A 52 year-old man with HTN, HLD, and NICM/HFrEF (LVEF 35%) is brought to the ED by EMS overnight after being found down at home. He was working in the house and had fallen off a ladder, but wasn't able to call for help until his partner arrived home from work. He hasn't been able to feel or move his legs since then. He has some cervical neck nderness as well as dyspnea.
The ED and trauma surgery teams greet the patient upon arrival. His initial vitals are notable for BP 89/60, HR 110, RR 15, SpO2 95% on RA, and T 37.4C. He is started on norepinephrine gtt. Whole-body CT scans are obtained. Due to his neck tenderness and extent of injuries, they also obtain an MRI of his cervical and thoracic spine. Unfortunately, due to agitation and intolerance of the scan, he ends up getting intubated and sedated.
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You arrive to examine the patient. You ask his nurse to hold his sedation. His EMS cervical collar remains in place. He responds to voice and follows commands. He has full upper extremity strength. He has no movement of his lower extremities; there is no movement to noxious stimuli. He has a sensory level to pinprick at the level of the umbilicus.
Based on the history and clinical exam, we're already suspecting a spinal cord injury (SCI). So, it makes sense that everyone would jump to neurogenic shock as the etiology of his hypotension. Resist that urge. For trauma patients, we must assume that hypotension is from hemorrhagic shock until proven otherwise. Where can large amounts of blood hide? Thighs (associated with femoral fractures), peritoneum, retroperitoneum, and chest are really the places to note. Clinical exam is a start, but this is where the pan-scan can further help identify any hematomas. In this case, there isn't any of that, though that "right pleural effusion" should be monitored closely (could it be a hemothorax?).
So, if not hemorrhagic, then we can move on to other etiologies. Obstructive shock (e.g. tamponade), really also from hemorrhage in the context of trauma, is key to rule out. Bedside eFAST exam is essential here. Non-hemorrhagic-associated hypovolemia is a possibility. Neurogenic shock, from sympathetic denervation, can occur with traumatic SCI (tSCI) at/above the T6 level. (Below this level, the sympathetic fibers have already synapsed with the sympathetic ganglion that then innervate the smooth muscle for the systemic and splanchnic vasculature, as well as the adrenal glands.) Classically, you might expect bradycardia along with the hypotension, though the former doesn't always occur. Septic shock would be unlikely as an acute presentation now, but preceding signs/symptoms could persuade you otherwise. Finally, cardiogenic is an important consideration given his known NICM/HFrEF, so the bedside TTE with some quantitative measurements could help with this.
For simplicity's sake, only his sagittal STIR images were included here. When reviewing spine imaging, it's important to also review the axial images.
In his cervical spine, there is mild canal stenosis, worst at C4-C5 and C5-C6. There doesn't seem to be any cord signal abnormality. While not obvious in the images shown, this patient was also found to have a comminuted C1 arch fracture, as well as type 2 dens fracture.
In his thoracic spine, however, we can see some obvious abnormalities. There's severe canal narrowing at T4-T5 with intrinsic cord signal change, T4 fracture, and T5 fracture (three-column injury!).
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