This is From Novice to Night Shift, an original production from the Emergency Nurses Association. This Audible series takes you into the world of emergency nursing, where experienced professionals share real-life scenarios, discuss critical cases, and reflect on the challenges and triumphs of working in this dynamic field. Whether you're just starting your journey or a seasoned pro, this series is your go-to for expert insights and relatable stories from the front lines of healthcare. Now, here's From Novice to Night Shift. Welcome to ENA's From Novice to Night Shift, Audible learning series where experienced emergency nurses talk about and explore real-life nursing scenarios, discuss critical cases, and share our experiences as healthcare professionals. I'm your host, Monica Escalante-Kolbuck, the Director of Novice Nurse Education Programs at the Emergency Nurses Association. I'm joined today by two incredible nurses with extensive expertise in emergency nursing. Hi, I am Greta. I've been a nurse for about 17 years, 15 of that in the emergency department, and I am a Content Development Specialist for the Emergency Nurses Association. And I'm Amy, also a nurse for about 18 years, 12 of it being in the emergency room, and I'm also a Content Development Specialist at the ENA. Thanks, ladies. Well, I'm really excited today to talk about something that has essentially taken me oh, just 17 years to actually see in my nursing career. But before we jump into it, I think it's important, and we all agree, right, that we need to take a time out to recognize and pause for the patients that we've cared for. Our ability to care for patients that we encounter daily is strengthened by our ongoing remembrance and respect for those that we've treated in the past. Keeping our hearts compassionate, in turn, empowers us to provide excellent care to the future patients daily. Today, we're diving into a challenging case that involves neurogenic shock resulting from a gunshot wound to the neck. So let's walk through the case. We're gonna talk about the patient's presentation, the treatment, and since I was the nurse caring for this patient, my role as the trauma nurse in this case. When EMS rolled in, she was awake, she was alert and complaining of right shoulder pain. Initially, they said she was a GCS of 14, so she was okay spontaneously. She was a little confused and unclear about what had happened so that's what the discrepancy is with the GCS there. She was able to talk to us and she was indicating she was in pain. At that point, she was able to follow some commands. Initially, she did have a weak and thready pulse. She was hypotensive in the field and just kept really repeating, I can't breathe, I can't breathe, this hurts, I can't breathe. For all the nurses listening, it's important to make sure that when you're performing those baseline assessments that you paint the picture of what the patient changes, whether they're improving or deteriorating. So what about her injuries and what did you see and how bad were they? The GSW to the back was on the right. The upper side of, I guess at a level T6, when they transferred her over to the bed, I could see the coagulated blood, the big pool of seeping blood from her back. The GSW to the neck was also on the right side in like zone two, which was covered by EMS with gauze, but that gauze was already soaked. I mean, I could still see the blood coming out from around the tape and around from the gauze. Sorry, but did you guys immediately stabilize C-spine once you saw that and made sure she had a patent airway? Oh yeah, for sure. That's like our primary thing, we stabilize the spine and making sure that she was able to breathe. Okay, so let's go back a second for our novice nurses. For those who have not heard of zone two, there's actually three zones of the neck, but what Monica means by zone two, it's actually a specific anatomical region of the neck. It extends from the cricoid cartilage to the angle of the mandible. Within that zone, there's definitely a couple of critical structures, the carotid artery, the internal jugular vein, the vagus nerve and the trachea. It's clearly a vulnerable area. You have a lot of blood vessels and nerves that are in close proximity. We see zone two injuries, mainly penetrating trauma. So gunshots, stab wounds, sometimes you can see with blunt traumas like MVCs or direct blows, baseball bat to the neck, things like that. Zone two injuries can be pretty complex and severe, which sometimes will require surgical exploration to repair some of the damages, especially if the nerves or blood vessels are damaged. So clearly this is a critical situation, right? We're obviously concerned about this patient decompensating. What about the rest of her injuries? What else did you see? The right shoulder, her spine, scapula, yeah, in the back. That was oozing a little bit, but not nearly as bad as the back and the neck. I mean, she was pretty pale. What were her vitals? She was bradycardic. She was definitely hypotensive. She came in on 15 liters non-rebreather. Her SATs were like 97%, but she kept saying she couldn't breathe. She had a respiratory rate of 24. She was a febrile. I don't remember what it was, maybe 98, maybe somewhere around there. She was a febrile. Did you guys see any chest injuries at all that would maybe make you guys think there might be a pneumo? She's saying she can't breathe. Wait, wait, wait, don't answer that. Can you walk us all through the trauma nurse process first? Sure. So EMS gets called. They inform us that they're coming in through the radio. Charge nurse activates the trauma