Trauma Bullets - December 2019

July 11, 2020

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.

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