> Can you develop metabolic acidosis from lung contusion?
Not common. You can get it from thoracic contusion, but as Rowley implies,
it's the mass of tissue that matters. There's not that much tissue mass in
lungs. It may be part of it, but look for another cause.
> Is it the inotropes in a bleeding patient?
Fair bit of inconclusive research on inotropes in treatment of haemorrhage.
There certainly is a school of thought that says that if their BP is
dropping so much you have to do something before you control the bleeding,
inotropes are better than fluids (equally a school of thought that says
fluids in various quantities and a school that says do nothing). Certainly,
vasoconstrictors (and all inotropes- apart from maybe phosphodiesterase
inhibitors) are vasoconstrictors in the right circumstances) could cut down
local perfusion and cause acidosis even if overall cardiac output and BP are
OK.
> Where else can you generate severe metabolic acidosis?
Leaving aside the acidosis from the fluids you've given, which is rarely
severe, some cells are metabolising anaerobically either because they're not
getting enough blood to them or because
One of the big causes is the body shutting down. The bleeding's been
controlled. What you have is similar to a septic shock picture. The problem
is a cellular level. A lot of research going into Macrophage Toll Like
Receptors as mediators at the moment.
Abdominal compartment syndrome is a pretty common cause of acidosis, but
unlikely here. However, retroperitoneal compartment syndrome is common.
Another thing I've seen quite often in trunk degloving is effectively a
crush syndrome affecting the muscles of the trunk wall. The patients die.
Just because you can see the gut doesn't mean that there isn't part of the
gut infarcting.
> Are we doing something wrong? or Not enough of something?
> Are these patients doomed but because they are young are
> going to take their time in dying?
If they're dying because of the innate response, there's nothing you can do
(maybe activated protein C as in septic shock, but I wouldn't at the current
state of evidence)
Matt Dunn
Warwick
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