S 52 Neurogenic Cardiopulmonary Instability with Pulmonary Edema after a Traumatic Head Injury-A case report

Duk-Kyung Kim, Kyoung-Min Lee, Kwon, Seung-Min Jeong
2007 Korean J Anesthesiol   unpublished
There are substantial clinical and experimental evidences to support the hypothesis that catecholamine surge causes cardiac failure and pulmonary edema after the acute neurological events. A previous healthy 74-year-old man was submitted to an emergency craniotomy for the evacuation of the delayed subdural hemorrhage after a motorcycle accident. After anesthetic induction, profound hypotension and progressive decrease of arterial oxygen tension developed and continued for several hours in spite
more » ... eral hours in spite of fluid loading and inotropic support with dopamine in combination with dobutamine. Electrocardiographic changes and increase of serum cardiac isoenzymes suggesting myocardial infarction were absent. On auscultation, crackles were detected in both lung bases, indicating pulmonary edema. On the basis of the assumption that left ventricular dysfunction was combined with the acute pulmonary edema, with a possible neurogenic component, aggressive management including dobutamine in combination with isosorbide dinitrate was instituted. As a result, these cardio-respiratory complications rapidly resolved without any neurologic sequelae. (Korean J An-esthesiol 2007; 53: S 52~7) In the patient with the disease of or the injury to the central nervous system (CNS), sudden onset of pulmonary edema can occur in the absence of cardiovascular and pulmonary risk factors. This is referred to as neurogenic pulmonary edema (NPE). 1,2) In some cases, three major categories of cardiac abnormalities are also associated with neurologic injury: cardiac arrhythmia, repolarization abnormalities, and mechanical dysfunc-tion due to reversible and non-ischemic myocardial stunning. 3) The left ventricular failure related to CNS lesions, representing the most severe form among them, has been referred to as neurogenic myocardial stunning. In this situation, the deranged myocardium behaves as in a panic due to a sudden burst of catecholamine. 4) Neurogenic myocardial stunning has been described in the patients with brain tumor, 3) seizure, 5) subdural hemorrhage (SDH), 6) and aneurysmal subarachnoid hemorrhage (SAH). 2,7-9) In the prospective study 4) that included 715 cases with SAH, the incidence of transient left ventricular dysfunction was 9.4% (67/715). To the best of our knowledge, severe myocardial dysfunction with the NPE in association with a traumatic head injury has not been reported in Korea yet. Therefore, we report a case of profound myocardial dysfunction with the pulmonary edema, successfully reversed after the prompt treatment with dubutamine and nitrate. CASE REPORT A 74-year-old man (169 cm, 62 kg) was visited the Emergency Department after a motorcycle accident. He complained of headache with blood pressures of 140-150/70-80 mmHg, p우리나라는..lulse rates of 70-80 beats/min, and respirations of 16-18 breaths/min. Up to the accident, the patient had been in good health for his age with no history of cardiac or pulmonary disease. Findings of neurologic examination were normal but arterial blood gas analysis showed slightly low partial arterial oxygen pressure (Table 1; ①). Brain computer tomography (CT) showed multifocal hemorrhagic contusions in fronto-temporal regions, SDH along the falx cerebri and the right fronto-temporal convexity, and a small traumatic SAH in