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Mon, 11 Feb 2002 08:01:01 -0500

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First of all, I apologize now for sending the case to the list =
twice...sorry, sorry, sorry.

Ok

Head CT was done, negative for shear or space occupying lesions, no =
signs of cerebral edema (slit cisterns, effaced sulci, etc).

Levophed was started after about 2 liters crystalloids and 2 units =
blood.  I agree with your comment below regarding the steroids for the =
SCI.

After transfer to CCU, falling sats and progressive acidosis despite =
fluid, blood, pressors, PEEP.

Andrew

  Sounds like this case was handled well for the most part--levophed =
started way too early--the tachycardia is not quite consistent with =
neurogenic shock--the first management of spinal shock anyway is volume =
repletion BEFORE pressors are started.  There is no great urgency to =
getting BP up above 100--this is treating numbers rather than patient.  =
Patient was otherwise doing fine, and a pressure of 70's is just fine.  =
I won't dwell on the poor basis for steroids in this scenario.  Levophed =
adds a tremendous burden on the heart's MVO2, especially if blunt =
myocardial injury is possible.  You never addressed the head--no head CT =
was done in the face of falling mental status???  Seems some dangerous =
assumptions were being made without first confirming them.  The head and =
the heart are the likely causes of final demise--a myocardial injury is =
further supported by the a-fib.  I can't agree that pulmonary contusions =
should cause cardiac arrest when O2 s ats were OK.  If it wa! s head or =
heart, there was little that could have been done, as both are poor =
prognosis--head will only cause shock when herniating--a terminal event. =
 As I said, levophed would have aggravated the heart, and was =
unnecessary for hempdynamic support.
  ERF=20

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<BODY bgColor=3D#ffffff>
<DIV><STRONG><FONT face=3DTahoma size=3D2>First of all, I apologize now =
for sending=20
the case to the list twice...sorry, sorry, sorry.</FONT></STRONG></DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2></FONT></STRONG>&nbsp;</DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2>Ok</FONT></STRONG></DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2></FONT></STRONG>&nbsp;</DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2>Head CT was done, negative for =
shear or=20
space occupying lesions, no signs of cerebral edema (slit cisterns, =
effaced=20
sulci, etc).</FONT></STRONG></DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2></FONT></STRONG>&nbsp;</DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2>Levophed was started after =
about 2 liters=20
crystalloids and 2 units blood.&nbsp; I agree with your comment below =
regarding=20
the steroids for the SCI.</FONT></STRONG></DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2></FONT></STRONG>&nbsp;</DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2>After transfer to CCU, falling =
sats and=20
progressive acidosis despite fluid, blood, pressors, =
PEEP.</FONT></STRONG></DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2></FONT></STRONG>&nbsp;</DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2>Andrew</FONT></STRONG></DIV>
<BLOCKQUOTE=20
style=3D"PADDING-RIGHT: 0px; PADDING-LEFT: 5px; MARGIN-LEFT: 5px; =
BORDER-LEFT: #000000 2px solid; MARGIN-RIGHT: 0px"><FONT=20
  face=3Darial,helvetica><FONT lang=3D0 style=3D"BACKGROUND-COLOR: =
#ffffff"=20
  face=3DTahoma color=3D#000000 size=3D3 =
FAMILY=3D"SANSSERIF"><BR></FONT><FONT lang=3D0=20
  style=3D"BACKGROUND-COLOR: #ffffff" face=3D"Comic Sans MS" =
color=3D#0000ff size=3D2=20
  FAMILY=3D"SCRIPT"><B><BR>Sounds like this case was handled well for =
the most=20
  part--levophed started way too early--the tachycardia is not quite =
consistent=20
  with neurogenic shock--the first management of spinal shock anyway is =
volume=20
  repletion BEFORE pressors are started.&nbsp; There is no great urgency =
to=20
  getting BP up above 100--this is treating numbers rather than =
patient.&nbsp;=20
  Patient was otherwise doing fine, and a pressure of 70's is just =
fine.&nbsp; I=20
  won't dwell on the poor basis for steroids in this scenario.&nbsp; =
Levophed=20
  adds a tremendous burden on the heart's MVO2, especially if blunt =
myocardial=20
  injury is possible.&nbsp; You never addressed the head--no head CT was =
done in=20
  the face of falling mental status???&nbsp; Seems some dangerous =
assumptions=20
  were being made without first confirming them.&nbsp; The head and the =
heart=20
  are the likely causes of final demise--a myocardial injury is further=20
  supported by the a-fib.&nbsp; I can't agree that pulmonary contusions =
should=20
  cause cardiac arrest when O2 s ats were OK.&nbsp; If it wa! s head or =
heart,=20
  there was little that could have been done, as both are poor =
prognosis--head=20
  will only cause shock when herniating--a terminal event.&nbsp; As I =
said,=20
  levophed would have aggravated the heart, and was unnecessary for =
hempdynamic=20
  support.<BR>ERF</B></FONT> </FONT></BLOCKQUOTE></BODY></HTML>

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