37y M, motor vehicle collision. HR 110bpm, RR 24/min, Bp 90/60mmHg, JVD, tenderness of the sternum to palpation. Breath sounds are equal, heart sounds are decreased. Abdomen and upper and lower limbs are normal. IV 2L 0.9% saline, HR decresed to 100bpm, Bp increased to 100/70. During next 10 minutes, Bp decreases to 80/50. which one is most likely to explanation for the Bp?
A. MI
B. pericardial tamponade
C. PE
D. ruptured thoracic aorta
E. tension pneumothorax
hemorrhagic shock during vehicle collision, IV saline, the Bp increased, then drop again, what do we need think of?
1. cardic contusion ( with other arrhythmia?)
2. MI ( must have lung congestion?)
3. ruptured thoracic aorta ( maybe the Bp can not increase when IV saline?)
4. pericarsial tamponade
OK... topic 1
HYPOTENSION IN TRAUMA
1. Hypovolemia / Hemorrhage
There is a hole somewhere. Whether its into the peritoneum, into your thorax, or into your femur, its doesn't matter. The blood is leaving the intravascular space and going somewhere else. Your blood vessels are like a deflated hose. You put blood in them, they expand, you take it out, they go flat.
Less blood in the veins, flat.
2. Restricted Preload
Instead of a hole, the blood just cant get in the heart. Its still in the vascular space, you just cant get it into the heart. So, its going to back up. "Back up" means extra blood in the hose of your blood vessels, going to be distended.
This happens in Tamponade and Tension Pnuemo. Distended neck veins.
Tamponade has muffled heart sounds, JVD, and clear lung fields. Giving extra fluid will expand the preload, force open teh ventricle, and get more blood in. More blood in, more blood out, winning. Obviously, you need to drain the pericardial space.
Tension Pneumo will have tracheal deviation, JVD, and decreased lung sounds where the pneumo is. Giving extra fluid will expand preload, force open the ventricle, get more blood in. More blood in, more blood out, winning. Obviously, you need to decompress the tension pneumo with a needle.
Other shock not trauma
Decreased tone / decreased systemic vascular resistance: anaphylaxis, sepsis, spinal shock (spinal shock could be trauma, but I ususally associate it with poor anesthesia)
Broken pump as in MI or heart failure.
Ok...Topic 2:
ANTICIPATING UNDERLYING PROBLEMS
In a person with a sternal fracture, flail chest, or scaphoid fracture, you need to suspect underlying problems. The force required to break those bones that way means that there was significant blunt force trauma.
Myocardial Contusion. For all intents and purposes this is an MI. There is a troponin leak, there are ECG changes, the pump gets a little broke. You treat it like an MI (MONA BASH) in order to control arrhythmia.
Pulmonary Contusion. The lungs will be normal on initial xray. Then, you give the patient a lot of fluid to resuscitate them. Uh ohz... your contused lung has increased vascular permeability, and wham, fluffly white out on xray. So, in pulmonary contusion you need to avoid fluid.
Aortic Dissection. Body goes forward, internal organs with it. Rapid deceleration, only the ligamentum arteriosum is intact. RRRRRRIP! Complete transections die on scene. Partial transections will present with tearing chest pain, unequal blood pressure left to right, and a widened mediastinum on Chest xray. Evaluate with either CT angiogram or Transesophageal echocardiogram. Treat with blood pressure control (descending) or surgery (ascending)
