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Blood pressure changes in severely injured patients
Resuscitation, 7, 249-253
Blood pressure changes in severely injured patients P. HALL-MATTHEWS Accident and Emergency Department, The General Hospital, Nelson Street, Hereford HRl 2PA, U.K.
Summary Sixty-live severely injured patients with hypertension on arrival at the Accident and Emergency Department were studied. Forty-eight had head injuries. In children there were significantly higher diastolic blood pressures in those admitted unconscious than in those conscious on admission. The possible cause of this is discussed. There was a fall in both the systolic and diastolic blood pressures of all patients after treatment and rest for some hours. Introduction It has been observed clinically that some severely injured patients entering the Accident and Emergency Department of Hereford General Hospital show a transient hypertension. This has sometimes been explained as being due to the patient’s pain and anxiety as a result of injury. It was noticed, however, that hypertension occurred in unconscious patients as well as in conscious ones, and indeed that there was a greater degree of hypertension in unconscious patients with head injuries involving loss of consciousness than in less severely injured patients. The phenomenon was most clearly seen in children under 16 years who were unconscious. Patients and methods From a total of 334 patients admitted to Herefore Hospitals after major injury between August 1972 and October 1976,65 who had hypertension on admission to the Accident and Emergency Department were studied retrospectively. Patients with a systolic blood pressure reading of 140 mmHg or above, and/or a diastolic blood pressure reading of 90 mmHg or above, were included. Twenty-three patients were unconscious on admission and 42 were conscious; 48 patients had head injuries, with or without other injuries; 11 had multiple injuries without head injury; four had severe single fractures without head injury; three had chest injuries. 249
250
P. HALL-MATTHEWS
Table 1. Blood pressures of unconscious patients with head injury. Initial and subsequent readings taken 612 h after admission or on restoration of full consciousness are given in Tables l-3. n=23. Initial blood pressure (mmHg) 250/l 30 180/130 175/115 210/l 10 15OjllO llO/llO 160/100 155/100 15OjlOO 140/100 185/90 1SO/90 180/90 1so/90 150190 1so/90 150190 140/90 140190 140190 135/90 130/90 160/80
Subsequent blood pressure (mmHg) 120/70 11o/70 125/75 100/60 150/90 110170
130/85 120170 140/80 120/80 130/80 130165 130180 13d/80 125165 13$65 140/80 120/80 130/80
Age of patient (years) 64 3 9 41 13 8 20 45 12 19 20 19 19 32 1‘7 18 25 45 31 17 23 18 20
Site of injury injury Vault fracture Head injury +chest injury Vault fracture Vault fracture Head injury Head injury Severe head injury Vault fracture Head injury Head injury Vault fracture Vault fracture Vault fracture Head injury Head injury Head injury Head injury + multiple injuries Vault fracture Head injury Head injury Vault fracture Vault fracture Vault fracture
Outcome Death Recovery Recovery Death Recovery Recovery Recovery Recovery Recovery Recovery Death Recovery Recovery Death Recovery Recovery Recovery Recovery Recovery Recovery Recovery Recovery Recovery
Further blood pressure readings were recorded in all patients alive 6-12 h after admission, or on restoration of full consciousness. Four of the unconscious patients had died before this stage. The blood pressures were recorded by qualified staff uekg a cuff appropriate to the size of the patient, ranging from 7.5 cm wide to the standard adult size of 12.5 cm. All values given are means + SD with the numbers of readings in parentheses. The blood pressures are given in mmHg. Observations and results The blood pressures of the patients were measured initially. In the unconscious patients the mean systolic and diastolic pressures were (mmHg): 160.4 f. 26.9 and 102.8 + 11.9 (n = 23), and in the conscious patients, they were 158.0 f 16.8 and 97.9 + 9.4 (n = 42); P was > 0.1 and > 0.05, considered to be not significant (Tables 1 and 2). Of these patients, those below the age of 16 years were studied separately. In these unconscious children, the mean systolic and diastolic pressures on admission were 159.0+ 17.5 and 113 f 10.9 (n = 5), and in the conscious children, they were 145.0 + 19.3 and 87.2 & 12.5 (n =9); for the differences of systolic pressure between the unconscious and conscious children P was >O.l, and between their diastolic pressures the P was ~0.01 (Table 3).
