EMS World

SEP 2018

EMS World Magazine is the most authoritative source in the world for clinical and educational material designed to improve the delivery of prehospital emergency medical care.

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Page 47 of 51

EMSWORLD.com | SEPTEMBER 2018 47 cause organ injury and internal bleeding. 10 It is also rare for patients to present with the classic findings of neurogenic shock—brady- cardia and hypotension—in the prehospital setting. 19 Therefore, although it is important for EMS providers to consider neurogenic shock, it may be challenging to accurately detect. Treatment of Neurogenic Shock It is important to recognize and treat shock in patients with spinal cord injury because hypotension and hypoxemia can cause second- ary injury after SCI, worsening the initial insult to the spinal cord. 3 After appropriately managing the airway and ensuring adequate ventilations, neurogenic shock should initially be managed with IV fluid boluses. In most cases of neurogenic shock, fluid resuscitation alone is sufficient to resolve hypotension. 10 Some patients require vasopressors to maintain adequate perfusion, but hypovolemia should be excluded prior to administering them. Given that it's difficult to exonerate hypovolemia as a contributor to shock in the prehospital setting, vasopressors may have a limited role in the prehospital treatment of suspected neurogenic shock. There is no consensus blood pressure goal for treatment of neurogenic shock, though there is weak evidence to support maintaining a mean arterial pressure of greater than 85 to avoid secondary injury to the spinal cord. 19,20 Case Conclusion As the BLS crew begins to package your patient, you consider what might explain her shock. Given the combination of hypotension, bradycardia, and warm skin in the setting of neurological deficits concerning for SCI, you decide neurogenic shock is the most likely cause. You also consider hypovolemic shock from internal bleeding, given that she experienced a traumatic mechanism. Obstructive shock from either cardiac tamponade or tension pneumothorax is less likely given that lung sounds are clear bilaterally, there is no JVD, and heart sounds are not muffled. Because the patient is in shock, you establish two large-bore IVs and provide a 500-mL IV fluid bolus. You also place the patient on the cardiac monitor, which reveals sinus bradycardia. Meanwhile, the BLS crew has carefully protected the patient's spine by applying a cervical collar and holding manual stabiliza- tion. Following local protocol, they use a scoop stretcher to move the patient from the floor to the cot, then remove it and secure her. You load the patient into the ambulance and begin transport to a local trauma center. You recheck vitals, and her blood pressure has increased to 100/50 with the IV fluid bolus. After notifying the trauma center to prepare for the patient, you continue to carefully monitor her throughout transport. Find the references for this article at www.emsworld.com/arti- cle/220942. ABOUT THE AUTHORS Alexander Ordoobadi, NREMT-I, is a medical student at Harvard Medical School. He volunteers as a medic with the Bethesda-Chevy Chase Rescue Squad in Montgomery County, Md. He can be reached at alexander_ordoobadi@hms. harvard.edu. Sean M. Kivlehan, MD, MPH, NREMT-P, is director of the International Emergency Medicine Fellowship at Brigham and Women's Hospital and faculty at Harvard Medical School. He was a New York City paramedic for 10 years and is a member of the EMS World Editorial Advisory Board. He can be reached at smkivlehan@bwh. harvard.edu. For More Information Circle 32 on Reader Service Card RECOGNIZING THE HARMS OF BACKBOARDS Harms associated with backboards include causing pain and pressure sores as well as impairing ventilations. Because backboards force the naturally curved spine to conform to a flat surface, they are known to cause neck and low back pain. 1 There is even a case report of a patient with ankylosing spondylitis, a form of arthritis that can cause an abnormal curvature of the spine, developing a vertebral fracture and SCI after being secured to a backboard. 12 Backboards can also cause pressure ulcers, with early stages developing within 30 minutes of the patient being placed on a backboard. 1 In addition, the straps used to secure patients to a backboard can restrict ventilations. 1 It is also time-consuming to immobilize a patient to a backboard, and time is of the essence in trauma. —Alexander J. Ordoobadi and Sean M. Kivlehan

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