A Shocking Case Study

Spring break here in the Colorado Rockies is not full of beach parties and sand. Our county will have a ton of ski trauma during spring break, regardless of how good the snow is. Early afternoon on a fine April day, things had been steady, but we were able to handle it. We were down a medic and had sent a crew up to the ‘ski’ clinic to help transport a minor trauma down to our hospital. 

The ‘ski’ clinic operates during our tourist surges in the valley, both winter and summer. It is located next to one of the slopes and is a transport destination for ski/bike patrol during these times, and handles plenty of walk-ins. It is easy to brush it off as urgent care. However, they do a lot more and are frequently staffed with flight and ICU nurses and very experienced advanced care providers, so the quality of care for sick patients is above and beyond what you would expect from an ‘urgent care.’ 

The ED physician called me early that afternoon to give me a heads up on a call he got from the clinic. Ski patrol was out with a teenager who fell from a ski lift and had a loss of sensation and motor function from the nipple line down; they tried for a scene flight but were denied due to weather. The patient was stabilized at the ski clinic and arrived at our critical access ED with a Foley and on Levo. She had a sudden drop in her pressure at the clinic into the 70s, though she was not very tachycardic at 103-ish. 

Time for some Mise en Place, eh? 

I called the other captain who was home working on administrative work and asked him to get dressed so we could be ready to leave for Children’s. All the ambulances had been on calls, so I had our crew get our newer and nicer rig topped off with fuel and oxygen and park it in the bay. They also brought over our T-1 in case we needed it. 

I checked the weather because it’s Colorado. The weather 3,000 feet higher and 20 miles away may be bad, but it was not horrible outside the hospital where I was standing. Nevertheless, it was just as bad around the rest of the county. Even a fixed wing was out of play for 6 to 8 hours. (They are that busy these days, and the weather was getting worse in terms of a snowstorm.)

This builds up to the worst-case scenario we could face, and is on the list of things that keeps my team up at night: a really sick kid on a vent, horrible white-out snowstorm weather, 225-mile drive to Denver.

The other medic whom I called showed up, and we had a quick size-up together. We were concerned about the need for ventilation support and developed a threshold ourselves based on where her suspected spinal injury was and if we would need to protect her airway or not. We ran down some equipment checklists and went over to talk to the ED physician about our idea. He was walking over to have the same conversation, and she was in the CT scanner at the moment, which would help bring us some conclusions. 

Her presentation in the ED:

  • 16 YOF
  • No LOC, alert and oriented in the trauma room
  • Fall from 30-feet from a ski lift after slipping out of the chair; her father tried to hold on to her but could not. 
  • No sensation from the nipple line down still
  • On Levophed at 14mcg/min to keep her SBP in the 100’s with a MAP in the 70’s
  • HR 110’s

Her CT Results: 

  • C7 burst fracture
  • Multiple T-Spine compression fractures, T3-T5
  • Grade II liver laceration
  • Pulmonary contusions
  • Pelvic fracture that was not initially found on the first CT read

Given the location of her spinal injuries and the potential for decompensation on top of her pulmonary contusions, the ED physician elected to intubate her. We have a unique relationship working with the hospital, so my partner helped with the RSI. We got to work side-by-side with the ED physicians and RT’s. She was intubated with no issues but was not tolerating the ventilator well.

Hamilton T-1

The patient had a CStat greater than 30. We started troubleshooting everything mechanically. Things seemed fine, and we could not find a source or reason for the high pressure with any of the equipment. She also just had a chest x-ray done, and everything looked fine. One of the RT’s present felt like she had some upper airway wheezing, so we decided to try some albuterol down the tube. A shotgun approach, no doubt, but it worked, and within a handful of respirations, the vent was happy: her capnography was less shark-finned, and her CStat was back below 30. We figured she may have had some mucous plugging. However, it left us with her having a sustained HR in the 130’s. She did have a flat IVC on the US and had received a total of 600 mL crystalloids at this point. We decided to package her for transport and get on our way at this point.

Spinal Shock/Spinal Cord Injury

As much as shock gets covered in school these days, I feel like neurogenic and spinal shock are still somewhat nebulous in how we grasp the concept of these conditions. Our patient was experiencing signs and symptoms of a spinal cord injury (SCI) and spinal shock. 