alert and the trauma team arrives in the ED. Actually, little tip here is make sure you chart and document when the activation was done. Also, when the trauma team arrives in the ED, that's really important for trauma documentation. Our trauma room is prepped with everything that we need. I know that the trauma nurse process, when you look at it, it asks you or tells you to go ahead and don PPE, but real life scenarios, we're not always putting on personal protective equipment. Just really depends on what that patient's coming in with. She was alert, she was breathing on her own, so airway breathing. She was complaining of difficulty breathing, kept saying, I can't breathe. Obviously in the trauma process, we don't get far in your assessment until you address the things that need to be addressed right away. So in this case, our airway and her breathing is clear. It's stable. We are aware that she's breathing and talking, but I didn't see any obstructions in the mouth. She didn't have any loose teeth or any blood or anything like that. Obviously she's alert, she's talking. So that way you can see that her airway is pain. Yeah, yeah. But not for long. She had diminished breath sounds on the right side and was guarding. It was pretty difficult to tell if she had actual chest, equal chest rise and fall. I know in like the textbook version, you're looking for that rise and that fall, but when somebody is guarding and breathing shallow, you're not gonna see that quite easily. Plus there's a lot going on. We're getting her in dress and things like that. When the trauma room gets busy, sometimes it's hard to listen to breath sounds as well. That's why communication is key in making sure who's ever listening to lung sounds, that they're shouting out their findings because there's always one person documenting what's going on as well. So immediately the residents are addressing the ventilation status, right? She's breathing, she's talking, but she was complaining that she couldn't breathe. So we were looking at her ventilation. So what do you think that they ended up doing to help with that? They put in a chest tube? They put in a chest tube. Yes. So residents immediately began performing a thoracotomy and placing a chest tube. So as the trauma nurse role, you know, me being the primary, I am making sure that we're doing the TMP process and I'm documenting. I have two other nurses in the room with me. One is sort of the doer who's starting the line. In this case, she's setting up the chest tube drainage system for the resident as they're doing the thoracotomy. And then that third nurse is a runner to get any equipment or to get meds or anything like that. All that to say, yes, you're absolutely right. They put in a chest tube. Right away, we got about 200 mLs of blood that came out. At this point, you know, a lot of things are happening at once. People are shutting things out with their assessments. I'm documenting. Other people are trying to attempt controlling the hemorrhage and assessing her neurologic status. We cut clothes off. We're putting warm blankets on. We're getting a full set of vital signs and doing a point of care for labs. You know, the typical stuff that we do. What are the usual labs that you are drawing? Okay, so for our protocol, it depends on institutions. I'm at a level one trauma center. Our labs may be a little bit different, but pretty much a rainbow. So we're drawing the CBC with DIF. We're doing a CMP, a complete metabolic profile, a PT, PTT, a type and screen. And we also do ABO confirmation with that. Blood gases, a lactate, and usually we get urine for drug screen pregnancy tests. Patients with preexisting conditions that we do know about, if they're able to verbalize them, they'll likely get more labs drawn, but it really just depends on the patient and the provider ordering. Yeah, that seems like pretty routine. Is that what you guys do? Pretty much. Yeah. But in this, since this is an emergent case, you're not waiting for the urine, Craig. No, no, no, no. I mean, in our facility, anybody of childbearing age, and they actually go up to 45. So anybody of childbearing age up to 45 needs a pregnancy test before a CAT scan, whether it's urine, Craig, or beta on HCG. But in a case of trauma, you just, you have to weigh the benefits versus the risks. Luckily though, her husband did arrive and he had provided us with a past medical history, which included tubal ligation that she had had. It was at our hospital, so the residents were able to verify it through her chart. It doesn't always happen that way though. No. No, it doesn't. For a lot of us, we know that, because we've been in scenarios, but if you haven't been in scenarios like this, while we're talking about each little step in detail, most of this happens pretty simultaneously. Yeah. So up until now, how much time do you think has passed? 