The drowning victim is admitted to the intensive care unit (ICU) after being without oxygen for 10 minutes. When he was found, he did not have a pulse and was resuscitated at the site. Once return of spontaneous circulation (ROSC) occurred, he was transported to the hospital. He was found to be profoundly hypotensive and was fluid resuscitated in the ambulance. In the ICU, his Glasgow coma score is found to be 7. He is intubated and has a central line and a peripheral arterial catheter in place. Which constellation of symptoms concern the nurse the most?

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Hypothermia, systolic hypertension, diastolic hypotension, bradycardia. The patient was initially anoxic; after ROSC, the patient&rsquo;s profound hypotension likely caused brain ischemia. Reperfusion leads to cerebral edema and life-threatening elevated intracranial pressure. The Cushing&rsquo;s Triad, which signifies impending herniation of the brain out of the foramen magnum, is a widened pulse pressure (systemic hypertension and diastolic hypotension) and bradycardia. Brainstem herniation causes irreversible brain damage and is the most concerning complication of the event. The hypothermia is incidental and could be related to the drowning. Systolic hypotension/hypertension, diastolic hypotension, and tachycardia are consistent with impending heart failure and shock. These symptoms are certainly concerning but can be medically managed and do not involve irreversible brain damage. A narrowed pulse pressure, as evidenced by systolic hypotension and diastolic hypotension, may be indicative of hypovolemic shock due to blood loss. However, bradycardia does not fit with this picture; this is an unlikely symptom combination.

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