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A trauma mystery

yoram klein trauma-list@trauma.org
Tue, 29 Apr 2003 00:45:29 -0700 (PDT) 

A case from last night. 
 A 48 year old truck driver, rolled over with his full
trailer.   In the resuscitation bay he was alert
complaining of chest pain, sO2=89% with face mask,
heart rate= 150, systolic BP of around 70, base
deficit of -11, no neurologic compromise. CXR showed
right lung contusion and widened mediastinum. Normal
pelvic X-ray. FAST is negative. multiple ribs
fractures on the right. Despite continued fluid and
blood resuscitation, he remained hemodynamic unstable.
Intubated, Right chest tube = minimal amount of blood.
TEE = normal aorta, under filled heart, no pericardial
fluid. DPL = negative. Hemoglobin dropped from 13 on
admission to 12 an hour later. Chest CT = severe right
lung contusion, small retrosternal anterior
mediastinal  hematoma. Abdominal CT =  normal. In the
ICU the patient remained unstable, with no significant
drop in hemoglobin. A PA catheter is inserted and
there is a clear hypovolemic profile. During the night
the patient gradually got  better with no specific
treatment except for fluid. In the morning he is
hemodynamic normal , and even his oxygenation
improved. Any ideas about the source of his resolved
shock? 

Yoram




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