Hypotension

[DartmouthDave]

Hello,

What type of access dose this patient have for their hemo?

I know that Dopamine is the only option foe most services. But, a little fluid and a little Levophed would be useful in this situation.

I would like to give some pain control. But, I agree we need some more pressure first. If we get the pressure up perhaps some Fentanyl.

Cheers

[Jaymazing]

I'm sold now on the AAA.

STAT to hospital with appropriate surgical options (though the more I think about it, the less likely surgery is for this guy). Consult with OLMC for destination, possible flight options, or maybe blood.

I like the idea of pressors, shooting for a MAP of ~60. And ketamine sounds ideal, too, versus fentanyl.

Stop touching his abdomen; you're not likely to find a palpating mass in an obese guy. The "ripping" sensation has to be enough to make AAA your primary DDx, and if it ends up being something else, bonus!

Lets also make sure we're all clear on the DNR status of this gentlemen.

I'm with Mobey on prioritizing comfort measures like pain control; his survival chances are getting bleak, let's at least try our best to make sure he's not in complete agony.


Any luck with the pressors?

[Aussieaid]

If we are thinking ruptured AAA there is no indication for inotropes. You will actually make them bleed faster if you raise the BP. Ideally they should be given small boluses of fluid (~250 mls or so) to maintain cerebral perfusion if possible. You should not treat BP just to get a "normal" number. They accept SBP's of even 50-70 in a ruptured AAA pre surgery. The higher you raise the BP the faster they bleed out. Inotropes are not called for in any type of exsanguination as they just make the problem worse. You need to give fluids (preferably whole blood) just enough to keep them alive to get to surgery.

As much as I am an advocate for pain control, in this situation with his tenuous BP, pain relief is far down the list. The catecholamines circulating at the moment are probably all that is keeping this patient alive. Take them away with narcotics and you have a dead patient. His BP is also way too low to give any narcotics. You also want a good idea of his cerebral perfusion and don't want to confuse things with narcotics. If he is this shocky he won't be feeling as much pain right now in any case.

[DartmouthDave]

Hello,

This fellow has been feeling unwell for a couple of days. The three AAA I have seen in the field all had sudden onset pain followed by a rapid decline.

The rest have been post op AAA in an ICU. Not very helpful in this situation.

I was unaware only 1/3 of AAA have the classic presentation and the other 2/3 have a slower onset. I will have to read up on this some more.

The distended abd could be from the liver failure and acities.

Or, the distension could be from a AAA.

Looking back, it was noted that the patient was cool. So, lets try and warm him up and give warm fluids if possible. Hypothermia is the last thing we need.

I may be changing my tune here a go with a AAA.

Cheers

[ERDoc]

I'm too lazy to go back through the other pages, but what were the peripheral pulses like? How about the skin in the legs?

[fakingpatience]

Sorry for the long delay in the resolution of this case.

I ended up giving this patient 1 L of NS fluid on the way into the hospital, along with 100mcg fentanyl and 4mg zofran. He was much more comfortable with the pain medication. Stayed alert and oriented the entire ride, in fact joked with me "Its a good thing I'm talking to you, otherwise you wouldn't know if I'm alive!" when I was having trouble palpating a pulse. His blood pressure was 74/41 when we arrived at the hospital, so no significant change with the fluids. In hind site, I don't think I would have given him the L of NS, would have gone to a pressure much earlier.

Like many answers, a AAA was top of my list of differential diagnosis. However that was not the case. His abd was distended from ascities. Had 7L drained off in the ER, and they could have drained more, but his pressure kept tanking. Got put on a levaphed drip and antibiotics and admitted to ICU. I was told he was diagnosed with peritonitis and that his "levels" were off (sorry, don't have any specific values).

I am curious why some of you would have held off on giving fentanyl, I though it is safe for hypotensive patients as it does not vasodilate like morphine would.

[island emt]

Something about his presentation made me not sure of AAA diagnosis, & I'll admit I don't know what.

Maybe the chronic ETOH & liver failure along with dialysis tx regimen.

Seen this presentation before.

Fentanyl would have been my choice for pain.

[Kaisu]

I totally missed the impact of third spacing. The rales in the bases are now explained, Great post. Great first scenario. Thank you for the education.

[Aussieaid]

I'm positive the diagnosis was made AFTER the patient had a CT scan and labs done both of which we don't have the luxury of in the field. The first rule of medicine is "do no harm". You always rule out the diagnosis that is most life-threatening first and then work your way down the list. Yes, he had indicators of sepsis (or perforated bowel) and other possible diagnoses but the AAA diagnosis will kill the fastest especially if mistreated.

Since AAA was high on the list of diagnoses with his high risk factors (liver failure), hypotension, distended RIGID abdomen (not sure how you could palpate anything with that kind of abdomen) and description of the pain "ripping him in half and through to his back" then you can't rule it out. You don't want to do anything that could make him bleed out faster.

Since he remained A&O x 4 throughout, then not pouring fluids in or starting pressors was appropriate since he is obviously adjusted to low BP's and was still perfusing his brain.

I have seen too many incidents of people dropping their BP significantly with narcotics to risk it with that level of hypotension (with Fentanyl as well as Morphine). It's harder to get back a code than to prevent one from happening. I am a huge advocate of pain relief and if you gave fluids with no real success and he remained alert then I would trial small doses of narcotics, however he probably only didn't tank his BP because of the fluid boluses given as well. You had no BP readings along with no peripheral pulses so I would have been even more cautious about giving narcotics.

Once you rule out the AAA which couldn't be done until the ER, then it's appropriate to fluid resuscitate and add pressors and get his pain under control. Critical thinking is about keeping in mind all the most likely diagnoses and balancing the treatment so you don't make the patient worse by mistreating one possible diagnosis.

[systemet]

I think you tread gently here. The AAA is high on the list of differentials, and fluid resuscitation / 'trops / 'pressors are going to potentially worsen the situation. The patients requires assessment at a decent ER, and further diagnostics to guide treatment.

Expedite transport to an appropriate facility, gain redundant wide bore IV access; zofran is a great idea. Have some ketamine and succinylcholine drawn up in case he starts dying. Have the dope or (better yet) levo primed and ready to go. Have all the airway gear ready. Then drive fast, and cross your fingers.

Right now he's mentating. This might not, and probably won't last. But if we run around trying to arbitrarily normalise physiologic parameters without thought to the underlying cause, we're just going to make things worse, and expose the patient to a whole lot of risk for a poorly defined and arbitrary perceived benefit.

Just an opinion. Obviously, if we feel the AAA is unlikely and the most likely primary cause is sepsis, then the treatment plan changes.

Small aliquots of fentanyl are ok-ish. There's a risk of bringing down a sympathetically-driven pressure. Maybe even 25 ug is a reasonable idea, as the patient's likely vasoconstricted, and preferentially shunting their perfusion to the CNS. There's good arguments for ketamine, but my concern would be that right now, you know there's some degree of CNS perfusion, because he's GCS 15 -- but make him altered, and it's going to be hard to gauge that.

Edited May 20, 2013 by systemet