What is the immediate management for a 55-year-old male (M) with hypotension, inability to move his lower extremities, and a lacerated wound on the forehead after a road traffic incident (RCI)?

Immediate Management of Hypotensive Trauma Patient with Suspected Spinal Cord Injury

This patient requires simultaneous aggressive fluid resuscitation targeting mean arterial pressure ≥80 mmHg while maintaining spinal immobilization, with immediate preparation for intubation using ketamine and manual in-line stabilization if airway protection is needed. 1

Critical First Steps: The ABCs with Spinal Precautions

Spinal Immobilization (Immediate Priority)

• Immobilize the entire spine immediately with rigid cervical collar and backboard - any trauma patient with inability to move lower extremities must be assumed to have spinal cord injury until proven otherwise 2
• The combination of lower extremity paralysis and hypotension strongly suggests high thoracic or cervical spinal cord injury with neurogenic shock component 3
• Do NOT remove spinal precautions until imaging excludes injury 2

Airway Management (If Needed)

• If intubation becomes necessary (declining consciousness, inability to protect airway), use ketamine 1-2 mg/kg as induction agent - this is the only appropriate choice given the severe hypotension 1, 4
• Apply manual in-line stabilization (MILS) with removal of anterior cervical collar during intubation to limit cervical spine movement while improving glottic exposure 2
• Use direct laryngoscopy with gum elastic bougie technique 2
• Have vasopressors (ephedrine or metaraminol) drawn up and ready for peri-induction hypotension 1, 5
• Target PaCO2 4.5-5.0 kPa and PaO2 ≥13 kPa if intubated 2, 1

Circulation: Aggressive Resuscitation Required

Fluid Resuscitation Strategy

The presence of spinal cord injury absolutely contradicts permissive hypotension - you must maintain adequate spinal cord perfusion pressure 2, 1

• Begin immediate aggressive fluid resuscitation with 0.9% normal saline - this is the ONLY appropriate isotonic crystalloid for suspected brain/spinal injury 2, 1
• Target mean arterial pressure ≥80 mmHg (NOT the standard 65 mmHg used in other shock states) 1
• Avoid Ringer's lactate and other hypotonic solutions - they are hypotonic by real osmolality and will worsen spinal cord edema 2

Critical Assumption About Hypotension

• Assume hypotension is due to hemorrhage until proven otherwise - neurogenic shock alone rarely causes BP as low as 80/50 mmHg 1
• The forehead laceration suggests significant trauma mechanism; actively search for occult bleeding sources (chest, abdomen, pelvis, long bones) 2
• Perform FAST ultrasound examination immediately to identify intra-abdominal bleeding 2, 1

Vasopressor Support

• After adequate fluid resuscitation (typically 1-2L crystalloid), if hypotension persists, start norepinephrine 0.01-0.5 μg/kg/min 1, 5
• Have metaraminol or ephedrine boluses ready for immediate blood pressure support 1, 5
• Do NOT use dopamine - switch immediately to norepinephrine as first-line agent 5

Diagnostic Workup (Simultaneous with Resuscitation)

Imaging Priorities

• Obtain CT head, cervical spine, thoracic spine, and lumbar spine immediately once hemodynamically stable enough for transport to scanner 1
• If patient remains unstable (SBP <90 mmHg despite initial resuscitation), control bleeding source FIRST before any imaging 2
• Perform chest and pelvic X-rays at bedside if too unstable for CT 2

Laboratory Studies

• Complete blood count, coagulation profile (PT/INR, aPTT), blood gas with lactate 1
• Type and crossmatch for blood products 1
• Do NOT rely on single hematocrit measurement to guide resuscitation - it has poor sensitivity for acute hemorrhage 2

Positioning and Monitoring

Patient Positioning

• Once spinal injury is confirmed or if patient requires intubation, position with 20-30° head-up tilt while maintaining spinal immobilization 2, 1
• Use specialized trolleys that allow head elevation with spinal precautions 2

Monitoring Requirements

• Establish invasive arterial blood pressure monitoring (transducer at level of tragus) 2, 1
• Continuous end-tidal CO2 monitoring if intubated 2, 1
• Frequent assessment of end-organ perfusion: mental status, capillary refill, urine output, lactate 5

Critical Pitfalls to Avoid

The Permissive Hypotension Trap

Do NOT apply permissive hypotension strategies in this patient - the combination of suspected spinal cord injury and potential traumatic brain injury (head laceration) makes this absolutely contraindicated 2, 1, 6

• Hypotension (SBP <90 mmHg) is the single most important modifiable predictor of poor neurological outcome in spinal cord injury 6
• Even brief periods of hypotension cause irreversible spinal cord ischemia, particularly in watershed zones 7

The Fluid Choice Error

• Never use Ringer's lactate, dextran, or other hypotonic solutions 2
• Avoid albumin and synthetic colloids in early management 2

The Transfer Timing Mistake

Do NOT transfer this patient to another facility while actively hypotensive and bleeding - control hemorrhage takes absolute precedence over transfer 2, 1

Wound Management

• The forehead laceration is lowest priority - address only after hemodynamic stabilization and spinal clearance 1
• Apply direct pressure and sterile dressing; definitive repair after life-threatening issues resolved 1