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Decreased mixed venous oxygen saturation
5%
97/1888
Increased pulmonary capillary wedge pressure
4%
71/1888
Bradycardia
6%
119/1888
Loss of rectal tone
2%
37/1888
Decrease in systemic vascular resistance
82%
1544/1888
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This patient sustained an L3 burst fracture with no evidence of spinal shock on presentation, however, suffered an aspiration event causing pneumonia and is now in septic shock. Decreased systemic vascular resistance is observed during septic shock. Septic shock has a mortality rate estimated at 25%-50%. It is a medical emergency resulting from decreased tissue perfusion and oxygen delivery as a result of severe infection and sepsis. Septic shock is associated with increased cardiac output, decreased pulmonary capillary wedge pressure, decreased central venous pressure, and increased mixed venous oxygen saturation. It is differentiated from hypovolemic shock in that the systemic vascular resistance is decreased in septic shock, whereas it is increased in hypovolemic shock. Although this patient has a burst fracture, it is important to distinguish this injury from neurogenic shock, which is usually a consequence of traumatic spinal cord injuries to the upper thoracic or cervical levels that results in autonomic dysregulation (loss of sympathetic tone and unopposed parasympathetic response, leading to bradycardia and decreased vascular resistance). Schouten et al. reviewed the initial assessment and emergency treatment in the spine-injured patient. They reported that hypotension should always be assumed to be of hemorrhagic etiology until proven otherwise, with initial treatment involving fluid resuscitation with a focus on raising systemic vascular resistance in cases of septic shock. They recommended that all aspects of emergent care, including resuscitation and choice of imaging modalities, be systematically reviewed, and practice guidelines are adopted institutionally. Hadley et al. reviewed blood pressure management after acute spinal cord injury. They reported that hemodynamic alterations during acute spinal cord injury include hypotension, cardiac dysrhythmias, decreased peripheral vascular resistance, and reduced cardiac output. They recommended that hypotension (systolic blood pressure <90 mm Hg) be avoided if possible or corrected as soon as possible after acute spinal cord injury. Sekhon et al. reviewed the epidemiology, demographics, and pathophysiology of acute spinal cord injury. They reported that total peripheral resistance and cardiac output may remain depressed for a prolonged period of time in both neurogenic and septic shock. They concluded that survival has improved along with a greater understanding of patterns of presentation, survival, and complications. Figures A and B depict an L3 burst fracture with retropulsion of fracture fragments into the spinal canal. Illustration A is a table demonstrating the differences between hypovolemic and septic shock. Incorrect Answers: Answer 1: Septic shock is associated with INCREASED mixed venous oxygen saturation. Answer 2: Septic shock is associated with DECREASED pulmonary capillary wedge pressure. Answer 3: Septic shock is often associated with tachycardia, not bradycardia. Answer 4: Patients with cauda equina syndrome and spinal shock may present with loss of rectal tone, but this is not typical for patients in septic shock in isolation.
4.8
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