25 minutes. No, not at all. When I'm describing all this, like what I've talked to you guys about, really it was like six minutes, likely six minutes. That's real fast. So much goes on in a trauma. There's a lot going on in hospitals that have residents, attendings, physicians, a respiratory. There's a lot of people. There's a lot of people. There's a lot of resources. So we did the primary survey. Now we move on to the secondary survey. Before we ever turn our trauma patients, it's really important to remember that you make sure you have an IV access. Luckily, EMS had an 18 gauge to the lactase C, and one of the other nurses had put in a 16 gauge to the right AC. The patient was hypotensive. So we had 0.9 running. And at this point, I think if there was any more blood that we saw coming out of the neck or the chest tubes, I think we had about 200 coming out. Any more than that, then really you're thinking blood at this point. You're not thinking hanging another bag of fluid. Yeah, certainly. Especially we used to give trauma patients two liters of fluid before we did anything. And we've since have learned that that is not beneficial, obviously, for them. So typically it's after one liter, then people want to start looking at blood, especially, I mean, she's hypotensive. Where's the bleeding coming from? But what we know about the fluid, it doesn't have oxygen carrying capabilities. It doesn't have clotting factors. So giving more fluids is not really gonna do anything to them. So one of the things we use is that mass transfusion protocol if they do need a lot of blood. And I'm assuming that all facilities probably have an MTP policy for trauma centers. Yeah, absolutely. I would certainly ask about your policy or to see the policy, just so you kind of have an idea. So let's go back. We did the secondary survey, talked about the lines. Okay, before we turn the patient. Here, we obviously knew she was shot in the back. So you have a high probability of something happening to the spinal cord. So we did suspect a spinal injury. So we're always maintaining C-spine immobilization. At this point, we're deferring the secondary survey of turning her until after CT. Did you see any other bleeding or any other injuries? She had an expanding hematoma to the neck. You see this big bulge. The C-collar almost worked as applying pressure for us. There were four by fours on there that the EMS had put on to control it. But really at that point, we just wanted to get her to CAT scan and to see what we were dealing with. Any guesses on the CAT scan read? We know she has a hemothorax. Yeah, anything else? Guess it depends on where that bullet is. Yeah, that's for sure. Amy, guess? Nothing. That there was nothing on the CAT scan? That it was shot through and through and there's nothing there? Yeah, nothing. So, oh, wait a minute. Did I not tell you guys that she wasn't able to move her lower extremities? Vital information, Monica. It changes things. It changes things, yeah. Can we now get a second guess? I mean, this is exactly why the ICU hates us. Sorry, okay, so let me go back. That was another reason why we didn't turn and roll the patient is because when she rolled in, when they were doing the assessment, she was not able to feel her lower extremities. And so that was the other reason we deferred turning her until we saw what the CAT scan was. Yeah, that's probably a minor detail crash I should have told you guys. But anyway, we were more focused on her airway and fixing that. Fair enough. I mean, the airway is important. Yeah, so anyway, going back to the case, we went to CAT scan. The CAT scan ended up showing that the GSW to the back struck the vertebral body at T6. Yeah, so then and the neck, believe it or not, was rather superficial. It just happened to be a lot of blood accumulating there. And the right shoulder obviously caused the hemothorax. There's a lot going on here. Yeah. Poor woman. I know. It was really sad. One day, you're just minding your own business, walking to the mailbox, and then something senseless like this happens. It's super tough. I learned later, actually from police, that the son was involved in a gang and he was likely the target. It's pretty horrible. That's awful. Yeah. So senseless. I know, right? Okay, moving on the case, we did the primary survey. We did our secondary survey. We obviously know what the injuries are. We know we're going to talk about neurogenic shock. So Greta's going to explain neurogenic shock. Actually, neurogenic shock is a type of distributive shock, which occurs as an injury to the central nervous system. So obviously, with this case, the gunshot or the bullet, I guess, which damaged the vertebral body at T6, that impacted the sympathetic nerve of the spinal cord and disrupted her control, actually resulting in systemic vasodilation. This is kind of why we see that hypotension and that decreased perfusion to vital organs, because you have that systemic vasodilation. For all our newbies, remember that the sympathetic nervous system is our fight or flight response. Our bodies would normally react with dilation of the coronary blood flow. Right. And you saw the opposite. You saw a decrease in the systemic vascular resistance and the afterload. Yeah. Normally, we would have the release of catecholamines from the adrenal gland, which binds with receptors in our blood vessels. And that works to cause the vasoconstriction. But what's happening in neurogenic shock is we're not going to have this cascade of events. So what I saw was decreased vascular tone and decreased blood pressure. Right. Because you're no longer innervating the SA node. So you'll see the telltale sign of neurogenic shock, which is bradycardia. So decreased preload, decreased afterload, decreased contractility, and bradycardia without the ability of the sympathetic response is going to lead to a low blood pressure. Yep. Well, that makes sense. So because of the neurogenic shock and the vasodilation, I know you mentioned you gave her blankets in the beginning, but did you guys see any hypothermia at all? No, she was not hypothermic. What about the rest of her vitals? So when we came back from CT, she really started to decline fast. You guys know it's like you're transporting the patient back from CT. It was me and a tech, we're taking her off the monitor and putting her back on the room's monitor. She was hypotensive, like 70s over 40s. And she was bradycardic. In the 50s, I would say she had about 200 mls out from her chest and her respirations were dropping. We had her on capnography as well. And her end title CO2 was like 22. For those newbies, what's the normal range for end title CO2? 