Case Study 14

The Answer

Assessment

  • Due to the mechanism of injury, this is a possible spine injury.

  • Possible shock.

  • Abrasions on left upper back.

 

The Plan

  • Patient has been log rolled onto a sleeping pad and into a sleeping bag. Her legs are elevated 8”. We will try to calm her down, get her to drink some water, and monitor vital signs.
  • Reassess to make sure we have not missed anything i.e. internal injury.
  • Clean and dress the abrasions.
  • Perform a focused spine assessment and make a decision on the need for spine immobilization.
  • Develop a plan for evacuating the patient.

Anticipated Problems

  • Developing shock.
  • Developing spinal cord injury.

Comments

With this mechanism of injury we have to consider shock, an internal injury, and possible spine injury. It’s tempting to rule out a spine injury because the patient was seen running a short distance, but people can do amazing things when reacting to stress, and it’s within the realm of possibility that she could have hurt her spine and still be up moving around. 

It looks like she got through this without any long bone or pelvic fractures, but we still need to worry about an internal injury, especially with s/s indicating shock that is not explained by an obvious injury.  She was wearing a helmet, did not hit her head, had no loss of responsiveness, altered mental status, or head wounds.  We’ll keep our eye on this nonetheless.

A patient in shock has a rapid pulse rate that may feel weak and irregular. The skin is pale, cool, and clammy. These signs and symptoms are a product of our "fight or flight" response--our body's response to danger. The “adrenaline rush”  increases heart rate and respiratory rate, causing the skin to pale and sweat, and the nausea and restlessness.  These changes pump the blood faster, reduce the size of the blood vessels, and route the blood to essential organs, hopefully helping the body to compensate for the shock.

If the circulatory system is unable to adjust, a downward spiral of deterioration may begin in which first tissues, then organs, and finally entire systems fail from poor perfusion.  These patients need to be transported quickly to the hospital as our wilderness shock management tools--leg elevation, oral fluids, stabilizing injuries and keeping the patient warm and comfortable--may not be enough.

Most people, when frightened, injured, or ill, have a "fight or flight" or acute stress response that mimics shock. This is the familiar fast heart rate, sweaty pale skin, nervous shakes, and queasy gut from the adrenaline rush. If you're not seriously ill or injured and your circulatory system is healthy, this response should abate in short order. The heart rate slows, you relax, and the skin returns to its normal color. As you recover from the initial fright and measure a series of vital signs over time you want to see this acute stress response diminish.  

Orthostatic vital signs refer to our ability to compensate from changes in position and the effect gravity has on our cardiovascular system. Healthy people can stand from a supine position with little or no problems. People in shock may not react well to the position change.  We use an orthostatic vital sign test to help find patients with low volume status who don’t have obvious s/s of shock1. Test the patient by waiting two minutes with the patient supine, then stand the patient and wait one minute before measuring vital signs. An intermediate sitting position is not helpful. A positive test is an HR increase of 30 beats/min or more in adults, or the presence of dizziness or fainting. As well, let's remember that evaluating the patient’s symptoms is as critical as measuring numbers. Regardless of their heart rate, if they become pale, woozy and nauseated, lie them down and treat for shock.

1. McGee, S. Abernethy, W.B., and Simel, D.L. (1999). Is this patient hypovolemic?  Journal of the American Medical Association, 281, 1022-1029.

The Tale Continues

Over the next 45 minutes, you talk over the evacuation possibilities with your companion and the patient and sketch out a plan in the event the patient can’t walk.  You’re a long way from the trailhead and even if your cell phone works, it looks like it may be dark, or tomorrow morning, before help will arrive.

Under your calming influence the patient becomes less anxious. You gather another set of vital signs and don’t find anything new to report. You decide to perform a focused spine assessment. The patient is A+Ox4, is sober, is not distracted, has good CSM in all four extremities, and denies any spine pain or tenderness upon your second palpation. You confer with your friend and the patient and all agree you can release control of the spine.

You help the patient stand, explaining the orthostatic vital signs test, which you don’t remember, but look up in your Wilderness Medicine Field Guide. She is a bit dizzy, but this quickly resolves. Her HR does not change and she says she feels OK. This negative orthostatic vital sign change is welcome news. In fact, her only complaint is a sore and abraded shoulder. This is another indication she dodged a bullet and doesn’t have any major injuries.

End of the Tale

She wants to look for her horse. You want to clean the abrasions and monitor her condition–after all, it was a spectacular horse wreck. The solution presents itself when the horse, no worse for the wear, wanders back into the meadow, and you can take care of it while your friend cleans the abrasions. Although very sore, the rider is able to walk, and she is seems to be physically well. You take her to your camp where she makes a cell phone call home telling her folks not to worry, she will be out tomorrow. Not wanting to wait, her parents load the contents of her surprise graduation party onto the pack animals. That night you and twenty new friends dine surf and turf style under the stars. Lobster anyone?


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