GSW hypotension/brady

StCEMT

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So I ran a shooting today that went relatively smoothly, but he started having problems in the ED and it got me wondering about working with what I've got here and what approaches I have. Should have asked the doc while I was there, but I was trying to get other things done.

So 29 y/o M with a single GSW to the neck above the L clavicle, estimated to be about the height of C6, unknown what it really hit. Patent airway and breathing on his own. Radial pulses present on scene, couldn't feel them on arrival. Pt did not respond verbally or physically, but would blink when asked and did so all the way to the hospital.

Vx: 82 NSR, BP ??? (Failed 4x, pulses and response to command to vaguely ballpark perfusion status), 99% on 15L when it would read, RR 25~, EtCO2 35.

Tx: Collar, NPA/NRB, 14ga, many layers of blankets.

In the ED his heart rate dropped to 30. They ended up doing a thoracotomy I believe, so it didn't really get a typical ACLS run.

Now here is my question. Bradycardia + potential spinal injury. He is at 30 in your truck and its just you and a fire fighter. What would your plan to manage this be to buy yourself 5 minutes to get him to a hospital with a pulse? Just for fun, your ideal method in a perfect world and with what you actually have available if they differ.
 

NPO

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So I ran a shooting today that went relatively smoothly, but he started having problems in the ED and it got me wondering about working with what I've got here and what approaches I have. Should have asked the doc while I was there, but I was trying to get other things done.

So 29 y/o M with a single GSW to the neck above the L clavicle, estimated to be about the height of C6, unknown what it really hit. Patent airway and breathing on his own. Radial pulses present on scene, couldn't feel them on arrival. Pt did not respond verbally or physically, but would blink when asked and did so all the way to the hospital.

Vx: 82 NSR, BP ??? (Failed 4x, pulses and response to command to vaguely ballpark perfusion status), 99% on 15L when it would read, RR 25~, EtCO2 35.

Tx: Collar, NPA/NRB, 14ga, many layers of blankets.

In the ED his heart rate dropped to 30. They ended up doing a thoracotomy I believe, so it didn't really get a typical ACLS run.

Now here is my question. Bradycardia + potential spinal injury. He is at 30 in your truck and its just you and a fire fighter. What would your plan to manage this be to buy yourself 5 minutes to get him to a hospital with a pulse? Just for fun, your ideal method in a perfect world and with what you actually have available if they differ.
Let's assume that a heart rate of 80ish is low for this patient. Any compensated patient shot in the neck should have a pulse well above 100. Also, you say BP failed. Does that mean NIBP failed? Was a manual attempted?

Honestly, there's not much we can do. This man needs bright lights and cold steel. Recognition of this is key.

Fluids, with permissive hypotension consideration.

TXA.

Assess for hemothorax, consider simple or needle thoracotomy, but understand it's a short fix; there's still a bleeder somewhere.
 

bigbaldguy

Former medic seven years 911 service in houston
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Bullet fragments could have gone anywhere. Nicked plenty of things and as you said definite suspicion of spinal injury. Sounds like you did as well as possible considering. As NPO said your options are limitied outside a trauma center. The short run time probably saved him. If it were me there would definetly be some butt clenchin going on. Good job.
 

DrParasite

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BP ??? (Failed 4x, pulses and response to command to vaguely ballpark perfusion status)
after the second failure, why didn't you try for a manual BP?
 

Remi

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Now here is my question. Bradycardia + potential spinal injury. He is at 30 in your truck and its just you and a fire fighter. What would your plan to manage this be to buy yourself 5 minutes to get him to a hospital with a pulse? Just for fun, your ideal method in a perfect world and with what you actually have available if they differ.
I would not attempt to treat the heart rate during a 5 minute ride. If I really felt like I had to, then a cc of ephedrine or dilute epi would be the way to go.
 

CALEMT

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Fluids, with permissive hypotension consideration.

TXA.

Assess for hemothorax, consider simple or needle thoracotomy, but understand it's a short fix; there's still a bleeder somewhere.
This. What was his O2 sat on RA? Did he look hemodynamically unstable? 5 minute ride to the trauma center theres not much to do in that time span while en route. To be honest if I were that close I would just mitigate obvious life threats, establish a line and go.
 

Brandon O

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A lot of potential for a (non-compressible) large vessel arterial injury. Would transport ASAP for surgical hemostasis.
 

E tank

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Hi cord injury resulting in sympathectomy/neurogenic mediated fall in vasomotor tone and brady? Fluid and epi.
 

Brandon O

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Hi cord injury resulting in sympathectomy/neurogenic mediated fall in vasomotor tone and brady? Fluid and epi.
You really gotta assume these people are exsanguinating, though. You can do the aforementioned, but I would not delay transport for one moment, and he should probably have a thoracotomy ASAP upon arrival (in ED if truly crashing). Assuming "it's just neurogenic" is how folks bleed to death without a surgical incision.
 

