Case Study
A rapid response code was activated for a patient who developed decreased responsiveness along with tachycardia and hypotension. On arrival of the condition team, the patient was lying in bed, minimally responsive to painful stimuli. The patient was a 72-year-old female with a history of diabetes and coronary artery disease who was admitted to the hospital one day prior with unstable angina and was started on therapeutic dosing of enoxaparin (at 1 mg/kg twice a day). Her pain improved, and the plan was to continue her anticoagulation for a total of three days and to get a cardiac cath within one week in the outpatient setting. Overnight, the patient’s condition deteriorated, she became increasingly hypotensive, and the blood pressure had been unresponsive to 2 L of IV fluid boluses.
Vital Signs
Temperature: 98.9 °F, axillary
Blood Pressure: 80/50 mmHg
Heart Rate: 120 beats per min, sinus tachycardia on telemonitor
Respiratory Rate: 20 breaths per min
Pulse Oximetry: 99% oxygen saturation on room air
Focused Physical Examination
The patient was an elderly female who was poorly responsive to verbal stimuli, but was moving her extremities in response to pain. Her respiratory and cardiovascular examination was otherwise unremarkable. A neurological exam was non-focal. No apparent signs of overt bleeding were identified. No excessive or unusual bruising was visible. Her extremities were cool to touch, with distal pulses weakly palpable.
Interventions
A cardiac monitor and pacer pads were attached to the patient. Then, 1 L of IV fluid (Plasma-Lyte) bolus was initiated. Stat complete blood count (CBC) and lactate level were obtained. The patient’s blood pressure failed to respond to the rapid fluid bolus, and norepinephrine infusion was initiated. Her mean arterial pressure showed improvement with these measures. The patient’s mental status improved with improvement in blood pressure. CBC was reported in the meanwhile and showed a drop of 3 g/dL in her hemoglobin level. Type and screen were sent stat, and two units of packed red cells were ordered. Non-contrast computed tomography (CT) of the abdomen pelvis was ordered (results shown in Fig. 8.1 ). A CT angiogram was deferred at the time because of the patient’s tenuous hemodynamic status. The order for her next doses of enoxaparin was discontinued, and she was transferred to the intensive care unit (ICU) for further management of hemorrhagic shock due to retroperitoneal bleed.
Final Diagnosis
Hemorrhagic shock due to retroperitoneal bleed
Shock
Shock is a state of circulatory failure characterized by hypoxia at tissue and cellular levels because of reduced oxygen delivery, increased oxygen consumption, or inability to utilize the delivered oxygen adequately. Shock is classified into four etiologies based on the underlying pathophysiology: distributive, cardiogenic, hypovolemic, and obstructive . Undifferentiated shock is the presence of shock without a clearly defined underlying mechanism. This chapter will focus on the management of shock caused by reduced circulating volume, namely hypovolemic and distributive shock. Management of shock because of “pump failure” can be found in Chapter 12 .
Hypovolemic shock is caused purely by the loss of intravascular volume. In contrast, distributive shock is caused by a reduction in systemic vascular resistance leading to a drop in diastolic blood pressure and mean arterial pressure. The common etiologies of each are discussed in Table 8.1 .
| Category | Causes and Examples |
|---|---|
| Hypovolemic shock | Hemorrhagic causes
|
Non-hemorrhagic causes
| |
| Distributive shock | Infective causes
|
Non-infective causes
|
The signs and symptoms of hypovolemic and distributive shock can be similar; tachycardia, hypotension, and weak peripheral pulses are common to both types of shock. Hypovolemic shock is characterized by cool extremities and prolonged capillary refill. However, distributive shock is classically described as warm extremities with flushed skin.
A comprehensive history and physical examination are critical in the management of shock. For patients suspected of having hypovolemic shock, determining the source of volume loss is essential as management hinges on the replacement of volume and limiting/stopping volume loss. A history of recent trauma, surgery, or other interventional procedures should raise a flag for occult bleeding. Large volume upper and lower gastrointestinal (GI) bleeds usually manifest themselves; management of these specific etiologies can be found in Chapter 51, Chapter 52 . Patients with septic shock generally have a focus of infection that can be found through a detailed history, physical exam, and appropriate investigations. Patients with anaphylaxis typically have a history of exposure to an agent followed by abrupt precipitation of hypotension and shock.
The management of shock focuses on the restoration of adequate circulation. Volume replacement forms the basis of management. The choice of replacement fluid depends on the cause of hypovolemia and shock. In cases of non-hemorrhagic shock, crystalloid solutions can be used as the first-line resuscitation fluid. Crystalloids are preferred over colloid solutions. Among crystalloids, normal saline is the most used and the most inexpensive resuscitation fluid available. However, the use of normal saline for large volume resuscitation has been associated with hyperchloremic metabolic acidosis. Balanced fluids, such as Plasma-Lyte, are the preferred fluid of choice for large volume resuscitations. The composition of various intravenous fluids is given in Table 8.2 .
| Fluid | Sodium | Potassium | Chloride | Lactate |
|---|---|---|---|---|
| Plasma | 135-145 mEq/L | 3.5-5 mEq/L | 94-111 mEq/L | 1-2 mEq/L |
| Normal Saline (0.9% NS) | 154 mEq/L | – | 154 mEq/L | – |
| Lactated Ringer | 130 mEq/L | 4.0 mEq/L | 109 mEq/L | 28 mEq/L |
| Plasma-Lyte | 140 mEq/L | 5 mEq/L | 98 mEq/L | – |
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