Emergency (****); * (*): *-* This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2014 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com 101 Emergency (2014); 2 (2): 101-103 CASE REPORT Transient Unexplained Shock in 30-year-old Trauma Patient Farzad Rahmani1, Hanieh Ebrahimi Bakhtavar1*, Kavous Shahsavari Nia2, Neda Mohammadi3 1. Department of Emergency medicine, Tabriz University of Medical Sciences, Tabriz, Iran 2. Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, Iran 3. Department of Emergency medicine, Urmia University of Medical Sciences, Urmia, Iran Abstract Shock as an inadequate tissue perfusion is one of the frequent causes of death in trauma patients. In this context, there are various reasons for hemodynamic instability and shock including hypovolemic (hemorrhagic), obstruc- tive (cardiac tamponade, tension pneumothorax), cardiogenic, neurogenic, and rarely septic. In the present re- port, a 30-year-old trauma patient with full clinical signs and symptoms of shock referred while had unknown origin; it was finally recognized as anaphylactic shock. Key words: Anaphylaxis; shock; insect bites and stings; trauma Cite this article as: Rahmani F, Ebrahimi Bakhtavar H, Shahsavari Nia K, Mohammadi N. Transient unexplained shock in 30- year-old trauma patient. Emergency. 2014;2(2):101-3. Introduction:1 hock as an inadequate tissue perfusion is one of the frequent causes of death in trauma patients. There are various reasons in this context including hypovolemic (hemorrhagic), obstructive (cardiac tam- ponade, tension pneumothorax), cardiogenic, neuro- genic, and rarely septic shock (1). There are several diagnostic tools available for classification and explor- ing the origin of the shock. Nowadays, rapid ultrasound in shock (RUSH) examination helps practitioners in de- cision making regarding the source of shock and conse- quently proper management (2). In addition, evidences of spinal cord injury, head injury, and pelvic and long bone fractures on imaging are other adjunctive sources. In the present report, a 30-year-old trauma patient with full clinical signs and symptoms of shock referred while had unknown origin. Case report: A 30-year-old male, referred to the emergency depart- ment, complaining of respiratory distress and hemody- namic instability followed falling from motorcycle. On arrival, patient history was taken from the witnesses at the accident scene who accompanied the patient. Dur- ing motorcycle deriving, the patient had suddenly lost his control and hit the roadside guard. In initial evalua- tion, his vital signs were as follows: blood pressure: 80/40 mmHg, pulse rate: 143/minute, RR: 26/ minute and oxygen saturation of 66%. In physical examination, the patient was agitated, he had respiratory distress and lung sounds were symmetric on both sides; slight *Corresponding Author: Hanieh Ebrahimi Bakhtavar, MD. Emergency Medi- cine Department, Tabriz University of Medical Sciences, Tabriz, Iran. Postal code: 5166614756 Fax Number:00984113352078 Email: hanie_60@yahoo.com Received: 9 February 2014; Accepted: 21 March 2014 expiratory wheezing was heard in lung auscultation and lung sounds were not reduced. The pupils were iso- choric and responded to light and periorbital edema was seen around both eyes. All extremities did not have any deformities and had normal motion. No remarkable issue was found in the spine and the sphincter had normal tone in digital rectal examination. Two intrave- nous lines (gauges 14 and 16) were inserted and two liters crystalloid fluid was infused within 20 minutes. The results of patient’s initial arterial blood gas (ABG) were as follows: PH: 7.12, HCO3:17.2 meq/liter, PaCO2: 54.3 mmHg, and PaO2: 70 mmHg. Because of instability in his hemodynamic status, he was intubated through rapid sequence intubation (RSI) method. Chest, hip, and spine anteroposterior and lateral radiographs, extend- ed focused assessment with sonography for trauma (eFAST), and computed tomography (CT) scan of the brain and cervical spine were performed. While slight edema was seen in brain CT, the other imaging had not any positive findings. About eight hours later, the pa- tient’s level of conscious increased and clinical status improved. He was gradually weaned from mechanical ventilation and extubated. Vital signs after extubation were as follows: blood pressure: 130/80 mmHg, pulse rate: 80/minute, respiratory rate: 14/minute, oxygen saturation 97% (in room air). After he was able to speak properly, described the event in details; when he was driving the motorcycle, something like an insect abruptly hit his face and he felt an intense burning in the upper of left eye. He became lethargic and could not remember what happened after. The bite site on pa- tient’s face was carefully examined and