BLOOD PRESSURE IN INJURY Table 2. Blood pressures of conscious patients (initial and subsequent subsequently recovered. Initial blood pressure fmmHg) 170/110 170/l 10 160/l 10 140/l 10 170/100 170/100 170/100 160/100 160/100 160/100 150/100 150/100 15OjlOO 140/100 125/lOQ 120/100 145195 130195 180/90 170190 160/90 160190 160/90 160190 150190 1so/90 1so/90 150190 140190 140190 140190 130190 130/90 130190 130/90 11o/90 140/85 170180 1SO/80 150/80 145175 145170
Subsequent blood pressure fmmHg) 115/70 130/80 1so/so 120/70 150190 130/80 135/80 130180 130170 130/80 130/80 130180 120/80 130/80 120170 lOO/SO 120170 120/70 140/80 15OjSO 140/80 130/80 140170 140/70 120170 130175 1SO/SO 150/80 120170 115jSO 140/70 120175 120170 110/70 130170 110/70 130/80 9oj50 130/75 130160 120160 110/55
Age of patient (years) 5 69 76 16 16 37 62 19 58 28 22 50 28 19 25 6 18 17 19 65 20 18 77 5 29 38 61 73 15 70 19 25 6 19 69 17 22 4 15 76 4 9
25 1
readings). All 42 patients
Site of injury Head injury Multiple injuries Fracture shaft of femur Head injuries Multiple injuries Multiple injuries Head injury Fractured pelvis Head injury Multiple injuries Head injury + fractured humerus Multiple injuries Head injury Head injury Head injury Head injury Head injury + vault fracture Multiple injuries Chest injury Multiple injuries Multiple injuries Head injury + fractured base Head injury Head injury + multiple fractures Head injury Head injury + fractured base Pelvic fracture Multiple injuries Head injury + vault fracture Chest injury Head injury + vault fracture Spinal fracture Head injury + vault fracture Head injury + other injuries Multiple injuries Head injury Head injury Head injury + vault fracture Multiple injuries Head injury + ankle fracture Head injury Head injury
There were no significant differences in the blood pressure recordings taken 6-12 h after admission between the patients who had been unconscious on admission and those who had been conscious throughout (Tables 1 and 2). In all patients, however, the differences between the initial and subsequent blood pressures were highly significant. In the unconscious patients, on admission the mean
252
P. HALL-MATTHEWS
Table 3. Blood pressures of children with head injury (giving initial and subsequent readings). In both groups all patients recovered. Initial blood pressure (mmHg) A.
Subsequent blood pressure (mmHg)
Unconscious children 180/130 120170 1751115 110/70 150/110 125175 140/l 10 100/60 150/100 130/85
B. Conscious children 170/l 10 115170 120/100 100/50 160190 140170 140190 120170 130/90 120170 170/80 90/50 1SO/SO 130175 145175 120160 145170 110/55
Age of patient (years)
Site of injury
3 Concussion +chest injury 9 Vault fracture 13 Concussion 8 Concussion 12 Concussion Total patients = 5 5 Vault fracture 6 Concussion 5 Maxillary fracture 15 Vault fracture 6 Vault fracture 4 Vault fracture 15 Multiple injuries 4 Concussion 9 Concussion Total patients = 9
systolic and diastolic pressures were 160.4k26.9 and 102.8 & 11.9 (n =23), and subsequently they were 130.0f 12.6 and 79.0+9.0 (n = 19, PcO.001 in each case). In conscious patients on admission, the mean systolic and diastolic pressures were 158.0 f 16.8 and 97.9 + 9.4 (n = 42), and subsequently they were 132.0 + 13.2 and 78.0 +_7.5 (n =42; P
BLOOD PRESSURE IN INJURY
253
Conclusion There is a significantly higher diastolic blood pressure in children admitted unconscious with head injuries, compared with children with head injuries who were conscious on admission. It is possible that the observation of a raised diastolic pressure in severely injured patients without major blood-loss may prove a useful index of the severity of injury (Barton, Little, Stoner & Yates, 1977; Bull, 1978) and that further studies of plasma cortisol levels and other metabolic variables (e.g. catecholamines) may throw further light upon the matter. Acknowledgments I am most grateful to Dr R. H. Hardy, Consultant Hereford General Hospital, for his help.
in Accident and Emergency at
References Barton, R. N., Little, R. A., Stoner, H. B. & Yates, D. W. (1977) Measuring the severity of injury. Brit. Med. J. iii, 1247-1249. Bull, J. P. (1979) Measures of severity of injury. Injury, 9, 184-187. Keele, C. A. & Neil, E. (1971) Samson Wight’s Applied Physiology, 12th edn, p. 392. Oxford University Press, London.
