Drop in BP

[cointosser13]

To sum up the story, sheriffs find an unconscious male in his 50's on the side of the road, unconscious throughout the whole ride to the hospital and at the hospital. Once at the hospital doctors intubate the guy. While I'm trying to get another IV line in I see that this guy's BP is around 180/130. Pulse is tachy at about 120. My initial thought was hypertension encephalopathy. We find that his PMH is extensive (hypertension, diabetes, CAD, two stents placed in and so on). Anyway, 10 minutes in and I see that this guy's BP just drops.....to like 60/30. Can anyone explain to me any reasons why this could happen?! A sudden drop in blood pressure like that. I've never see it before.

At the end of it, doctors find out that he had a brain bleed.

 

[Gurby]

What kind of monitor are you using? My first thought is that one or both of those BP readings are not accurate. If I saw 180/130 on my E-series, I'd be cycling another pressure, and then taking one manually or at least palpating one real quick to see if 180 systolic is even in the right ballpark. But assuming those numbers are accurate:

What was the guy's breathing like? Posturing? Pupils? Check Babinski sign?

Are you confident that the HR was 120 when his BP was up there? It sounds like it could be Cushing reflex, especially given that with hindsight we know he had a head bleed. I think that would explain the high diastolic pressure, but my understanding is that usually that has reflex bradycardia with it.

If I had to guess, the high blood pressure was Cushing reflex, and then the drop in pressure signified herniation:
https://en.wikipedia.org/wiki/Cushing_reflex
https://en.wikipedia.org/wiki/Brain_herniation

Interesting case, and a good reminder that the "unresponsive on the side of the road" patient is not always going to be a drunk or OD.... Maybe someone smarter than I am can give you a better explanation @Brandon O @ERDoc ?

 

[Carlos Danger]

180/130 isn't at all unusual for a bad bleed. By the textbook, a HR of 120 is unusual in that scenario, but we all know that sick people with complicated histories often don't present the way the books say they should. For instance, long-standing diabetics often have an autonomic neuropathy that prevents normal BP and HR responses to various stimuli - in other words his baroreceptor reflex to the high MAP might not be working right. Plus, with a history of uncontrolled (I'm assuming) hypertension, his cerebral perfusion requirements will be shifted well to the right, basically meaning that he could need a much greater MAP than most people to trigger a bradycardic response.

The hypotension could have been from the induction meds or from general decompensation.

 

[Nova1300]

The Cushing response is taught and makes sense in the patient with normal anatomy and functional physiology.

However, in my own experience, a textbook Cushing response is relatively uncommon.

In fact, though we may see brief periods of bradycardia during herniation, the picture you present is what I more commonly see in our devastating head bleeds: tachycardia, severe hypertension, a discreet moment of hemodynamic deterioration (sometimes with bradycardia) often followed by hypotension which may be brief and self-resolve or may require pressors.

At my institution we usually make note of the time of likely herniation and that time will dictate when we may proceed to brain death testing for organ donation.

The mechanism is a little vague to me. It seems to be a sudden loss of vascular resistance because we put pulmonary artery catheters in these folks and they almost universally have high cardiac output. And both the cardiac output and the vascular tone seem to normalize in most patients within several hours of the hemodynamic event, though a few will remain a little hypotensive and require drips.

Anyway, a little detailed. But, that sudden hypotension is not uncommon, with or without bradycardia in the setting of a devastating head bleed in patients with comorbidities

 

[teedubbyaw]

The last 2 hemorrhagic strokes I've had, including the one from last night, were both showing classic cushing's.

 

[Nova1300]

The last 2 hemorrhagic strokes I've had, including the one from last night, were both showing classic cushing's.

Interesting. I'm curious, what was the mental status exam like in these two patients?

 

[teedubbyaw]

Interesting. I'm curious, what was the mental status exam like in these two patients?

One was unconscious upon our arrival and only withdrew from pain, which deteriorated to a GCS of 3, with a BP in the 180's and a pulse in the 40's. She got RSI'd due to vomitting.

The last one was mostly alert and talking, progressing to opening eyes on command and squeezing my hand on command, further progressing to not following commands to open eyes, still squeezing hand, furthering to none of the above and not withdrawing from pain. Over about a 30 minute period. Blood pressure was 210/108, pulse in the 50's.