You have been requested by a technician responder to a patient who has collapsed. On arrival, you are told the patient is fully conscious but is unable to move any limbs and is struggling to breathe. She says she fell and hit her neck but is not sure how.
On examination, the patient's airway is clear, present, and self-maintaining. She has very laboured, diaphragmatic breathing and is cool, clammy, and ashen.
RR - 34
SpO2 - 92% on room air
HR - 28 regular
BP - 64/30
CRT - >6 secs
Tº - 35.0
BSL - 6.2
PEARLA @ 3
What is your next move?
The patient had a medical collapse and fell on her neck, damaging cervical vertebrae and resulting in an acute spinal cord injury (SCI). It is likely that the spinal damage occurred in the area of C4-5 as the patient had muscular movement and sensation of the shoulders but not arms, wrists, hands or below the diaphragm. Furthermore, the motor supply for the diaphragm originates from C3-4-5, while the motor supply for the intercostal muscles originates from T1-11, explaining the abnormal respiratory effort.
Spinal cord damage and resultant spinal shock often results in unopposed parasympathetic activity, causing bradycardia, hypotension, and hypothermia. It is also important to rule out other causes of shock associated with trauma such as haemorrhagic, as treatments differ (SCI and Neuro. Shock, JEMS, 2014).
Once immobilised, breathing can be optimised with a stepwise approach (JRCALC, 2013). "An abnormally high or increasing end-tidal carbon dioxide may indicate impending ventilatory failure and therefore a lowering of the threshold for intubation and ventilation" (UK-HEMS, SCI Injury, 2010). It is worth noting, respiratory complications are the highest cause of morbidity and mortality in SCI patients (Zimmer et al, 2007; Berlly et al, 2007).
Fluid management is indicated for the hypotension. JRCALC (2013) advocates 250ml boluses of Sodium Chloride (<2 litres maximum) for "blunt trauma, head trauma or penetrating limb trauma", aiming for an SBP of 90mmHg. UK HEMS guidance (2010) includes the use of "100mcg aliquots [of adrenaline] titrated to effect in an adult" ... "where all other causes have been excluded and / or treated and the patient is thought to be euvolaemic...".
As with any trauma patient, standard rewarming with blankets and ambulance heater will be beneficial and rapid triage to an appropriate hospital with spinal surgery ideal.
For an idea of the continuing in-hospital care, check out this great summary by Life in the Fast Lane.
If we've missed anything, let us know in the comments. Thanks again everyone.