Shock Solution 7

Clinical Scenario 7

A 42 year old female is transferred from another hospital for chemotherapy. Two days prior to transfer the patient had undergone a laparotomy for a hysterectomy. The procedure was abandoned when the surgeon realized that there was an inoperable tumor present in the pelvis, and there was a considerable amount of blood loss, which continued into the post-operative period.

Hours after transfer the patient becomes initially hypoxemic and subsequently hypotensive. Her temperature is 37 degrees Celsius, her heart rate is 140, blood pressure is 80/36, ECG shows a sinus tachycardia, SpO2 is 79%. The patient’s hemoglobin is 10.2g/l, and creatinine is 1.4.

What is your differential diagnosis, and how would you manage this patient?

This patient has an appropriate heart rate response to hypotension. The differential diagnosis is between hypovolemia due to continued blood loss (unlikely with a normal range hemoglobin), cardiac inflow or outflow obstruction and septic shock. The history of hypoxemia preceding hypotension is suggestive of a cardiorespiratoty problem. Initial oxygen therapy and airway control is followed by aggressive volume loading. There is no evidence of a myocardial problem, and given the history of pelvic surgery and surgery, cardiac inflow-outflow obstruction due to pulmonary embolism is the most likely scenario. This diagnosis needs confirmation – echocardiography (if not stable enough to travel) or, ideally a spiral CT scan or pulmonary angiogram. If this is a pulmonary embolism, anticoagulation, thrombolysis or pulmonary embolectomy is required.

Echocardiogram shows a hyperdynamic heart and an empty left ventricle, consistent with inflow obstruction. The patient remained hypotensive and hypoxemic, and the decision was taken to proceed with thrombolysis, with good results.

Dx: cardiogenic shock, outflow obstruction, pulmonary embolism.