Blood pressure changes in severely injured patients P. HALL-MATTHEWS Accident and Emergency Department, The General Hospital, Nelson Street, Hereford HRl 2PA, U.K.
Summary Sixty-live severely injured patients with hypertension on arrival at the Accident and Emergency Department were studied. Forty-eight had head injuries. In children there were significantly higher diastolic blood pressures in those admitted unconscious than in those conscious on admission. The possible cause of this is discussed. There was a fall in both the systolic and diastolic blood pressures of all patients after treatment and rest for some hours. Introduction It has been observed clinically that some severely injured patients entering the Accident and Emergency Department of Hereford General Hospital show a transient hypertension. This has sometimes been explained as being due to the patient’s pain and anxiety as a result of injury. It was noticed, however, that hypertension occurred in unconscious patients as well as in conscious ones, and indeed that there was a greater degree of hypertension in unconscious patients with head injuries involving loss of consciousness than in less severely injured patients. The phenomenon was most clearly seen in children under 16 years who were unconscious. Patients and methods From a total of 334 patients admitted to Herefore Hospitals after major injury between August 1972 and October 1976,65 who had hypertension on admission to the Accident and Emergency Department were studied retrospectively. Patients with a systolic blood pressure reading of 140 mmHg or above, and/or a diastolic blood pressure reading of 90 mmHg or above, were included. Twenty-three patients were unconscious on admission and 42 were conscious; 48 patients had head injuries, with or without other injuries; 11 had multiple injuries without head injury; four had severe single fractures without head injury; three had chest injuries. 249
250
P. HALL-MATTHEWS
Table 1. Blood pressures of unconscious patients with head injury. Initial and subsequent readings taken 612 h after admission or on restoration of full consciousness are given in Tables l-3. n=23. Initial blood pressure (mmHg) 250/l 30 180/130 175/115 210/l 10 15OjllO llO/llO 160/100 155/100 15OjlOO 140/100 185/90 1SO/90 180/90 1so/90 150190 1so/90 150190 140/90 140190 140190 135/90 130/90 160/80
Subsequent blood pressure (mmHg) 120/70 11o/70 125/75 100/60 150/90 110170
130/85 120170 140/80 120/80 130/80 130165 130180 13d/80 125165 13$65 140/80 120/80 130/80
Age of patient (years) 64 3 9 41 13 8 20 45 12 19 20 19 19 32 1‘7 18 25 45 31 17 23 18 20
Site of injury injury Vault fracture Head injury +chest injury Vault fracture Vault fracture Head injury Head injury Severe head injury Vault fracture Head injury Head injury Vault fracture Vault fracture Vault fracture Head injury Head injury Head injury Head injury + multiple injuries Vault fracture Head injury Head injury Vault fracture Vault fracture Vault fracture
Outcome Death Recovery Recovery Death Recovery Recovery Recovery Recovery Recovery Recovery Death Recovery Recovery Death Recovery Recovery Recovery Recovery Recovery Recovery Recovery Recovery Recovery
Further blood pressure readings were recorded in all patients alive 6-12 h after admission, or on restoration of full consciousness. Four of the unconscious patients had died before this stage. The blood pressures were recorded by qualified staff uekg a cuff appropriate to the size of the patient, ranging from 7.5 cm wide to the standard adult size of 12.5 cm. All values given are means + SD with the numbers of readings in parentheses. The blood pressures are given in mmHg. Observations and results The blood pressures of the patients were measured initially. In the unconscious patients the mean systolic and diastolic pressures were (mmHg): 160.4 f. 26.9 and 102.8 + 11.9 (n = 23), and in the conscious patients, they were 158.0 f 16.8 and 97.9 + 9.4 (n = 42); P was > 0.1 and > 0.05, considered to be not significant (Tables 1 and 2). Of these patients, those below the age of 16 years were studied separately. In these unconscious children, the mean systolic and diastolic pressures on admission were 159.0+ 17.5 and 113 f 10.9 (n = 5), and in the conscious children, they were 145.0 + 19.3 and 87.2 & 12.5 (n =9); for the differences of systolic pressure between the unconscious and conscious children P was >O.l, and between their diastolic pressures the P was ~0.01 (Table 3).
