Paradoxical bradycardia and hemorrhagic shock

Abstract

Hypotension, poor peripheral perfusion, and tachycardia are the most common presenting signs of hemorrhagic shock. Many patients fail to show initial signs of tachycardia and paradoxically present with bradycardia. An 81-year-old man presenting with lower gastrointestinal bleed showed initial vital signs significant for tachycardia and normal blood pressure. After resuscitation with fluids and blood products, his heart rate stabilized to between 64 and 86 bpm. It later dropped to 30 bpm, which improved after administration of atropine. The patient soon experienced two episodes of hematochezia. The paradoxical bradycardia proved to be a false reassurance that the hemorrhage had resolved. Identification of paradoxical bradycardia is important in suspecting ongoing gastrointestinal hemorrhage.

Keywords: Bradycardia; hemorrhagic shock; paradoxical bradycardia; relative bradycardia.

Figure 1.

Hemoglobin vs systolic blood pressure and heart rate. The first arrow indicates initial blood transfusion on presentation. The second arrow indicates the time of the second bleeding event, with blood transfusion administered shortly after. Times are approximate.