The patient is hypotensive  is there Abnormal Vasodilation?

The first thing I do when asked to review a hypotensive patient, is run my hand along the patient’s skin peripherally: if they are freezing cold (“shut down”), the chances are that this is an appropriate compensation to hypovolemia or cardiac insufficiency. If the patient is red hot (“you could fry an egg on their skin”), then there is probably abnormal vasodilatation. There are essentially two different possibilities: anaphylaxis to a drug, and sepsis.

It is usually not difficult to separate the two. In anaphylaxis there is often an antecedent history of drug administration, angioedema, wheezing and a rash (all histamine related). In sepsis the mediator is inducible nitric oxide, the patient may well have a thermoregulatory abnormality, a leucocytosis (or leucopenia), and a source. Treatment is both cases is aggressive volume loading. The single biggest worry in anaphylaxis is loss of airway (bronchospasm and laryngeal edema): the treatment is epinephrine, 100μg doses repeatedly given intravenously, or 1mg given subcutaneously. In sepsis the treatment is fluids, fluids and more fluids, using the strategy described above. If vasopressor are required, then norepinephrine with or without dobutamine is indicated to optimize gut perfusion and myocardial function. Again, if in doubt, use what “God gave you” – epinephrine.

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