Case 1: Spinal Shock
- Clinically seen as a physiologic loss of spinal cord function below the level of the injury including flaccid paralysis, anesthesia, loss of bowel/bladder continence, and loss of reflexes. Priapism may be present in males.
- Neurogenic shock is the loss of sympathetic and vasomotor tone resulting in vasodilation, hypotension, and bradycardia.
- Temperature control/diaphoresis below the lesion may be lost, therefore temperature management is key in patients with traumatic spinal cord injuries.
- MAP goals are >85 mmHg in order to maintain cord perfusion
- “C 3, 4, & 5 keeps the diaphragm alive” : Beware of potential respiratory compromise with high cervical injuries. Pulmonary therapy is likely required with high thoracic injuries. An ileus may develop with lower thoracic involvement.
- Evidence regarding the use of glucocorticoids in these patients is limited at best. Animal models have shown a reduction in edema, prevention of intracellular K+ depletion, and improvement of neurologic recovery. The best results were observed within 8 hours of injury. Academic recommendations are split; however methylprednisolone has been associated with increased mortality in patients with moderate to severe traumatic brain injury... thus avoid.
Case 2: Arterial Injury Requiring Tourniquet Placement
- Hard signs of arterial injury: (1) Active hemorrhage (2) Expanding or pulsatile hematoma (3) Bruit or thrill over wound (4) Absent distal pulses (5) Extremity ischemia.
- In a study of 366 patients with penetrating trauma, a single ‘hard sign’ was nearly 100% predictive of vascular injury requiring surgical repair.
- Place tourniquets as distal as possible, preferably 5cm proximal to the injury. Always document the time of placement, and avoid placement over a joint.
- If a single tourniquet is ineffective, a second may be placed proximal to first.
- When placing a tourniquet in the field or in a mass-casualty event, write a “T” on the patient’s forehead…(if you are placing a tourniquet you have plenty to write with)
- Blood products take precedence over IVF and should be given in a 1:1:1 ratio of pRBCs, plasma, and platelets.
Case 3: Flank Hematoma and Hypotension Five Days after a Fall
- Trauma is a spectrum ranging from the acute phase of injury to the sequelae that may develop hours to days later. Pay attention to delayed presentations.
- Recall that hepatic patients have the potential to be coagulopathic.
- Trauma patients with preexisting cirrhosis carry as high as a 33% mortality in some studies (compared to 1% in the general population) due to being more coagulopathic.
- Ascites will likely result in a positive FAST exam.
- Beware of medications such as beta blockers which may artificially mask tachycardia.
