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Obtunded sensorium in a trauma patient
  1. A Mazumdar,
  2. S Kumar,
  3. S P Balasubramanian,
  4. A K Sharma
  1. Department of Surgery, Post Graduate Institute of Medical Education & Research, Chandigarh, India
  1. Mr Ajay Sharma, Renal Transplant Unit, Link 9C, Royal Liverpool University Hospitals, Prescot Street, Liverpool L7 8XP, UK

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Answers on p 130.

A 36 year old man, a victim of road traffic accident, with head injury and epistaxis, was taken to a district hospital. He was intubated with an orotracheal tube and his scalp injury was dressed, and he was referred to this tertiary care institute accompanied by his relatives. Three hours after the injury, when he was brought to the emergency room, he was noted to have intercostal recession while breathing, a systolic blood pressure of 95 mm Hg, and Glasgow coma score (GCS) was 2/10. Air entry on both sides of the chest was minimal and equally diminished on both sides, the percussion note on either side was not dull, and the neck veins were empty. Flow from the endotracheal tube was hardly audible. An endotracheal suction catheter was inserted but it could not be pushed beyond 20 cm. Arterial blood gases were sampled while trying hard to ventilate with an Ambu bag and were: oxygen tension 10.4 kPa, carbon dioxide tension 6.9 kPa, and pH 7.26. As per referral note, his systolic blood pressure at the time of referral was 110 mm Hg and GCS 5/10. There was no apparent external loss of blood. (Monitoring by pulse oximetry was not possible because no pulse oximeter was available.)

Questions

(1)
What is the most likely cause of deterioration of GCS in this case?
(2)
What should be the next step?
(3)
What is the most probable cause of hypotension in this case?
(4)
What is the finding shown in fig 1?
(5)
What is the most likely explanation for the development of blockage of this endotracheal tube?
Figure 1

Blocked endotracheal tube extubated from patient with deterioration in sensorium.

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