Management of Spinal Shock due to Gunshot Wounds

Initial Hemodynamic Management

The American Heart Association recommends immediate hemodynamic stabilization, control of bleeding, broad-spectrum antibiotic therapy, and conservative management of spinal lesions, avoiding routine immobilization with a rigid collar and spinal board in penetrating trauma 1, 2
Classify the severity of hemorrhagic shock according to ATLS: Class I (<750 ml loss), Class II (750-1500 ml), Class III (1500-2000 ml with decreased PA, HR >120), or Class IV (>2000 ml with decreased PA, HR >140, altered mental status) 3, 4
Identify the source of bleeding immediately through clinical evaluation of the thorax, abdomen, and pelvic ring stability 3
Use ultrasound FAST to detect free intraperitoneal fluid in patients with hemodynamic instability 3
Initiate crystalloid therapy immediately with a goal systolic blood pressure of 80-100 mmHg until major bleeding is controlled (permissive hypotension) 3
Proceed to urgent surgical control of bleeding if the patient presents with hemorrhagic shock with an identified source of bleeding, especially in penetrating abdominal or thoracic injuries 3, 5
Consider norepinephrine for persistent hypotension despite adequate fluid resuscitation, maintaining systolic blood pressure 80-100 mmHg 3
Avoid excessive administration of crystalloids that can worsen coagulopathy and cause abdominal compartment syndrome 3

The American Heart Association recommends against routine spinal immobilization in penetrating trauma: do not use a rigid cervical collar or spinal board in gunshot wounds, as spinal immobilization in penetrating trauma is associated with increased mortality without benefit in neurological deficits 1, 2
Maintain the patient as still as possible (unless safety considerations require movement) and activate the emergency system 1, 2
Manual in-line stabilization (MILS) is only indicated during intubation procedures in suspected cervical lesions, not as a measure of continuous immobilization in penetrating trauma 6

Administer first-generation cephalosporin with or without an aminoglycoside for 48-72 hours in high-velocity wounds 4
Add penicillin if there is gross contamination to cover anaerobes (Clostridium species) 4

Adjust parameters for classification of hemorrhagic shock considering that ATLS values are estimated for 70 kg adults 5
Serial clinical evaluation every 4-6 hours for at least 48 hours is the gold standard for deciding operative versus non-operative management 7
Monitor hemoglobin serially and consider surgery if more than 2-4 units of transfusion are required in 24 hours 7

Employ damage control surgery in severely injured patients with profound hemorrhagic shock, signs of ongoing bleeding, and coagulopathy, hypothermia, and acidosis 3