a small dot no- ticed. Based on above-mentioned, anaphylactic reaction was recognized. S mailto:hanie_60@yahoo.com This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2014 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com Rahmani et al 102 Discussion: In the introduced case, we initially suspected to hemor- rhagic shock caused by trauma but despite of using all diagnostic tools the reason of shock remained un- known. After taking the necessary measures and moni- toring the patient, his clinical status improved gradual- ly. When he was extubated and gave a detailed history of what happened, the mystery was solved. Anaphylaxis is a life-threatening systemic allergic reac- tion that requires early diagnosis and treatment. In some studies, the prevalence rate of this shock has been reported more than 2% (3). It may be arises from varie- ty of foods, medications, or insect bites (4, 5); it begins following adhesion of allergens to the mast cells mem- brane bound immunoglobulin E (IgE). This results in activation of mast cells and release of various inflamma- tory mediators and histamine which mediate clinical manifestations of anaphylaxis from hives and localized rash to severe anaphylactic shock with symptoms such as respiratory distress, hypotension, dermal manifesta- tions of localized erythema, urticaria, angioedema, and nausea and vomiting (6). Physicians are faced with some significant challenges in diagnosis of anaphylaxis. First, despite numerous defi- nitions of anaphylaxis, there are no reliable diagnostic criteria accepted by all international societies. Second, anaphylaxis may appear with numerous atypical mani- festations. Furthermore, the patients may deny any con- tact with any stimulus. Finally, there is no reliable and acceptable emergency diagnostic testing to rule out or diagnose anaphylaxis (7). Despite such challenges in diagnosis, we applied the Canadian pediatric surveil- lance program among several definitions. It defined the anaphylaxis as a “severe allergic reaction to any kind of stimulus with sudden onset lasting less than 24 hours and affecting one or more body systems. It will also produce one or more symptoms such as: hives, itching, flushing, angioedema, stridor, dyspnea, vomiting, diar- rhea, and shock” (8). Rare manifestations of this disease may be appeared as bradycardia and/or myocardial infarction (9, 10). Considering these challenges, diagno- sis and treatment of anaphylaxis could be delayed (11). Because any delay in diagnosis or incomplete treatment may lead to patient death, emergency physicians should be able to recognize anaphylaxis clinical manifestations and treat it accurately (12). Risk factors associated with mortality in these patients include asthma, cardiopul- monary disease, delay or failure to administer adrena- line, and patient’s age. The mortality rate of anaphylac- tic shock caused by foods (such as peanut) is high among younger ages (adolescence and youth), while in older ages (adult and older adult), the mortality rate of anaphylaxis following insect or animal toxins is high. Anaphylactic patients are treated by crystalloid intra- venous fluids, corticosteroids, blockers of histamine receptors 1 and 2, and epinephrine, followed by check- ing and ensuring from the airway and breathing. Gluca- gon can be used for treatment of refractory cases such as resistant hypotension. Bronchospasm can be treated by albuterol, ipratropium bromide, and magnesium sul- fate (13). After discharging, the patient should be trained in prevention of future contacts, medications use, and use of auto injector device, if it happens again (6). An effective prophylactic method for patients with a positive history of severe allergic reaction to the hyme- nopterans bites is cluster protocol. This protocol is in- troduced as a safe and effective treatment modality for immunotherapy of these patients. In this method in de- fined intervals, an escalating dose of insect venom is injected to patients (14-16). Conclusion: For a rapid diagnosis, early treatment and increase sur- vival of patients, anaphylactic shock should be always considered as a differential diagnosis of shock even in a trauma patient. Acknowledgment: We acknowledge all staffs of emergency department of Imam Reza hospital, Tabriz, Iran. Conflict of interest: None Funding support: None Authors’ contributions: All authors passed four criteria for authorship contribu- tion based on recommendations of the International Committee of Medical Journal Editors. References: 1. ATLS Subcommittee, American College of Surgeons’ Committee on Trauma, International ATLS working group. Advanced trauma life support (ATLS(R)): the ninth edition. J Trauma Acute Care Surg. 2013;74(5):1363-6. 2. 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