BLOOD PRESSURE IN INJURY Table 2. Blood pressures of conscious patients (initial and subsequent subsequently recovered. Initial blood pressure fmmHg) 170/110 170/l 10 160/l 10 140/l 10 170/100 170/100 170/100 160/100 160/100 160/100 150/100 150/100 15OjlOO 140/100 125/lOQ 120/100 145195 130195 180/90 170190 160/90 160190 160/90 160190 150190 1so/90 1so/90 150190 140190 140190 140190 130190 130/90 130190 130/90 11o/90 140/85 170180 1SO/80 150/80 145175 145170
Subsequent blood pressure fmmHg) 115/70 130/80 1so/so 120/70 150190 130/80 135/80 130180 130170 130/80 130/80 130180 120/80 130/80 120170 lOO/SO 120170 120/70 140/80 15OjSO 140/80 130/80 140170 140/70 120170 130175 1SO/SO 150/80 120170 115jSO 140/70 120175 120170 110/70 130170 110/70 130/80 9oj50 130/75 130160 120160 110/55
Age of patient (years) 5 69 76 16 16 37 62 19 58 28 22 50 28 19 25 6 18 17 19 65 20 18 77 5 29 38 61 73 15 70 19 25 6 19 69 17 22 4 15 76 4 9
25 1
readings). All 42 patients
Site of injury Head injury Multiple injuries Fracture shaft of femur Head injuries Multiple injuries Multiple injuries Head injury Fractured pelvis Head injury Multiple injuries Head injury + fractured humerus Multiple injuries Head injury Head injury Head injury Head injury Head injury + vault fracture Multiple injuries Chest injury Multiple injuries Multiple injuries Head injury + fractured base Head injury Head injury + multiple fractures Head injury Head injury + fractured base Pelvic fracture Multiple injuries Head injury + vault fracture Chest injury Head injury + vault fracture Spinal fracture Head injury + vault fracture Head injury + other injuries Multiple injuries Head injury Head injury Head injury + vault fracture Multiple injuries Head injury + ankle fracture Head injury Head injury
There were no significant differences in the blood pressure recordings taken 6-12 h after admission between the patients who had been unconscious on admission and those who had been conscious throughout (Tables 1 and 2). In all patients, however, the differences between the initial and subsequent blood pressures were highly significant. In the unconscious patients, on admission the mean
252
P. HALL-MATTHEWS
Table 3. Blood pressures of children with head injury (giving initial and subsequent readings). In both groups all patients recovered. Initial blood pressure (mmHg) A.
Subsequent blood pressure (mmHg)
Unconscious children 180/130 120170 1751115 110/70 150/110 125175 140/l 10 100/60 150/100 130/85
B. Conscious children 170/l 10 115170 120/100 100/50 160190 140170 140190 120170 130/90 120170 170/80 90/50 1SO/SO 130175 145175 120160 145170 110/55
Age of patient (years)
Site of injury
3 Concussion +chest injury 9 Vault fracture 13 Concussion 8 Concussion 12 Concussion Total patients = 5 5 Vault fracture 6 Concussion 5 Maxillary fracture 15 Vault fracture 6 Vault fracture 4 Vault fracture 15 Multiple injuries 4 Concussion 9 Concussion Total patients = 9
systolic and diastolic pressures were 160.4k26.9 and 102.8 & 11.9 (n =23), and subsequently they were 130.0f 12.6 and 79.0+9.0 (n = 19, PcO.001 in each case). In conscious patients on admission, the mean systolic and diastolic pressures were 158.0 f 16.8 and 97.9 + 9.4 (n = 42), and subsequently they were 132.0 + 13.2 and 78.0 +_7.5 (n =42; P
BLOOD PRESSURE IN INJURY
253
Conclusion There is a significantly higher diastolic blood pressure in children admitted unconscious with head injuries, compared with children with head injuries who were conscious on admission. It is possible that the observation of a raised diastolic pressure in severely injured patients without major blood-loss may prove a useful index of the severity of injury (Barton, Little, Stoner & Yates, 1977; Bull, 1978) and that further studies of plasma cortisol levels and other metabolic variables (e.g. catecholamines) may throw further light upon the matter. Acknowledgments I am most grateful to Dr R. H. Hardy, Consultant Hereford General Hospital, for his help.
in Accident and Emergency at
References Barton, R. N., Little, R. A., Stoner, H. B. & Yates, D. W. (1977) Measuring the severity of injury. Brit. Med. J. iii, 1247-1249. Bull, J. P. (1979) Measures of severity of injury. Injury, 9, 184-187. Keele, C. A. & Neil, E. (1971) Samson Wight’s Applied Physiology, 12th edn, p. 392. Oxford University Press, London.