Shock Solution 3

      
   

 

      
     

Clinical Scenario 3

A 79 year old female presents with central abdominal pain radiating through to the back. Background history of hypertension, treated with nifedipne 20 mg bid and enalapril 10 mg daily. She is cold and clammy. ECG normal. Pulse 100. Blood Pressure 100/60. Femoral pulses impalpable. Catheterized: only 10 ml of urine in the bladder. Hemoglobin 6.0.

 

  • Is this genuine hypotension? Yes

  • Is the heart rate appropriate for the blood pressure? Yes

  • What is the patient’s volume status (cardiac filling)? -> Low: hypovolemic shock

  • Does the heart contract normally? Unknown

  • Is the patient abnormally vasodilated? No

 		        
      Solution 3        
     

This woman is in hypovolemic shock, secondary to hemorrhage, in addition there is relative hypotension (this patient is normally hypertensive). Low cardiac output, high peripheral resistance.

Ensure a patent airway and adequate ventilation and administer oxygen. Large bore i.v. access is obtained: this patient requires urgent surgery (leaking abdominal aortic aneurysm). Perioperative management involves aggressive volume loading (preferably after application of an aortic cross-clamp).

The same patient undergoes surgery. On day 3 you are called to review her in the ICU. Her urinary output has been less than 30 ml/hr for the last 6 hours. Her creatinine today is 2.7 (yesterday it was 1.9, and the previous day it was 0.8). Her blood pressure is 90/40. You prescribe 500 ml of hydroxyethyl starch. Two hours later you are called because this has had no response. The nurse suggests renal dose dopamine.

What do you think? How would you treat this?