What is the cause of hypotension in a 55-year-old male with a lacerated wound on the forehead, alcohol intoxication, and paralysis of the lower extremities?

Cause of Hypotension in This Patient

The hypotension in this 55-year-old male is most likely due to hemorrhagic shock from occult bleeding (potentially intra-abdominal or intrathoracic), exacerbated by acute alcohol intoxication which impairs normal compensatory mechanisms to blood loss. 1, 2

Primary Differential Diagnosis

Most Likely: Hemorrhagic Shock with Alcohol-Impaired Compensation

Assume hypotension is due to hemorrhage until proven otherwise in any trauma patient. 1 The combination of trauma, hypotension (BP 80/50), and alcohol intoxication creates a particularly dangerous scenario where:

• Acute alcohol intoxication inhibits the normal release of epinephrine, norepinephrine, and vasopressin in response to acute hemorrhage, making intoxicated patients more likely to be hypotensive on admission despite similar injury severity. 2
• Intoxicated trauma patients are more likely to present with hypotension even with lower-grade injuries compared to non-intoxicated patients, and they require significantly more packed red blood cells and intravenous fluids during resuscitation. 2
• The forehead laceration is a visible injury, but the inability to move lower extremities suggests spinal cord injury, which commonly occurs with associated thoracic or abdominal injuries that can cause significant occult hemorrhage. 1

Critical Consideration: Spinal Shock vs. Neurogenic Shock

The paralysis of lower extremities raises concern for spinal cord injury with neurogenic shock, which presents with:

• Hypotension due to loss of sympathetic tone below the level of injury
• Typically associated with bradycardia (not mentioned in this case)
• Loss of vasomotor tone causing distributive shock 1

However, neurogenic shock alone rarely causes BP as low as 80/50 mmHg without concurrent hemorrhage. 1 The combination of both mechanisms is likely present.

Less Likely but Must Exclude: Alcohol-Induced Hypotension Alone

Severe acute ethanol poisoning can cause hypotension and hypothermia through direct vasodilatory effects, but this typically occurs:

• Several hours after ingestion in patients who normally abstain from alcohol 3
• With blood alcohol levels causing severe CNS depression
• This mechanism alone is unlikely to explain BP 80/50 in the acute trauma setting 3, 4

Immediate Management Algorithm

Step 1: Assume Hemorrhagic Shock and Begin Resuscitation

Begin immediate fluid resuscitation with isotonic crystalloids (0.9% saline) while simultaneously searching for bleeding sources. 1, 5

• Target mean arterial pressure ≥80 mmHg due to the likely presence of traumatic brain injury (forehead laceration suggests possible head trauma). 1
• Do NOT use permissive hypotension strategy because spinal cord injury requires adequate perfusion pressure to prevent secondary ischemic injury. 6, 1, 5
• Avoid hypotonic solutions such as Ringer's lactate if any concern for head trauma exists. 6, 1

Step 2: Rapid Source Identification

Perform FAST (Focused Assessment with Sonography for Trauma) immediately to identify intra-abdominal or pericardial bleeding. 1

• Obtain urgent CT imaging once hemodynamically stable enough for transport 1
• Do not transfer a patient who is actively bleeding and hypotensive without stabilization 1, 5
• Consider CT angiography if vascular injury suspected 1

Step 3: Vasopressor Consideration

If hypotension persists despite adequate fluid resuscitation, initiate vasopressor therapy (norepinephrine or metaraminol). 6, 1, 7

• Transient norepinephrine is recommended when systolic BP <80 mmHg persists despite fluid resuscitation to maintain life and tissue perfusion. 6
• Consider vasopressors earlier in alcohol-intoxicated patients because they have impaired endogenous catecholamine response. 2
• Place arterial line for accurate blood pressure monitoring and guide vasopressor titration. 1, 7

Step 4: Address Spinal Cord Injury Considerations

If neurogenic shock is confirmed:

• Maintain mean arterial pressure ≥85-90 mmHg for spinal cord perfusion 7
• Consider atropine if bradycardia is present (not mentioned in this case)
• Assess cardiac function before choosing between vasopressors and inotropes 7

Critical Pitfalls to Avoid

Do not delay fluid resuscitation while waiting for blood products in this hypotensive patient. 1, 5

Do not assume "normal" vital signs are reassuring in elderly or alcohol-intoxicated patients. 6 A 55-year-old may have baseline hypertension, making BP 80/50 represent severe hypotension. Additionally, alcohol intoxication masks the normal tachycardic response to hemorrhage. 2

Do not attribute hypotension solely to alcohol intoxication without excluding hemorrhage. 1, 4 This is a common and potentially fatal error in trauma management.

Recognize that alcohol intoxication increases mortality and morbidity through multiple mechanisms: impaired hemodynamic compensation, increased bleeding requirements, neutrophil dysfunction, and impaired host response to infection. 4, 2, 8

Obtain blood alcohol level on admission to guide resuscitation expectations, as intoxicated patients require more aggressive fluid and blood product administration. 2

Summary of Most Likely Mechanism

This patient's hypotension represents hemorrhagic shock (from occult thoracic, abdominal, or pelvic bleeding associated with the mechanism causing spinal cord injury), with impaired compensatory responses due to acute alcohol intoxication, potentially compounded by neurogenic shock from spinal cord injury. 1, 2 The alcohol intoxication has masked the typical tachycardic response and impaired catecholamine release, making the patient appear more hemodynamically stable than the actual degree of blood loss would suggest. 2