Arrow to the Chest

A 33-year-old male was brought to the emergency department after a penetrating arrow injury to the chest. Initial evaluation revealed the arrow was penetrating the sternum, lung, and aortic arch. Because the patient was in a remote area, timely transfer to a specialized center for definitive operative repair was delayed approximately 24 hours. Treatment was focused on minimizing risk of hemorrhage with tight blood pressure control, while tube thoracostomy was deferred to avoid a change in intrathoracic pressure. The left-sided hemothorax was monitored with serial point-of-care ultrasounds. Ultimately he was successfully transferred and underwent successful surgical intervention.

Focal Weakness

The case illustrates how to approach the management of intracranial hemorrhage related to severe hypertension. Early recognition is the key initial step, which will mediate downstream management and help distinguish this entity from mimics such as ischemic cerebrovascular accident, encephalopathy, and hypoglycemia. Management of intracranial hypertensive hemorrhage is predicated upon tight blood pressure control, reducing intracranial pressure, and possible neurosurgical intervention. Prognosis is uniformly poor, even when recognized early. Key management issues include the consideration of hypoglycemia in the differential diagnosis, obtaining an emergent noncontrast head computer tomography scan in a patient with stroke-like symptoms, and rapid blood pressure management.