Paradoxical bradycardia in a patient with haemorrhagic shock secondary to blunt abdominal trauma

Abstract

A 47-year-old woman, with no previous medical problems, presented to the Accident and Emergency department with left shoulder pain following a fall onto her left side from a horse. Physical examination was unremarkable and she was discharged with simple analgesia. However, 2 h later, she re-presented with worsening left shoulder pain, dizziness and mild epigastric discomfort. A new examination revealed blood pressure of 100/60 mm Hg, which dropped to 95/65 mm Hg on standing, a Glasgow Coma Scale score of 15 and pulse of 62 beats/min. She was resuscitated with 2 litres of Hartmann's fluid. A focused assessment with sonography for trauma (FAST) scan of her abdomen was negative. Then, 1 h later she experienced generalised abdominal pain and developed postural hypotension. However she remained bradycardic (heart rate 45-60 beats/min). Repeat examination revealed peritonitis. A further FAST scan showed free fluid in the left hypochondrium. A CT scan demonstrated a complex tear of the spleen, for which she underwent an emergency total splenectomy. Her postoperative recovery was uncomplicated.

Spontaneous Heterotopic Pregnancy Associated with Massive Intraperitoneal Haemorrhage and a Normal Heart Rate, Illustrating the Concept of Relative Bradycardia

“…Several papers describe a similar relative bradycardia concept in the context of trauma [11, 20–22].…”

Nontraumatic Splenic Rupture

“…The absence of tachycardia in our patient can be explained by the elevation of his baseline enteric vagal tone due to the continued presence of blood in the peritoneum. 5 There are also other factors associated with the absence of tachycardia. For example, a well-conditioned athlete presenting with states of shock due to splenic rupture may not show signs of tachycardia.…”