Jay James is a 24-year-old male who was rock climbing with his friends at a national park 25 miles from the nearest hospital when he suddenly lost his footing and slid 20 feet to the ground. Mr. James was alert and oriented when his friends reached him, and he could move all extremities quite easily. He had multiple scrapes over his anterior chest and a large gash over his left thigh (near the groin), which was bleeding profusely. His friends made a makeshift tourniquet, which slowed the bleeding. They immediately contacted the park ranger, who secured a helicopter to evacuate Mr. James to the nearest hospital. Two large-bore IVs were placed in each arm in-flight, and normal saline was administered. The flight medic placed a 100% non-rebreathing mask on Mr. James. Mr. James became disoriented and confused during the flight. Mr. James arrived in the emergency department (ED) in 45 minutes after the fall. On arrival in the ED, Mr. James is lethargic but responsive to painful stimuli. He has multiple abrasions over his chin and neck. His pulse oximetry is 99% on the non-rebreathing mask, so the ED team replaces the mask with a nasal cannula at 4 L/m. A repeat pulse oximeter reads 95% saturation. Vital signs are as follows: HR 130, BP 100/60, R 30 and TO 99.1°F. Skin is cool and clammy, nail beds are pale, and mucous membranes are dry. All pulses are palpable but weak and thready. Lungs are clear, heart sounds regular. Output via urinary catheter for the last hour is 20 mL.
What is the most likely cause of Mr. James’s high heart rate and low blood pressure?
If you were the nurse assigned to Mr. James, what would be your primary concerns at this time?
What is the priority plan of care for Mr. James at this time?