cause of hypotension

[John Annen]

Thanks for posting this interesting case. In considering it, quite a few questions come to my non-physician's mind. (I'm just a part time medic.) At the risk of looking silly, I'll throw a few of them out there. Please feel free to consider or ignore them, as you see fit.
 
Did the patient have a palpable carotid pulse on arrival? If so, how strong was it? What was the pulse rate before the fluid and red cells? Given the severe hypotension, malperfusion of the brain / cerebral hypoxia seems at least to me to be not an unlikely cause of the fixed and dilated pupils.
 
How long between the time the BP was first measured at 110/70 and pulse at 110 and the decision to take the pt to CT? Were the vitals stable during that time? Was any additional therapy administered during that time?
 
I know you said for the sake of this discussion to discount hemorrhage as the cause of shock, but is there not a possibility of significant intrathoracic or intraabdominal bleeding that wasn't picked up by the imaging studies you did?
 
And one last question, do you have access to the patient's prior medical history or can you otherwise rule out preexisting blindness and pupils fixed and dilated as his baseline status?

John Annen
Zurich, Switzerland


----- Original Message ----
From: Dr.Asif Huda Ansari <asifhansari at yahoo.com>
To: trauma-list at trauma.org
Sent: Sunday, February 24, 2008 2:25:59 PM
Subject: cause of hypotension

SUB: Cause of hypotension in MVA patient.

Hellow,

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.
please give your expert opinions.
Thanks

Dr.Asif.H.Ansari;MBBS, MRCS (Std)
King Khalid Hospital
Saudi Arabia

      
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