Neurogenic shock is generally associated with cervical and high thoracic spinal injuries and can cause autonomic dysregulation. Other characteristics include:

  • Hypotension
  • Bradycardia,
  • Respiratory insufficiency 
  • Associated with SCI and autonomic dysregulation
  • Temperature dysregulation can occur in the form of hypothermia with flushed and warm skin. 
    • 38.5-71.7% of SCI patients experience fevers following an acute injury due to issues with thermoregulation from the dysfunction of the autonomic system (Savage et al., 2016). 

Spinal shock can often be confused with neurogenic shock. Spinal shock can present as loss of reflexes, bladder function, and muscle function below the level of spinal cord injury. In contrast, neurogenic shock refers to hypotension and bradycardia due to the interruption in the physiologic reflex depression of the cord function below the level of the injury. It is important to remember that it is not a classic ‘shock’ like that of a circulatory collapse but depressed spinal reflexes. 

Spinal shock can include:

  • A state of transient physiologic reflex depression of cord function below the injury, often in congruence with loss of sensorimotor functions
  • Reversible reduction and sometimes loss in sensory and motor function after an acute SCI
  • Depression of cord function below the injury
  • Reflexes return in a pattern, with the return of superficial function before deep tendon reflexes
  • Flaccid paralysis, anesthesia, and areflexia/hyporeflexia may occur (Singhal & Aggarwal, 2016). 

The team was able to get together and get our patient on the road. The weather was not bad until we got to a significant mountain pass, which was in a total white out. We were cruising in a foot of unplowed snow on rough roads at 10 mph. Our patient was seemingly well sedated, except when I would try to suction her; she was a RASS -4 when not disturbed. The rough roads were waking her up to a -1.

This presented a few issues at this point. On top of the pass, I could see tractor trailers off the road. Not pulled off to the side, but off the road. With great skill, our EMT was weaving in and out of disabled vehicles, and even in 4-wheel drive, the rear end was breaking loose. I looked at my partner at this point and suggested we come up with a plan if we got stuck, or worse yet, went over the edge and had to wait for rescue. We planned to stay with the rig as long as the power and O2 lasted and would move from there. Thankfully we didn’t have to use this plan, but I honestly felt better knowing we discussed it before we were reaching for the Sked and going for a hike. 

We bolused and increased our Ketamine and Fentanyl drips. At this point, she was on 300 mg/hr of Ketamine and 125 mcg/hr of Fentanyl, and to get her through the rough, snow-covered roads, we ended up giving pushes of Versed and Ativan. I neglected to bring our second drug box, so we were running relatively dry at this point, and our vial of Dilaudid was going to be our last stand, if we needed it.

Slowly but surely, we got closer to Denver. Our patient was better sedated as the roads cleared up. I prepped to give a 1-minute report covering our 5-hour transport; something I hadn’t done in a while, and I wanted to nail it since this was going to happen in the trauma bay at the big Children’s hospital. Never cool when you do not nail that report, right? 

Besides remembering the differences between neuro and spinal shock, we learned a lot on this call. Our patient spiked a temp that was honestly somewhat worrying. We could not do anything about it in transport besides passively cooling her off by opening a window, turning down the heat, and moving some blankets around. We also learned that the suggested MAP for these patients is higher than those I generally associate with permissive hypotension and trauma, being 80 mmHg. 

Having a plan and putting everything in place served us well. I ended up giving a report to what was probably the largest crowd I have ever seen in my career in a trauma room and spilling down the hall.

Savage, K. E., Oleson, C. V., Schroeder, G. D., Sidhu, G. S., & Vaccaro, A. R. (2016). Neurogenic Fever after Acute Traumatic Spinal Cord Injury: A Qualitative Systematic Review. Global Spine Journal6(6), 607–614. https://doi.org/10.1055/s-0035-1570751

Smith, P. M., & Jeffery, N. D. (2005). Spinal Shock-Comparative Aspects and Clinical Relevance. Journal of Veterinary Internal Medicine19(6), 788–793. https://doi.org/10.1111/j.1939-1676.2005.tb02766.x

Singhal, V., & Aggarwal, R. (2016). Spinal Shock. In Complications in Neuroanesthesia (pp. 89–94). Academic Press. https://doi.org/10.1016/B978-0-12-804075-1.00011-0

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