hi scripty! so my main character was kidnapped + before she escaped, she was choked, punched in the face, pushed down a flight of stairs + shot in the stomach. right now i have her in ICU bc of hypovolemic shock but to make things really interesting + emotional, i need her to be unconscious/otherwise unresponsive for like 1.5 days. i liked the idea of sedation w propofol, espec bc at one point her bp/heart rate drop suddenly and they fear she wont make it + i believe i read somewhere (1)
(2) propofol can do that? i probably sound really dumb but i just want to make this is as realistic as possible so i wanted to ask you. she didn’t hit her head when she fell so no concussion. i know this is fiction but i just want to know if this is reasonable/logical/possible, i guess. also i know she won’t be wide awake and coherent when she wakes up but would she be completely out of it/loopy or just groggy? thanks and sorry if this doesn’t make any sense would she be able to breathe on her own for the most part or would she have to be placed on a ventilator? thanks and sorry again!! 😭
Hey there nonny! ER & ICU medicine is one of my wheelhouses, so let’s take a look at all of this!
So first things first: you seem to have bypassed a super important part of this character’s medical journey.
This gunshot. In the belly. This is an Un-Goodness. Hypovolemic shock is going to be from internal bleeding, which means something in there got hit. The liver and the spleen both bleed like hell from puncture wounds.
She’s going to need surgery.
So here’s the thing: your character is going to have abdominal surgery once she gets to the ER. She’ll be evaluated, she’ll probably have a blood transfusion begun in the ER, and she’ll be sent into surgery to control the bleeding, repair the damage, and generally find out what happened. (Even with great imaging it can be impossible to tell what exactly was damaged internally; generally speaking, penetrating abdominal trauma requires surgery to check on things.)
After surgery she’ll be admitted to the ICU, where they’ll monitor her heart rate, blood pressure, blood oxygen levels, and more.
Now, she should be pretty zonked, from the head injury, from the surgery, from the pain meds. So her not really being awake for the first day and a half or so after all of this is mostly believable, especially if she’s got a good nurse defending her from others who want to wake her up.
Whether or not she’d be sedated is a whole other story, and honestly…
I don’t think she’d be sedated during her hospital stay, much less put on propofol (outside the OR, anyway).
She’s got no head injury and no reason to go on a ventilator. She’ll be in pain from her wound, for sure, and from the surgery. But this will be managed by IV pain medication, such as IV morphine, hydromorphone/Dilaudid, or fentanyl (most likely in a trauma patient). This can make her super groggy without “sedating” her.
(There is a special place in hell for ICUs that consider pain meds like fentanyl to be sedatives and to use them as such, but that’s another rant entirely.)
During the surgery she would be anesthetized, and it might be with propofol (though for bleeding and serious trauma, I would think something that uses less propofol, such as propofol/ketamine AKA ketafol), or no propofol at all, such as a combination of fentanyl and midazolam and/or ketamine, would be more likely.
But the point is, outside the OR, she likely won’t be sedated, unless she needs to stay on the ventilator.
You want her blood pressure to drop and for her to nearly die again?
Very simple: have an internal stitch rip when she shifts. She starts bleeding again internally and gets taken back into the OR for more surgery to repair the bleeding. (This also gives you lovely hours of your supporting characters waiting to find out whether she lives or dies.) This adds the drama of MOAR SURGERY, a longer period of uncertainty, and physical separation of the other characters.
Now: As To Your Propofol Question
Let’s throw reality out the window, or change the situation to one where she needs a ventilator. Why? Because we can. (We could even make her need a ventilator in your scenario, with a complication from multiple transfusions known as Transfusion Related Acute Lung Injury, or TRALI, which is essentially the lungs reacting badly to Way Too Much Foreign Blood and causing a lot of edema, i.e. fluid, i.e. drowning. This results in a longer ICU stay, though.)
So let’s assume she’s on the vent, and to keep her on the vent, she’s been sedated.
Yes, propofol causes hypotension. It is legendary for causing hypotension. But intensivists and anesthetists are well aware that it has that property, and there are a few workarounds they would tend to use to counterbalance that tendency.
1) Use a different sedative. Propofol and Versed/midazolam are both great sedatives, but if pressure is a concern, they may opt for another kind of sedation. They might use something like Precedex/dexmedetomidine, which doesn’t depress blood pressure. (In some cases, they might be put on a drip of – you knew this was coming! – ketamine. I’ve seen a switch from propofol to ketamine bump a patient’s blood pressure by 30 points.)
1a: Switch her off of propofol when her pressure drops. Either let her wake up a bit or put her on a different medication.
2) Compensate with pressors. Pressors are medications that raise blood pressure, such as Levophed / norepinehprine, which squeezes the blood vessels.
Critically ill patients are often in a delicate balance between propofol and Levophed. They need the propofol to stay down and they need the Levophed to keep their pressure up. Again, this is a very common practice in the ICU.
3) Add More Fluids. Fluids, such as normal saline or Ringer’s Lactate, will help… a bit. Temporarily. It’s a short-term fix, for a lot of reasons. But mostly because they don’t stay in the bloodstream for a long time (1/3 of the volume is lost into the interstitium in the first 3 hours), and they can cause electrolyte imbalances.
4) Add More Blood Products. There are two products in particular I’m thinking of. Red blood cells (PRBCs) improve oxygen carrying capacity of the blood – making the character less “shocky” – and also improve blood pressure. And albumin helps raise pressures by essentially making the blood a bit thicker and thus pulling in fluid from the surrounding tissues, because the physics of fluids are kind of neat.
But really, the number one reason for your character to have their blood pressure drop is to have their bleeding start again, and have them go back into the operating room.
One Other Reason Her Blood Pressure Could Fall
Sepsis. Sepsis is one of the Big Fears in abdominal trauma because the GI tract is full of bacteria, and bacteremia (bacteria in the blood) can trigger sepsis. Check out [the sepsis tag] for more!
Phew! I hope this has helped!
This is kind of a long and rambly post, so let me know if anything needs clarified.
Thanks for your ask and I hope this helped!
xoxo, Aunt Scripty
[disclaimer]
[Maim Your Characters: How Injuries Work in Fiction is out and can be yours! If you like books on writing and books about medicine (without all the jargon), check it out!]
