunction.
Neurogenic Is Different
Neurogenic = bradycardia + hypotension + warm skin. Every other shock = tachycardia + cool skin. The sympathetic system is OFFLINE.
Storming Episodes
TBI patient with sudden tachy, HTN, diaphoresis, posturing = paroxysmal sympathetic hyperactivity. Minimize stimulation. Treat episodes.
A spinal cord injury cuts the power lines to the sympathetic nervous system below the injury. Without sympathetic signals, blood vessels dilate wide open (warm skin, low BP) and the heart cannot speed up (bradycardia). The body has lost the ability to compensate.
After a severe TBI, the damaged brain sends out random electrical surges through the sympathetic system. These surges cause sudden spikes in heart rate, blood pressure, breathing rate, and sweating. It is like a damaged power grid sending random voltage spikes through the wires.
Neurogenic shock is too little sympathetic activity. Storming is too much. One is a blackout, the other is an electrical surge. Both come from damage to the nervous system, but the treatments are opposite.
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