Weird But True

[DartmouthDave]

Hello,

I hope this the right section.

I thought that this may be a good area to present unique cases for all the members of the form to learn from.

CASE:

A 52 year-old male was riding a motor bike accross North America. Traffic ahead was breaking and he was caught by surprise. He applied the breakes and the bike torqued to the side and threw the drive in to on coming traffic. He slid along the ground and was clipped by a small car a tossed in to the ditch.

EMS arrive shortly. He was lucid (GCS 15)with no deficits (strong x 4). He c/o right sided chest pain (# ribs) and left arm pain (humerus #). His VS were:

HR 80

EKG - NSR

BP 70/28

Resp 20

SpO2 99%

EMS called a trauma alert and insert IV x2, gave 1L NS, and Morphine and Gravol IV.

Upon arrival to the ED a full trauma work up was done (FAST, CT, XRAY). No source of bleeding was noted. However, despite this the patient remained hypotensive despite fluid challenges. In fact, a central line was inserted. CVP was noted to be quite low (3) and Levophed and more fluid were administered.

This fellow was Dx with SIRS. The violent impact had set off a septic-like immune/inflamatory response that caused the low blood pressure. He was weaned of Levophed and was transfer to the ward and was discharge shortly after with a surgical of his fractured arm.

It was very wierd to have the patient so profoundly hypotensive without any major injuries....

Cheers

Edited August 28, 2010 by DartmouthDave

[mobey]

Thank you dave.

Did the patient get a fever?

Is it possible that the impact ruptured a cyst? or something along those lines?

[DwayneEMTP]

Great idea! Great case! Great questions Moby....

But would a source of infection of that type create enough of a reaction to cause sepsis in that time frame do you think?

Dwayne

Edit. Why the Gravol?

Edited August 28, 2010 by DwayneEMTP

[chbare]

Also remember that infection need not be present for a SIRS response to occur. Any injury or insult can potentially lead to a cascade of events that cause SIRS or worse. Took care of a healthy gentleman in his 20's who had am elective surgical procedure. No operative problems or post op infection or haemorrhage occurred. However, he developed a SIRS response and ultimately died of MODS.

Even something as seemingly simple as administering volatile anaesthesia agents can significantly alter the normal homeostatic mechanisms.

Take care,

chbare.

[p3medic]

Was there ever a consideration of adrenal insufficiency? Monday morning quarterbacking, maybe a stress dose of steroids would be in order.

[DartmouthDave]

Hello,

DawyneEMTP & Mobey:

The Gravol is a local thing that ALS dose around here. Not sure why.

The theory was the immune/inflammatory was due to trauma not infection (as noted by chbare). Here is a defination of SIRS from Up-To-Date:

Systemic inflammatory response syndrome (SIRS) — SIRS refers to the consequences of a dysregulated host inflammatory response. It is clinically recognized by the presence of two or more of the following (table 1):

•Temperature >38.5ºC or <35ºC

•Heart rate >90 beats/min

•Respiratory rate >20 breaths/min or PaCO2 <32 mmHg

•WBC >12,000 cells/mm3, <4000 cells/mm3, or >10 percent immature (band) forms

SIRS can result from a variety of conditions, such as autoimmune disorders, pancreatitis, vasculitis, thromboembolism, burns, or surgery

P3Medic:

Good point. No steroids were given or labs done at the time he arrived in the ED. It could be an other possibilty or contributing factor. Adrenal insufficiency is often overlooked. I didn't look to see if steriods were added once he left the ICU/ED.

It was very odd. The fellow wallked out of the hospital a week or so later. In fact, he left with boardline hypertension!

Cheers

[Quakefire]

Cool Story! We usually give gravol with morphine just in case of nausea, just whats done by our medics and the hospital here.

As for SIRS, why was his HR so low with a BP like that? From what I understand (which probably isnt much) He should have been getting tachy, as a compensatory response to the hypovolemia. Was there something else found to account for this? Or was he previously borderline hypotensive and possibly tolerated it better.

Last question, how was his response to the levophed?

[fiznat]

Morphine for a trauma patient with a BP of 70?

[Eyegor]

Going old school and probably oversimplifying but what about the infamous neurogenic shock? The S&S don't really support what little I know of SIRS, but I certainly am not questioning that. I'm more interested in the classic idea of overwhelming insult to CNS causing systemic vasodilation. Not very precise but it does happen. Usually transient over an hour or two.

[chbare]

It is a consideration and clearly we have what I would call a relative bradycardia in the presence of hypotension. Look at beta blockers and other concepts would also be indicated.

Take care,

chbare.