A 19-year-old female has been admitted to your ICU 12 hours after an isolated severe traumatic brain injury. She is intubated and mechanically ventilated with FiO2 = 0.3. Complete radiological imaging and clinical examination does not demonstrate any other injuries.

You have been called to review her as she is persistently hypotensive and has not responded to fluid therapy or vasopressor treatment. She is currently receiving 30 μg/min of noradrenaline and 15 μg/min of adrenaline.

Her vital signs are:

  • Heart rate 135 beats per minute, sinus rhythm
  • Blood pressure 70/35 mmHg
  • CVP 11 mmHg
  • SpO2 100%

Two images from the CT scan (CT scan A and B) of her head are shown.

(only one CT is supplied in this version of the question; it is not the original image from the paper)

What is the cause of her hypotension and how would you treat it?

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College Answer

Secondary adrenal insufficiency secondary to pituitary injury. Treatment is with IV hydrocortisone.

Discussion

The image above was once a normal CT brain. You would not believe the difficulty of finding a CT with a sella turcica fracture via Google Images. Thus, a normal CT brain image was acquired, and a sella turcica fracture was photoshopped into it. Trainees should be aware that this is a poor second to an actual CT image, and that the college tend to use real CT images. The original was omitted from the publicly available paper, presumably because the college plans to reuse it.

Anyway: pituitary trauma.

It happens.

And it is not always associated with grossly obvious sella turcica trauma.

The question is a short one, and as such does not merit an indepth answer (see the college model).

If one were interested in more detail about secondary adrenal insufficiency due to pituitary trauma, one could read this 2005 article from Critical care medicine.

Adrenal insufficiency in general is explored in greater depth elsewhere.

References

Kusanagi, Hiroaki, Kazunari Kogure, and Akira Teramoto. "Pituitary insufficiency after penetrating injury to the sella turcica." Journal of Nippon Medical School 67.2 (2000): 130-133.

Feiz-Erfan, Iman, et al. "Incidence and pattern of direct blunt neurovascular injury associated with trauma to the skull base." (2007). J. Neurosurg. / Volume 107 / August, 2007

Kelly, Daniel F., et al. "Hypopituitarism following traumatic brain injury and aneurysmal subarachnoid hemorrhage: a preliminary report." Journal of neurosurgery 93.5 (2000): 743-752.

Tanriverdi, Fatih, et al. "High risk of hypopituitarism after traumatic brain injury: a prospective investigation of anterior pituitary function in the acute phase and 12 months after trauma." The Journal of Clinical Endocrinology & Metabolism91.6 (2006): 2105-2111.

Benvenga, Salvatore, et al. "Hypopituitarism secondary to head trauma." The Journal of Clinical Endocrinology & Metabolism 85.4 (2000): 1353-1361.

Cohan, Pejman, et al. "Acute secondary adrenal insufficiency after traumatic brain injury: A prospective study*." Critical care medicine 33.10 (2005): 2358-2366.