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Mon Feb 25 08:03:08 GMT 2008

good day all


i am ER specialist  please if samebady can sand me a ower poit
persentation for tarige system or any subject in ER department

thank you for this interesting case

best regard

On 2/25/08, Matthew Reeds <mgreeds at reeds.uk.com> wrote:
> 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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-- 
Dr: Ibrahim  Makdah
Head of ER Department
Master degree Emergency Medicine
ATLS, ACLS, PALS ,NRP ,BCLS , instructor

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