Akulahawk

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This particular patient doesn't need much more than a Surgeon to begin doing damage control, first and foremost, hemostasis. I'm not going to waste time on scene that don't move the patient toward said Surgeon. En route to said Surgeon, I probably would try to place a couple of relatively large bore saline locks (or small volume IV lines) as I know that placement later could become a big problem.

As to getting vital signs, if the NIBP won't get a reading after a couple tries, I'll go for a manual but I'm not going to be all that worried about it if I can't get that done. Same for SpO2... if it's on a finger. I already know this patient is in significant trouble and I don't need VS to tell me that. Sure, part of this guy's problems include a neurogenic shock but he's also got uncontrolled bleeding somewhere. I'm going to be VERY reluctant to hang fluids and pressors because of the uncontrolled bleeding problem.

Beyond the above, about the only stuff I'm going to do is look for an exit wound. If I don't see one, given the known injury, I'm going to assume one of two things happened: the spinal column stopped the bullet or deflected it elsewhere, or the trajectory was more along the longitudinal plane of the body and the bullet is somewhere in the thorax. Either way, it's bad and any bleeding is likely non-compressible.
 

E tank

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You really gotta assume these people are exsanguinating, though. You can do the aforementioned, but I would not delay transport for one moment, and he should probably have a thoracotomy ASAP upon arrival (in ED if truly crashing). Assuming "it's just neurogenic" is how folks bleed to death without a surgical incision.
Who said "it's just neurogenic"? Part of the differential for hypotension/brady in the setting of a c-spine injury. Notice the question mark? Doesn't change the management at all. If you can save someone a thoracotmy in the ER by restoring sypathetic tone, I'd say thats a win.
 

Brandon O

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Who said "it's just neurogenic"? Part of the differential for hypotension/brady in the setting of a c-spine injury. Notice the question mark? Doesn't change the management at all. If you can save someone a thoracotmy in the ER by restoring sypathetic tone, I'd say thats a win.
Sure, but unless they respond spectacularly to that management, this is an unequivocal emergent surgical case. Delaying for any other efforts at stabilization or exploration of the differential would not be acceptable.
 

VFlutter

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Was there bleeding or a hematoma? Probably would have packed the wound.
 

Brandon O

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As to getting vital signs, if the NIBP won't get a reading after a couple tries, I'll go for a manual but I'm not going to be all that worried about it if I can't get that done.
This is definitely a case where the BP is a big whoop. Doesn't matter at all at at this juncture. Get 'em to the hospital. IVs if you can.
 

Akulahawk

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Was there bleeding or a hematoma? Probably would have packed the wound.
I would give packing a consideration as well, as long as it doesn't slow down transport to a Surgeon. It's instances like that where civilian EMS could learn a LOT from Military EMS.
 

E tank

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Sure, but unless they respond spectacularly to that management, this is an unequivocal emergent surgical case. Delaying for any other efforts at stabilization or exploration of the differential would not be acceptable.

Right, don't delay, got it.
 

StCEMT

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@DrParasite
Very short transport + prioritization of other more important things to squeeze in within that window.

@Remi
Fortunately it never came to that, but this was the big thing I was debating. Within the limitations of what I have available, regardless of how ideal, a dose of push dose epi seemed to have been the best option to avoid his heart rate dropping further. Purely hypothetical, but...

@CALEMT
Still in the 90's. Any significant trauma I get like this usually gets O2, all the blankets I have within arms reach, and little/no NS to prevent what I can of the trauma triad. He got my oh **** flag waving when I saw him. Pretty much how it went.

@Akulahawk pretty much hit my thoughts on it while we were going. While I agree on the heaitation of hanging pressors, this was where I wanted people to discuss. Help heart rate and possibly vasomotor tone vs unonown and uncontrollable hemorrhage. What is the lesser of two evils? Considering the alternative is CPR moving, which you might as well be pissing in the wind...

@VFlutter 4cm above the clavicle give or take. It was a fairly small wound, I didn't think about wound packing. Don't think I've heard of packing neck wounds, although I do believe I've heard of Foleys being used to create pressure there.
 

Brandon O

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Right, don't delay, got it.
It's not much different from penetrating trauma to the abdomen that's crashing in front of you. For whatever reason people sometimes want to do everything but surgery. Must be neurogenic, or inflammatory, or the cuff is wrong... it's like the guy in the horror movie who says "it's just the wind." The occasional negative laparotomy is not the end of the world, but watching someone code in the trauma bay while people push epi and do the no-surgery dance is quite poor form.
 

Brandon O

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Fortunately it never came to that, but this was the big thing I was debating. Within the limitations of what I have available, regardless of how ideal, a dose of push dose epi seemed to have been the best option to avoid his heart rate dropping further. Purely hypothetical, but...
If they seem to be inappropriately bradycardic, fair bet it's either neurogenic or they're decompensating and headed for arrest. I'd say a trial of an inotrope is totally reasonable, IF you don't delay transport and if you give just enough (i.e. don't push up their pressure too far, just maintain a reasonable heart rate). An IO might be a good starting point, letting you give your drugs and then fool around with bigger IVs at your leisure.
 
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