were eye (E) 4, verbal (V) 4, and motor (M) 6. Blood pressure(BP) was 120/85 mm Hg, and heart rate (HR) was 125 beats per minute.
The patient was intubated after the primary survey, because massive bleeding from contusion of the lower lip was present in the mouth, and upper airway obstruction from cervical hematoma growth was a concern.
We cleaned and debrided the contusions, Hemoglobin concentration was 8.6 g/dL on hospital day 1. After transfusion of 1 U each of packed red blood cells and fresh frozen plasma, hemoglobin concentration increased to more than 9g/dL; no further transfusions were necessary.
Beginning on hospital day 2, an intermittent fever was present, with temperatures exceeding 39°C twice a day. The patient became confused. Coinciding with peaks of body temperature, systolic BP and HR significantly in- creased, from 90 to 160 mm Hg and 110 to 170 bpm, Respectively .
In the predawn hours of day 4, hypotension (40/20 mmHg) suddenly ensued, and the Glasgow Coma Scale scores fell to E 2, V (intubation), and M 4. A bolus infusion of 800 mL of crystalloid solution promptly increased BP to120/35 mm Hg. A pulmonary artery catheter was then introduced to measure hemodynamic parameters. The cardiac index was 8.36, whereas the systemic vascular resistance index was 680,indicating a hyperdynamic state with high cardiac output and low systematic vascular resistance index (SVR)
We initiated a continuous intravenous infusion of norepinephrine (0.02 ug .kg-1.min-1) together with crystalloid solution at approximately 150 mL/h. BP then stabilized (systolic BP,120–140 mm Hg; diastolic BP, 50– 80 mm Hg), but tachycardia persisted (120–140 bpm). On day 5, HR gradually decreased, recovering to normal on day 6 (80–90 bpm). With complete stabilization of hemodynamics, norepinephrine was withdrawn on day 6. The patient then progressed uneventully, undergoing internal fixation of mandibular fractures on day 35, using a plate. He was discharged home on day 62.