S3E10: Neurogenic shock from gunshot wound - South Africa Special I
Our very own Callum Swift is in South Africa gaining some valuable out of programme experience, and has put together this excellent episode over there with some excellent EM colleagues.
For the case, Callum is joined by Dr Heounohu Hessou. Their work is looked over by the Adult in the Room, Dr Martin de Man.
Callum is then joined by Dr Katya Evans, who discusses palliative care in EM.
Let's get to it!
Environment - South Africa
We're taking a trip across the world for this case! Many South African EDs see a similar amount of case presentations per day as what we would see in Ireland. The difference often lies in the acuity - Callum gives us an interesting insight into a typical day in the life with many more penetrating traumas, RTC victims and major trauma than would be typical for Irish EDs. Patients are often brought in by friends and family and arrive in resus without a pre alert… so much for prepping your resus! With so many simultaneous acute presentations, staffing can be a challenge, so it is a matter of assessing the severity of each case and allocating resources appropriately.
The Frantic First Few Seconds - Gunshot Wounds
In his approach to the case, Heounohu emphasises the importance of doing the basics right. Your priority is ruling out the life threatening injuries. Transfer the patient to a monitored bed, cABCDEs, strip clothes off and look for an entry and exit site. Patients with gunshot wounds can present in shock with multisystem involvement, so if ever there was a time for methodical approach to assessment and treatment, it's now!
Penetrating vs blunt trauma
In a catchment where presentations of penetrating trauma is so common, not all patients are initially seen in resus. Early vital signs and eFAST are used to triage patients. Methodically and rigorously assessing for pneumothorax and tamponade early on helps you to deliver the right intervention as soon as possible. In the absence of a dedicated trauma team, ruling out/ruling in the life threating injuries becomes crucial.
Differentiating shock
Heounohu’s rule of thumb - hypotensive trauma patients should be assumed to be haemorrhaging until proven otherwise. Note anything that seems out of place. In our case something didn't quite fit - we had a young male who was both hypotensive and bradycardic with warm peripheries and a cap refill of 2 seconds. Further clinical exam led us to the diagnosis of...
Neurogenic Shock
Neurogenic shock is secondary to an injury to the spinal cord which can present with:
Hypotension
Bradydysrhytmias
Temperature deregulation (due to peripheral vasodilation)
It is caused by a sudden loss of sympathetic tone with maintained parasympathetic activity, leading to autonomic instability causing the above. Of note, this is usually caused by injury to the spinal cord above the level of T6.
Spinal shock
It’s worth a few words here on establishing the difference between spinal shock and neurogenic shock. Spinal shock is a transient physiological reflex depression of the spinal cord function below the level of injury which usually has a level of reversibility.
Early targeted neurological exam
In unstable patients where you may proceed to RSI before transfer to a tertiary centre, the importance of a focused but structured neurological exam is vital in assessing for the possibility of neurogenic shock. Heounohu’s assessment for tone, reflexes, a DRE for anal tone and a bulbocavernosus reflex supported the differential of neurogenic shock.
Under Pressors
Most literature recommends aiming for a Mean Arterial Pressure (MAP) of around 85 in cases of neurogenic shock, thus knowing the aetiology of the shock changes management immediately and all the way through to long term management. In the initial phases of trauma management when the cause of hypotension is unclear, hypotension may be primarily managed with fluids or blood. The mainstay of maintaining MAP in neurogenic shock will be with vasopressors - ideally aiming for one like Noradrenaline with both A1 and B1 adrenergic activity. Atropine can also be considered if the patient remains persistently bradycardic. As our Adult in the Room points out later on, often adrenaline is the only vasopressor available in South African EDs. Careful titration of adrenaline /kg/min is required to sustain both A1 and B1 activity, as lower doses of adrenaline only stimulate A1.
Other management of this patient which awaiting transfer to a major trauma hospital include temperature control and immobilisation of the spine. Steroids are no longer recommended in neurogenic shock.
Words of wisdom - Dr Martin de Man - AITR
We were delighted to have Dr Martin de Man join us this month to correct our homework as our Adult in the Room. Dr de Man is an ED consultant working in South Africa. Having initially worked in China for 12 years as a GP, he came back to South Africa to train in EM with a special interest in disaster medicine.
Here are a few of Dr Martin de Man’s thoughts on listening to the case:
Finger thoracostomies
In a low resourced ED where time is of the essence, finger thoracostomies can be a great way of getting rapid intracostal access to insert a chest drain.
"Crossing the Mindline Badness"
Dr de Man uses this phrase to describe the unpredictable effects of a bullet crossing the midline. It can be difficult to appreciate the anatomical structures which were affected in the object getting to it's final destination. He reiterates that if you can only appreciate an entry site, it is absolutely imperative to look for an exit site and to look for a bullet. As we’ll talk about much more in our next episode (hint hint!), performing a log role and completing a primary and secondary survey often reveal findings that would otherwise be missed, that may change clinical management.
Differential for bradycardia
In addition to the differential given by Callum and Heounohu, our AITR encourages us to think broad and consider potential diagnoses such as hypoxia, beta blocker use and decompensated shock when considering the undifferentiated patient who is bradycardic.
Auto-transfusion
Little heard of in Irish EDs, auto-transfusion is utilised to great effect in many South African EDs. Given the sheer volume of trauma presentations, and the amount of those requiring transfusions, auto-transfusion offers a sustainable option for transfusing patients in a setting where blood needs to be rationed and given to patients who most require it.
Our team and Dr de Man note that while there are some contraindications to auto transfusion for which patients need to be carefully assessed, it is used to great effect and saves vital blood products for those who need it. It is important to note that should a patient be suitable for autotransfusion, they will still require clotting factors. You can read more about autotransfusion including the methods and contraindications here.
Palliative Care
We were honoured to be joined by Dr Katya Evans for our bonus episode this month, who talks to Callum about palliative care in the ED. Dr Evans has a detailed discussion with Callum about how we can improve palliative care in the Emergency Department setting, approaching conversations with families and patients, and how challenging but crucial it is as emergency physicians to change our usual approach, to best serve those who require palliative care. From a South African perspective, Dr Evans discusses how the pandemic challenged and forced Emergency Departments to change to cope with the unexpected.
We’re in the process of making some great infographics for this bonus section that can be put up in your department as a reference to help guide small changes which can make a huge difference in palliative and end of life care. Watch this space!