Cause of hypotension

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Thanks for your interesting case.

 

I am sure that his chances of surviving were very low (mainly due to the
underlying brain injury). However I agree that it is very important to
analyse what could have been done differently and see how one could improve
for the future. The mechanism of injury and details of further injuries (if
known) would be helpful but I shall comment from what you notified.

 

His bilaterally blown pupils clearly signify a substantial traumatic brain
injury. He will undoubtedly have substantially raised ICP and, as an end
stage sign, this might indicate Cushing's response (hypertension with
bradycardia) due to herniation of the brain. As has been stated however,
Cushing's response is not always present and it is important to remember
that everything doesn't always fit the "nice little boxes we have all been
taught to expect"

 

I completely agree with Ken, a contained mediastinal haematoma does not
cause hypotension; merely with a contained mediastinal haematoma one should
apply hypotension (so as not to "pop the clot/haematoma" etc.)

 

A soft abdomen in this case is irrelevant as he is intubated and it is not
going to tell you anything - the patient won't guard/rebound etc and this
will be further explained by the fact that he will no doubt have muscle
relaxant on board.

 

With no BP or pulse, he was not perfusing his vital organs (especially
brain) and this is an avenue that should certainly be explored emergently
given his injuries. I am also intrigued by your comments on the USG (I
presume that you mean a FAST scan?) This certainly is not a 100% accurate
test (either specific or sensitive) and there are many sources of error
(such as operator etc.) Whilst the neurological brain problem could account
for his hypotension and relevant bradycardia etc. (vasomotor centre in the
brain etc. being compressed), I personally do not see (and therefore doubt)
that you would get a BP and pulse back with fluids if this was the cause of
the problem. I am convinced that this is haemorrhagic in nature (more
likely) or cardiac tamponade (less likely - but still possible) and is one
of those cases where a negative fast is in fact a false negative result. The
descriptions that you give of the CXR, pelvic x-ray and FAST doesn't
coincide with haemorrhage. These are either misleading or cardiac tamponade
is present and accounting for the signs/vitals that you give.

 

Acknowledging that you do not get significant haemorrhage in the brain (but
that minimal haemorrhage can cause a haematoma resulting in signficant ICP
and midline shift etc.), this needs investigating and any haematoma
evacuation treated within 4 hours but I would focus on an alternative source
as his main problem. You state "CVS - audible heart sounds." Were they
muffled? - if so, cardiac tamponade becomes more likely. In this situation,
given the patient's history and likely diagnosis, I would suggest looking
into the chest and abdomen through a thoraco-abdominal approach (better a
negative laparotomy than a dead patient.) I personally would be very
concerned in going to CT with a patient who, in essence, had a cardiac
arrest (i.e. no BP & no pulse) as he is likely to arrest again (as he later
did.) When he arrested though, given that you need to act quickly, I would
suggest that a cardiac tamponade becomes his likely primary problem and that
you need to go into his chest via an anterior left sided thoracotomy (I
might have suggested sternotomy but you are not EXACTLY sure what you are
dealing with - despite you anticipating it being a cardiac tamponade and
there being bilateral chest sounds which make lung injuries less likely -
although not impossible) so an anterior thoracotomy would, in my opinion, be
an ideal choice of incision, which could be extended into a clamshell if
required. I agree that external chest compressions have no role in this
case.

 

I would be very interested in other people's views on the above and how they
would approach this case.

 

Interesting points for discussion on this case. Thank you for sharing it
with us.

 

Regards,

 

 

Matthew 

 

 

 

 

i am a Gen.Surg resident and in 2 years of i have seen 2 pts coming to
trauma, in shock,25yr male,Unconscious(intubated),BP not
recordable,peripheral pulse absent, Pupils B/L dilated and fixed,chest-B/L
breath sound +,CVS-audible heart sounds. Abdomen Soft/lax/Bowel sound+

aftr resuusitation with 2 Lit RL and 2 U PRBC, BP  came to 110/70,pulse110

CXR no pneumo/hemo

Pelvic xray-no #

USG abdomen- no free fluid

we decide to shift the pt to CT with the above vitals-as the pt is shifted
to CT table, pt. arrest , CPR done 40mins 

but pt declared dead.

 

my question here is, what could be cause of shock if we excluded hemorhage,
as there was no bleeding in the chest/abdomen/

pelvic/no long bone fractures.

 

the only thing was the pupils B/L Dilated and fixed !

now is there any cause in the Head which can cause this?

i mean after excluding Hemorrhagic cause, if we label   Neurogenic shock,
the pt should be Hypertensive and Bradycardic.

 

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