Neurogenic Shock With Internal/External Hemmorhage

[AeroClinician]

Trauma pt., fell 4 stories off of the roof of a house onto an adjacent wall with resulting evisceration of intestines + Bleeding, Neurogenic shock is suspected with HR:58 B/P:86/52 Sp02 86%.

What do you do? Give fluid bolus right? Then Dopamine as well? Wouldn't that make the hemorrhage worse?

Please let me know.

BTW this is a fictional pt. , I did not have this in real life.

 

[Carlos Danger]

Why would you want to give fluid or dopamine?

 

[AeroClinician]

Why would you want to give fluid or dopamine?

Umm, because the pt. is in hemorrhagic and neurogenic shock.

Pt. is bleeding from the abdomen, Approx. 1 liter is found on the ground.

What would you do?

 

[Akulahawk]

Me? Considering that the MAP isn't too horrible (60.3) I'm going to start a line... but keep this patient dry. I'd probably look more at providing oxygenation and ensuring the patient is breathing effectively than running lots of fluids or pressors because I don't think I'd be doing that patient any favors by popping clots...

 

[Carlos Danger]

Umm, because the pt. is in hemorrhagic and neurogenic shock.

Pt. is bleeding from the abdomen, Approx. 1 liter is found on the ground.

What would you do?

Well, I wouldn't speed up his blood loss by needlessly raising his BP......

 

[epipusher]

Well, I wouldn't speed up his blood loss by needlessly raising his BP......

I agree,titrate to 90 if anything.

 

[AeroClinician]

Ah, ok. So if anything the lowered heart rate is beneficial because the pt. wont bleed out as quickly as without the neurogenic shock.

 

[Tigger]

Do you think dopamine is indicated in cases of hypovolemic shock?

Why or why not?

 

[AeroClinician]

Do you think dopamine is indicated in cases of hypovolemic shock?

Why or why not?

No, hypovolemia is a contraindication to dopamine.

I was throwing that in there because dopamine is given for neurogenic shock.

 

[FiremanMike]

Get MAP to 65mmHg with fluid and (if available/necessary) push dose pressors so the kidneys are perfusing and get him to a trauma surgeon.

 

[chaz90]

No, hypovolemia is a contraindication to dopamine.

I was throwing that in there because dopamine is given for neurogenic shock.

What takes precedence in this case though? Neurogenic shock can be difficult to diagnose in the field, and it certainly isn't present in isolation in this scenario. Again, the MAP is OK for this patient, and I'd give fairly minimal fluids. I wouldn't even think of touching Dopamine.

 

[VFlutter]

Are you within ~15min of a level one trauma center? If not, it does not really matter. Even if you are down the street it really doesn't matter.

Spinal precautions, permissive hypotension, cover exposed organs and rapid transport.

This guy would most likely end up paralyzed, trached, and encephalopathic until either the septicemia or organ dysfunction ends it.

Get MAP to 65mmHg with fluid and (if available/necessary) push dose pressors so the kidneys are perfusing and get him to a trauma surgeon.

I think kidney perfusion is the least of this patient's problems.

 

[AeroClinician]

Ok, if your giving fluids titrated to a permissive hypotensive status, and then the MAP drops more than the fluids will reverse. Are vasopressors at that point, advantageous?

 

[FiremanMike]

I think kidney perfusion is the least of this patient's problems.

This is true, but fluid resuscitation in hypovolemia should be guided towards a map of 65 and no more so as not to encourage more blood loss. 65 being the point where the kidneys are perfused, which people way smarter than me decided should be the threshold..

 

[Akulahawk]

Ok, if your giving fluids titrated to a permissive hypotensive status, and then the MAP drops more than the fluids will reverse. Are vasopressors at that point, advantageous?

Considering that such a patient is probably bleeding and therefore losing fluid, would I give much consideration to pressors in the field?

In the words of Al Borland: I don't think so, Tim.

Consider the rate of blood loss if you're having to pour crystalloid in through a large cath or two and the MAP is still dropping... You're just turning what blood that is still in there into Kool Aid and greatly diluting any remaining clotting cascade components... In other words, that equals minimal to no ability to clot which equals continued unstoppable hemorrhage.

Might it be a good idea to use vasoconstrictors at some point? Yes. Under some very controlled conditions. The field isn't exactly all that well controlled, we don't have FFP, platelets, whole blood, PRBCs, etc so we can't exactly improve the ability of the patient to form clots...

 

[FiremanMike]

Considering that such a patient is probably bleeding and therefore losing fluid, would I give much consideration to pressors in the field?

In the words of Al Borland: I don't think so, Tim.

Consider the rate of blood loss if you're having to pour crystalloid in through a large cath or two and the MAP is still dropping... You're just turning what blood that is still in there into Kool Aid and greatly diluting any remaining clotting cascade components... In other words, that equals minimal to no ability to clot which equals continued unstoppable hemorrhage.

Might it be a good idea to use vasoconstrictors at some point? Yes. Under some very controlled conditions. The field isn't exactly all that well controlled, we don't have FFP, platelets, whole blood, PRBCs, etc so we can't exactly improve the ability of the patient to form clots...

Sounds like a beautiful scenario for 1-2cc of 1:100,000 epi IVP. Just enough bump in MAP to get you to definitive care..

 

[Akulahawk]

This is true, but fluid resuscitation in hypovolemia should be guided towards a map of 65 and no more so as not to encourage more blood loss. 65 being the point where the kidneys are perfused, which people way smarter than me decided should be the threshold..

With as much damage as the hypothetical patient in this post has sustained, I quite suspect that renal perfusion would be the least of the issues to deal with. If he survives, dialysis is still a possibility if the kidneys completely shut down. Kidneys we can do without if necessary. Most of my fluid titration in the field would be diesel to engine titration... to get the patient to a Trauma Center. Even then, with that much damage, I'd be amazed if the patient survived more than a few days.

 

[Carlos Danger]

Sounds like a beautiful scenario for 1-2cc of 1:100,000 epi IVP. Just enough bump in MAP to get you to definitive care..

I think someone has been spending a little too much time on EMCrit

 

[FiremanMike]

I think someone has been spending a little too much time on EMCrit

I was actually a fan from practice before listening to that particular podcast, but after listening to it, I'm that much more a fan..

 

[FiremanMike]

With as much damage as the hypothetical patient in this post has sustained, I quite suspect that renal perfusion would be the least of the issues to deal with. If he survives, dialysis is still a possibility if the kidneys completely shut down. Kidneys we can do without if necessary. Most of my fluid titration in the field would be diesel to engine titration... to get the patient to a Trauma Center. Even then, with that much damage, I'd be amazed if the patient survived more than a few days.

Everyone needs a target goal for fluid resuscitation. Some people choose 90 systolic, I choose a map of 65 for my stated reason.