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Difficulty: HardTrauma and Burns

Following a fall from a second-story residential roof, a 54-year-old male is evaluated in the trauma center. He was reportedly cleaning gutters when he lost his balance and fell approximately 20 feet (6 meters) onto the grass below. The patient is awake, alert, and secured to a rigid backboard with a cervical collar.

Vital signs are:
Temperature: 36.6°C (97.9°F)
Heart rate: 122/min
Blood pressure: 80/50 mm Hg
Respiratory rate: 22/min
Oxygen saturation: 96% on room air

Physical examination reveals a patent airway with midline trachea. Breath sounds are clear and equal bilaterally. Heart sounds are normal without murmurs, rubs, or gallops. His abdomen is soft, non-distended, and non-tender to deep palpation, though he notes he cannot feel the examiner's hands well. The pelvis is stable to anterior-posterior and lateral compression. Neurologic examination reveals flaccid paralysis and areflexia of both lower extremities, with a complete loss of pain, temperature, and light touch sensation below the level of the umbilicus. Upper extremity strength and sensation are intact. Two large-bore peripheral intravenous lines are established, and a bolus of warm isotonic crystalloid is initiated.

Which of the following is the most appropriate next step in management?

  1. A
    Helical CT scanning of the spine and torso
  2. Focused assessment with sonography for traumaAnswer
  3. C
    Initiation of a continuous norepinephrine infusion
  4. D
    Urgent transfer to the operating room for celiotomy
  5. E
    Intravenous administration of high-dose corticosteroids

Answer

The correct next step is to perform a focused assessment with sonography for trauma (FAST) to evaluate for intra-abdominal hemorrhage.
The correct next step is a focused assessment with sonography for trauma (FAST). This patient has sustained significant blunt force trauma and presents with severe hemodynamic instability (blood pressure 80/50 mm Hg) and tachycardia (heart rate 122/min). Although his physical examination reveals an obvious and severe spinal cord injury (paraplegia and a distinct sensory level), his tachycardia is a crucial differentiating clinical sign. Neurogenic shock, caused by the sudden loss of sympathetic autonomic tone following cervical or high thoracic spinal cord injury, classically presents with hypotension and bradycardia (or an inappropriately normal heart rate). The presence of marked tachycardia in this patient strongly suggests an ongoing compensatory response to severe hypovolemia. Therefore, he must be presumed to have hemorrhagic shock until proven otherwise. Because the patient is hemodynamically unstable, he cannot be safely transported out of the trauma bay for a CT scan. The FAST exam is the most rapid, non-invasive bedside test available to evaluate for life-threatening intra-abdominal and pericardial hemorrhage.

Step-by-Step Solution

1
Analyze the vital signs to determine the patient's hemodynamic status.
The patient has marked hypotension (80/50 mm Hg) and tachycardia (122/min), indicating severe hemodynamic instability.
Identifying hemodynamic instability is the critical first branch point in the trauma management algorithm.
2
Evaluate the clinical presentation to differentiate the cause of shock.
Despite having classic signs of a severe spinal cord injury (flaccid paraplegia, sensory level at the umbilicus), the presence of tachycardia strongly points toward hemorrhagic shock rather than isolated neurogenic shock.
Neurogenic shock typically presents with hypotension and bradycardia (or a lack of compensatory tachycardia) due to the sudden loss of sympathetic autonomic tone.
3
Select the appropriate immediate diagnostic modality for an unstable patient with suspected hidden hemorrhage.
A bedside ultrasound (FAST exam) is indicated.
FAST rapidly identifies intraperitoneal free fluid (blood) and pericardial effusion without requiring the hemodynamically unstable patient to leave the resuscitation bay.

Key Concept

In any trauma patient presenting with a spinal cord injury, hemodynamic instability accompanied by tachycardia must be presumed to be hemorrhagic shock until proven otherwise, warranting immediate bedside evaluation for bleeding.
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Topics

Trauma and Burns

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