35 to 45. Okay, so 22 is no bueno. She wasn't ventilating well, so we decided to intubate. What'd you give her for RSI? We gave etomidate, which that one serves as a sedative, and then succs, because I cannot say succinicoline, that is the paralytic. Another nurse grabbed propofol for me along with fentanyl drip. So what did you start the propofol? I started the infusion at five mics, and then I increased it by like five to 10 mics every five to 10 minutes until you end up reaching your desired level of sedation. It's best practice is to start low, titrate up, but you always have to follow your hospital's policies and procedures. Most hospitals will have charts with drip rates and most smart pumps will have the drug dosages, but always check with your provider orders. And what about the fentanyl drip? Would the provider order for that? So the fentanyl drip for someone who's intubated is highly variable. It really depends on the patient's like specific needs and their condition. For fentanyl, the range is like 25 mics an hour to 100 mics, and it can be obviously adjusted up or down as needed based on the patient's pain. I know a lot of people are afraid to start a fentanyl drip or worried about respiratory depression. But you know, for more information, you can actually go to our episode notes where we've linked some information on fentanyl if you want to learn more about administering fentanyl as a drip. So for some of those who aren't really familiar with the fentanyl, can you just take a second to tell us what are some of the things you want to monitor when they're on that drip? Anytime you have a patient that's intubated, you know, we're giving etomidate, gave SOX as a paralytic. Now I added in propofol to maintain the sedation, and then the fentanyl drip. So with fentanyl, you're really going to watch respiratory depression. I mean, she's intubated, right? So we're breathing for them. But you want to make sure that you're not overly sedating somebody. Also, fentanyl can cause nausea and vomiting and hypotension, which can be even more significant for people who already are hypovolemic or hypotensive. And you also have to watch the heart rate, right? Because higher doses of fentanyl can cause bradycardia. Right. So at this point, I just kind of want to summarize. So she's intubated. Yep, you've got her on propofol and fentanyl drip. That's right. I'm sure you guys probably put in an oral gastric tube. Yes. And I'm assuming a urinary catheter. Anything else? I'm closely watching my pressures. I'm trying to maintain my mean arterial pressure or my MAP above 60. And what's the target range? The target rate, this is a point of contention, right? Because in all different references and books of what is the ideal MAP you want, and you're going to get variation. I'm trying to keep the MAP above 60, right, for perfusion. However, if it was a traumatic brain injury involved, you want to keep the MAP, you're looking at a minimum of 50. Target ranges, though, you look in like any medical book, nursing books, they always say like 85 to 90. But even that's variable. I guess really the point is I'm trying to maintain a good enough blood pressure, a MAP of above 60 to maintain perfusion. But I'm also keeping an eye on the chest tube drainage as well, because 200 is out. But if I see that doubling or going more than we know that we're losing a lot of blood, right? And we have to move to administering blood or seeing, you know, what else is happening. At this point, were you guys thinking, oh, this is neurogenic shock, what we just kind of talked about? You know, not really. I don't know. When you're at the bedside and you're taking care of a patient like this, it's not like I'm thinking, oh, this is indubitably, this is neurogenic shock. Like it's a combination of mechanism of injury, your CAT scan results, the vitals, really all the labs that are coming back as well. The odd thing was that every time I tried taking a blood pressure, it was wacky. I was getting pressures that didn't make sense. I remember getting readings that were like 60 over 20. And, you know, was that maybe what was happening? Maybe, I don't know. But then it would be like 80 over 12. I mean, when have you ever seen that? So the first thing you want to do is check the monitor, check the equipment. You turn off the monitor, you check the cables, taking a manual blood pressure. Once I knew it's not the machine that's malfunctioning, the resident just happened to walk in at that point conveniently enough. You know, at this point, we need to put in an art line so we can monitor the blood pressure a lot better. As soon as we got an art line established, her readings were like 80 over 40. And so at that point, you started treating her blood pressure? Yeah, we started norepinephrine. All right, so let's break down norepinephrine. It's a vasopressor like dopamine. And it's typically the vasopressor we use for neurogenic shock. Although some patients, don't they respond better to alternative options? Yeah, I guess sometimes it depends on the case. Did you guys have a central line at this point? Yeah, one resident was doing an art line, the other ended up putting a femoral central venous catheter. So I guess the only reason I asked, obviously, because I started norepi. Because she started norepi. And we know that it's actually