Hypotension case 5

Hypotension case 5


A 45-year-man was brought in by paramedics for vomiting blood. He was not responding to the questions by the medical staff. The patient had a heavy odor of alcohol on his breath. On examination, his temperature is 37.7 C (99.8 F), blood pressure is 75/35 mm Hg, and pulse is
120/min. There is blood crusting around the patient's mouth and he is only oriented to person, but not place or time. His neck veins are flattened, and his heart examination shows tachycardia without any murmurs. His lung and abdomen examinations are not significant. Rectal
examination is guaiac negative. No peripheral edema is seen. A nasogastric tube is placed and about 1.5 Iiter of normal saline is used until the nasogastric lavage is clear of blood. Laboratory results show:

Sodium 143 mEq/L
Potassium 4.3 mEq/L
Chloride 96 mEq/L
Bicarbonate 19 mEq/L
BUN 36 mg/dL
Creatinine 1.3 mg/dL
GIucose 89 mg/dL

A complete blood count (CBC) and a chest x-ray film are pending. His ECG shows normal sinus rhythm at 117/min, and no other changes.

Q 1
Which of the following is the most likely diagnosis?
/ A. Adrenal insufficiency
/ B. AIcohol withdrawal
/ C. Cardiogenic shock
/ D. Hypovolemic shock
/ E. Septic shock

Q 2
Which of the following would rule out shock?
/ A. AItered mental status
/ B. Cold extremities
/ C. Low systolic pressure
/ D. Metabolic acidosis
/ E. Urine output > 40 cc/hr

Q 3
Which of the following is the most appropriate initial therapy?
/ A. Dopamine
/ B. Hydrocortisone
/ C. IV FIuids
/ D. Nitroglycerin
/ E. Norepinephrine

Q 4
Which of the following is the patient's mean arterial pressure?
/ A. 35
/ B. 40
/ C. 48
/ D. 60
/ E. 75

Q 5
Which of the following would most likely represent this patient's pulmonary artery catheterization (Swan-Ganz) values?
/ A. A
/ B. B
/ C. C
/ D. D
/ E. E

Q 6
Which of the following is the best treatment for Patient C in the chart above?
/ A. Dopamine
/ B. Hydrocortisone
/ C. IV FIuids
/ D. Nitroglycerin
/ E. Norepinephrine


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Hypotension case 5 answers

A1
The correct answer is D. The patient is suffering from hypovolemic shock secondarily from an upper GI bleed.
Adrenal insufficiency (choice A) can present with severe hypotension in the setting of a patient who stopped taking his chronic steroid dosage. It can occur after severe stress, trauma, or infections. It is often associated with hyponatremia and hyperkalemia.
Alcohol withdrawal (choice B) should be considered in the management of this patient; he may go into delirium tremens (DTs) in the next 24-48 hours.
Cardiogenic shock (choice C) is suggested by symptoms of heart failure, e.g., bulging neck veins and crackles on lung examination. There may be some old or acute changes on the ECG.
Septic shock (choice E) can be a possibility for investigation if the patient does not respond to fluids/blood products.


A2
The correct answer is E. Patients in shock tend to be oliguric (urine output < 20 cc/hr).
Patients in shock can have altered mental status (choice A), cold and clammy extremities from peripheral vasoconstriction (choice B), low systolic pressure (choice C), and metabolic acidosis (choice D) from the buildup of the serum lactate from anaerobic metabolism.


A3
The correct answer is C. IV fluids are the first and foremost important intervention for hypovolemia; whole blood products would be the next step for hypovolemic shock from hemorrhage.
Dopamine (choice A) is used in patients with cardiogenic shock or pump failure.
Hydrocortisone (choice B) is necessary, in addition to fluids, for patients with suspected adrenal insufficiency.
Nitroglycerin (choice D) is used to relieve chest pain, and may be used in hypertensive crises and urgencies.
Norepinephrine (choice E) has alpha adrenergic/vasoconstricting properties used in septic shock in which the SVR (systemic vascular resistance) is low.

A4
The correct answer is C. The mean arterial pressure (MAP) estimates the perfusion of the body and brain; a pressure > 60 (choice D) ensures sufficient perfusion. It is measured by 2/3 diastolic + 1/3 systolic pressure = 2/3 (35) + 1/3 (75) = 70/3 + 25 = 48.3 The normal ranges are 75 to 110.
Choice A is the diastolic blood pressure.
Choice B is the pulse pressure = systolic bp-diastolic bp.
Choice E is the systolic blood pressure.


A5
The correct answer is B. Hypovolemic shock is characterized by a low wedge pressure (PCWP) because of low LV preload/filling leading to low stroke volume, leading to low cardiac output (CO), leading to high systemic vascular resistance (SVR).
Patient A has normal pulmonary artery catheterization values: normal PCWP (12-15 mm Hg), CO (3.5-5.5 L/min), and SVR (800-1200 dyne/sec/cm2).
Patient C is in cardiogenic shock; the hallmark is low CO, leading to high PCWP (pump backs up) and high SVR.
Patient D has septic shock with the distinguishing low SVR, leading to low PCWP, leading to high CO for compensation.
Patient E has obstructive shock (from massive pulmonary embolus/tension pneumothorax) with low filling pressure, leading to low wedge pressure, leading to low CO, leading to high SVR as compensation.

A6
The correct answer is A. Patient C has cardiogenic shock, and therefore dopamine would be appropriate to increase pump activity.
Hydrocortisone (choice B) is used in patients with adrenal insufficiency.
IV fluids (choice C) would cause even further cardiac pump failure.
Nitroglycerin (choice D) is used to relieve chest pain, and may be used in hypertensive crises and urgencies.
Norepinephrine (choice E) has alpha adrenergic/vasoconstricting properties, and is used in septic shock in which the SVR is low.