1/5. Traumatic cardiogenic shock due to massive air embolism. A possible role for cardiopulmonary bypass.Systemic arterial embolism is a potentially lethal complication of bronchopulmonary venous fistula in trauma patients with blunt chest trauma or isolated penetrating lung injury on positive pressure ventilation. A high index of suspicion, early diagnosis and management in specialized centres are keys to a successful outcome.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
2/5. Acute adrenal insufficiency presenting as shock after trauma and surgery: three cases and review of the literature.Profound nonhemorrhagic shock developed in one postoperative and two trauma patients. Cardiovascular collapse was characterized by severe hypotension (systolic blood pressure less than 80 mm Hg), hyperdynamic cardiac indices (CI greater than 4 L/min/m2), low systemic vascular resistance (SVR less than 500 dyne.sec/cm5.m2), and multiple organ failure. sepsis was not found by culturing of specimens or visual inspection at laparotomy. Screening cortisol levels were low (less than 2 micrograms/dL in two patients) and did not respond appropriately to synthetic ACTH (cosyntropin) challenge. Administration of exogenous glucocorticoids promptly and dramatically reversed shock and organ failure in two patients. Oral glucocorticoid and mineralocorticoid supplementation were required at hospital discharge. Acute adrenal insufficiency is rare after trauma, but may produce life-threatening cardiovascular collapse, mimicking the "septic" shock state. cosyntropin stimulation testing confirms the diagnosis and is accurate in traumatized patients. Outcome is dependent upon early recognition and exogenous glucocorticoid administration. Appropriate endocrine evaluation prevents unnecessary use of steroids in a population of trauma patients who are already in a state of immunosuppression.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
3/5. Bilateral lower extremity amputations after prolonged application of the pneumatic antishock garment: case report.The authors describe the case of a 29-year-old man with multiple trauma who suffered compartment syndromes necessitating bilateral lower limb amputations as a result of the prolonged (9.5 hours) application of a pneumatic antishock garment (PASG). There was no evidence of lower limb trauma before the garment was put on. Despite the apparent benefits of the PASG in traumatized hypovolemic patients, the lowest possible inflation pressures should be used and removal attempted as soon as hemodynamic stability can be assured.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
4/5. Principles of treatment and indications for surgery in severe multiple trauma.Despite major advances, pitfalls in diagnosis and emergency treatment influence the survival chances of multitraumatized patients considerably. Diagnosis of traumatic shock cannot be made by blood pressure, pulse rate and shock index. Immediate shock therapy is indicated in all cases with severe trauma of two body regions, combined injury of one body cavity and long bone fractures and in all cases with one major thoracic or pelvic injury. In a consecutive series of 418 multitrauma patients, extremity injuries were present in 90%, severe head injuries in 65%, major thoracic trauma in 50% and abdominal or pelvic injuries in 40%. The most frequent pattern of multitrauma was long bone fractures with associated head trauma and one thoracic, abdominal or pelvic injury. Priorities of treatment are based on a 4-stage-schedule: Stage 1 includes intubation and hyperventilation for cerebral trauma, volume replacement by central venous catheter, emergency x-ray of cervical spine, chest, abdomen, pelvis and diagnostic peritoneal lavage. In 25% of admitted cases, diagnosis of abdominal hemorrhage was missed by the referring surgeon despite hemorrhagic shock, falsely attributed to cerebral trauma. At Stage 2, emergency surgery of internal and external bleeding is indicated. Wide open fractures are stabilized by external fixation. Stage 3 is concerned with stabilization of vital systems and further diagnostic evaluation, its duration varying from 2 hours to 2 days. At Stage 4, internal fixation of fractures and other non-emergency-operations are indicated. Operating time can be reduced considerably by 2 surgical teams operating simultaneously or overlapping. Early shock diagnosis, immediate intubation, ventilator treatment and the "4-stages-schedule" are considered the most successful steps in the management of multitrauma, as well as volume replacement with Fox' hypertonic saline solution and blood constituents instead of colloids. This has reduced mortality due to respiratory failure from 31% to 20%.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
5/5. bradycardia during severe but reversible hypovolemic shock in man.Severe bleeding and hypovolemic shock causing hypotension are most often associated with tachycardia. In response to passive head-up tilt, five healthy men exhibited an increase in heart rate (HR) from 62 to 79 beats X min-1 and a gradual increase in the plasma concentration of aldosterone and protein. The increase in HR was followed by a decrease of 29 beats X min-1 (range 11-46) at the time when blood pressure decreased 38 mmHg (6-73). When tilted back to 0 degree, blood pressure immediately reversed while HR remained unchanged. hypotension was associated with large but variable increases in plasma vasopressin (86 /- 28 pg X ml-1) accompanied by peripheral vasoconstriction. In two cases where patients with internal bleeding presented with a moderate HR of 96 beats X min-1, the ensuing fall in blood pressure was associated with a decrease in HR to 68 and 76 beats X min-1, respectively. Administration of albumin solution and blood normalized cardiovascular function. Two other patients showing initial HR of 130 and 100 beats X min-1, respectively, also developed relative bradycardia in conjunction with a decrease in blood pressure. Administration of ephedrine and atropine increased HR temporarily from 56 to 90 and from 36 to 110 beats X min-1, respectively. The latter two patients died in extreme bradycardia and autopsies revealed severe internal bleeding. It is concluded that although hypovolemic shock is most often associated with an increase in HR, the increase is modest and a paradoxical bradycardia develops in severe but potentially reversible hypotensive hypovolemic shock.- - - - - - - - - - ranking = 4keywords = pressure (Clic here for more details about this article) |