Evaluation and treatment of shock in an automobile accident victim

Abstract

?? lDr Campbell: This is a case of a 36-yearold white male police officer who was involved in a moderate-speed, single-car traffic accident. His car struck two trees and a chain-link fence, resulting in moderate vehicular damage. There was no apparent reason why the officer should have run his car off the road. He was found by the paramedics in the driver’s seat, unrestrained, with agonal respirations. The steering wheel and windshield were intact. His eyes were open and deviated to the right. A carotid pulse was palpable at a rate of 100 beats per minute, but a blood pressure could not be obtained. He was unconscious and flaccid, with no apparent external trauma. Following extrication and immobilization, there were several unsuccessful attempts at nasotracheal intubation with resultant epistaxis. A nasopharyngeal airway was placed; two 1Cgauge IVs were started in the upper extremities infusing normal saline. Following his arrival in the emergency department, his blood pressure was 68 mm Hg palpable and pulse rate 138 beats per minute. His ventilations were being bag-assisted. Decerebrate posturing was noted in response to deep pain. The skin was warm and dry, and it was noted that there was a slight generalized flush. Head, eyes, ears, and throat were normal except for the epistaxis, as mentioned. Pupils were 4 mm bilaterally and reactive to light, with eyes remaining deviated to the right. The fundi were normal; tympanic membranes were normal. No cervical spine deformity was apparent. Chest was clear to auscultation, but breath sounds were markedly decreased bilaterally. No chest injuries were present. The abdomen was soft with rare bowel sounds. The pelvis was stable and extremities were unremarkable. A rectal examination revealed good tone with hemenegative stool. Normal saline and type 0, Rh negative blood were given on arrival. The following sequence of events then transpired: Nasotracheal intubation was attempted and was again unsuccessful. Cricothyrotomy was performed, and a No. 7 tracheostomy tube was placed. At this time the patient was noted to have a palpable blood pressure of 70 mm Hg and a pulse rate of 131 beats per minute. A cutdown was performed on the right saphenous vein. A right subclavian line was placed after multiple attempts. Initial central venous pressure (CVP) was 2 cm H,O. Blood pressure was M/54 mm Hg with a pulse rate of 130 beats per minute. At this time a persistent oozing of blood was noted at all needle puncture sites. A nasogastric tube was passed without difficulty, and a Foley catheter was placed. Gastric aspirate and urine were both negative for blood. Dexamethasone 10 mg was given. Seven-