a vesican so it can cause tissue necrosis. I mean, sometimes in trauma situations, or even other situations that it's needed, you want to put it in a large vein is recommended to help reduce that risk. Yeah, I mean, I started it in the right AC, and then I switched it over. But you can still run norepi in like a large bore, AC peripheral for what, 24 hours? Yeah, ideally, you don't want to, but yes, then I just switched it over. So norepi comes in 16 mics per ml. So it comes a couple of different ways. You either get it in the vial, and you have to mix it yourself. Or if you're lucky enough, and already have it pre mixed, like I did, it comes in a 500 ml bag of D5W. That is a big difference to that you, you know, some medications come in 0.9 saline, but know that norepi comes in D5W. So this was already pre made by pharmacy, it is weight based, and it depends on the ordering provider, obviously, in your in your policies, I started at five mics, and I increased like one mic per minute, every five minutes I titrated. And then I believe the max dose is 30. Right. So that's what I did. Did it help? Yeah, I mean, I had it titrated up a bit, but it definitely helped stabilize her pressures at least enough to get her up to ICU. So kind of overall, that primary approach to managing neurogenic shock was immobilizing the spine and certainly stabilizing her blood pressure, right? We want to prevent any additional damage to the spinal cord and give her the best possible outcomes. You want to make sure that you're perfusing the vital organs and enhancing really her overall prognosis at this point. Yeah, because management of hypotension is super important in neurogenic shock and persistent hypotension will lead to spinal cord hypoperfusion and ultimately can worsen the injury. Right. I feel like as nurses, we certainly play a crucial role in identifying those signs and symptoms of injury. Of course, we all want to work as a team, but definitely our actions can help kind of manage that patient condition or at least make providers aware of. Oh, absolutely. It's really imperative to work as a team. We have to notify our providers of any changes that are happening, but always be asking questions. And to this day, I'm constantly asking questions like, why did you order that or what's the rationale or why are you doing this task? That's how you learn. I think the day you stop asking questions is the day I would be worried about my practice. I don't know. So in that case, you essentially you stabilize the airway, you manage the breathing and ventilation with the intubation. You address the circulation with basal pressure since the fluids weren't working and not going to be beneficial. Right. So the hypotension wasn't from the gunshot wounds because fortunately, those injuries were pretty much controlled. Had they not been, though, she would have been taken straight to OR once she was a little bit more stable. Yeah, that's a pretty complex patient. Yeah. But as we wrap up, what are some of the takeaways from this case that we want to relate to our fellow nurses out there? I mean, other than what we already talked about, defining neurogenic shock, we talked about the different zones of neck injuries. I guess other key takeaways I would say is hypotension in the trauma patient can come from a couple of factors, right? It could be hypovolemia. It could be hemorrhagic shock, tension pneumothorax. In this case, it was neurogenic shock. As ED nurses, we have to be constantly looking for those red flags in any patient we take care of, whether it's trauma or medical. You have to also think about the mechanism of injury, which can always clue you into what you might be seeing physiologically in the patients. Definitely. I think the treatment approach for neurogenic shock differs from that of other cases of shock and trauma, but neurogenic shock, when that spinal cord loses that sympathetic tone, that vasodilation, you have to turn to a different kind of treatment. We know that fluids and blood are likely not going to help, but typically earlier interventions include fluids and certainly vasopressors to help support that blood pressure until that nervous system responds, if it's going to respond at all. Exactly. Identifying neurogenic shock involves a process of elimination. So you have to explore potential sources and, you know, which may require more interventions and things and tasks that we may have to do in order to identify it before you're actually treating the neurogenic shock. And I think for me, one last thing is to remind nurses to always look at provider orders, double check drug dosages. Oh, absolutely. And make sure you know how to titrate drips and also ask questions if you don't and use resources that you have available to you. All right. Well, thank you, Greta and Amy, for sharing your insights and experience on this case of neurogenic shock. Yeah, it was pretty exciting, actually. And to the listeners, thanks for joining us. We hope you found this informative. Remember to always follow your provider's orders and your individual hospital's policies and procedures. And always, if you have any questions or want to share your own experiences or cases, we'd love to hear from you. So please reach out to us at residency at ENA.org. Yeah, I would love to see somebody share a case with us and us break it down. That would be fun. It would be. Until next time, stay safe, stay compassionate. And remember, as nurses, we play an essential role in saving lives and making a difference.

emergency nursing

neurogenic shock

trauma care

patient stabilization

nursing education

teamwork