A Neu(ro) Low

On primary survey:

A- Patent & self-maintained.

B- Trachea central, equal chest expansion, good air entry bilaterally. SpO₂ 96% on air, RR 22.

C- Good bilateral radial pulses, no active bleeding, no obvious long bone deformity/injury, but there is a bruise to the right hip & ASIS with an overlying abrasion. There are no cannulas in situ. BP 79/52, HR 67.

D- GCS 11/15 (E3 V2 M6), drowsy, pupils 4+ sluggish but equally reactive.

E- Large vertical wound to forehead with active bleeding. T 35.2˚C, BM4.6. The pt is in wet cold clothes.

A cannula is inserted and bloods are taken whilst the primary survey is being done.

What are the possible causes of hypotension at this time? Select all that may apply.

The guidance from NHS England is that trauma patients should ideally have a CT scan within 30 mins (max 60 mins).

The patient remains with similar observations throughout assessment. There is no external bleeding seen.

The VBG shows Hb 129.

What steps do you want to take before going to CT? Select all that may apply.

You transfer the patient onto the CT scanner and whilst the radiographers are doing their checks the blood pressure cycles and reads 60/41.

Which action is most appropriate?

You give 1 unit of red cells and the next BP is 80/61. You proceed with the CT scan and take the patient back to resus to await the report.

The obs on arrival back to resus are:

SpO₂ 98% on air

HR 81

BP 85/61

RR 15

T 33.6˚C

You repeat the VBG and the Hb is 142.

The hot report for the CT shows no significant or active bleeding.

Your team starts on the secondary survey and on examination of the limbs it is revealed that he can move and feel his arms as normal with power 5/5, but he cannot move or feel his legs with power 0/5. There is no response to plantar reflex. His sensory level is T6.

What is the most likely cause of hypotension now?

The CT scan shows fractures to the occipital condyle, C4+5 transverse processes. It also shows a grossly distended bladder. There are no haematomas or signs of active bleeding.

You are now convinced that there is a neurogenic shock. You refer to the neurosurgical team who will come and see the patient.

If his blood pressure remains low, what are the best treatment options now? Select all that apply.