05d Shock Discussion V1

By: Emergency Medicine

Hello. My name is Matt Strehlow from Stanford University. And in this case, we're going to be talking about a patient who presents in possible shock. And asking a few key questions on the evaluation and management of this patient.

Let's go ahead and get started. Pratt. I got a hypertensive patient here? 87 over 45. Alright. What's the patient-- Whoa. She runs low, always has. Why is it that you know that and don't? She's febrile too. 103.

Ok. Any vomiting? Any coughing? Just a little belly pain. I can see my doctor tomorrow when I get home. Where's home? Boston. We're here for her physics conference. [YELLING] We need some help here. Sam, a liter of saline, find her a monitored bed, and I'll be in as soon as I can.

Let me out of this thing right now. Can't you just give me an antibiotic or something? We've been waiting in triage nearly three hours. I know. I'm sorry. That's the way it goes around here. You know what? Let me see if there's an open bed. I'll be right back. So our patient, whose been waiting in the triage area for approximately three hours, comes in with mild abdominal pain.

05d Shock Discussion V1

And the nurse alerted the physician because the blood pressure was low at 87 over 45 and the temperature was high at 013 degrees Fahrenheit. The husband states that the patient, his wife, always runs a little bit low. However, the doctor then decides to tell the nurse to order an IV the fluid bolus. And the question is, what do you think of this order for an IV fluid bolus with this little information in this patient at this time? And if you were going to order IV fluids, what fluid order would you give? Our doctor ordered a 1 meter bolus.

Let's see what happens next. Anybody see our physicist in curtain three? Yeah. I got a slow down on SVT, but she's next for sure. Excuse me. We're still waiting for a doctor. I'm sorry. We're really busy? How you feeling? Run down.

I've been working my ass off for the last six months prepping for this conference. Six months? Try 20 years. You've been working on quantum processing your entire career. Quantum processing? Oh, a theory in physics, which says that an atom can exist in two places at the same time. And I showed that it can work in a larger matrix. I have no idea what you just said, but it sounds impressive. It pretty much blew the lid off the entire field. Well, I think what you've got is probably viral, but I'm going to send some blood tests to be safe.

So our patient tells us that she feels run down. So she still feels what we would describe as weak. She's gotten, if you look in the background, about 750 ml of IV fluids at this point. And her blood pressure, that you can see in the background, is 92 over 64. So asking ourselves a question about this patient, we've now given her 750 ml of a fluid bolus.

Her blood pressure now is above a systolic of 90. Would you give this patient further fluids? And if so, how much, and over what timeframe, would your order be? Additionally, as the nurse walks away, she states that she's going to order some lab tests. At this point with the patient, if you can see this patient and gathered this information, which lab tests and imaging would you order in this patient at this time? Alright. Let's see what happens next. Pratt. I need an antibiotic's order for a physicist in three. Micro called. She's got gram-positive cocci on stain.

That's probably just contaminated. She looks too good to be septic. Well, she's still febrile and tacky. I mean, how would you know how she looks? You haven't seen her since we brought her back an hour ago. Sam, I've got an obstructed newborn, a perfed ulcer on his sixth unit of blood, and my aphasic boxer just dropped his pressure in CT.

Give her 2 grams of ceftriaxone. And I'll see her as soon as I can, OK? So our patients Gram stain, which was sent by the nurse, has come back showing gram-positive cocci. The nurse then reports this to the physician. So we think that we have gram-positive cocci. The physician says that they believe this to be a contaminant.

The nurse then asks, says you haven't seen the patient for an hour. What should we do at this point? And the physician replies, well, let's give 2 grams of ceftriaxone, which is an antibiotic, and also says that he will come and see her very shortly. So what do you think of that order? And in a patient in septic shock, what is the appropriate timeframe from the time of recognition of the septic shock to the administration of the antibiotics? What' going on? Who are you? I'm Dr. Kevin Moretti. I'm the clinical director of the ICU. They were called down here because your wife's condition is deteriorating. Talk to me. Fever to 103.

Stain showed gram-positive cocci. Yeah. We thought it was a contaminant. Which is stupid. Katey set up for a subclavian. Prime the line, get a CVP monitor. Draw lactate now, you, and give me 6 units of packed blood cells standing by in the blood bank.

Who was the attending on this case? Me. Really? Well, you dropped the ball, didn't you? Excuse me. She's septic. It's obvious.

You should have anticipated this. She's young. She's healthy.

She had no reason to-- She doesn't need a reason. Breathe please. Katey, you see any signs of impending shock here? Tachycardia out of proportion with the fever, widening pulse pressures. See that? Even a medical student could see it coming from a mile away. Must be some new attending thing.

We'll take care of your wife, Sir. Don't worry about it. So the ICU physician comes down at the request of the nurse because the ER physician was too busy to see and evaluate the patient. The ICU physician then comes in and begins a series of orders, including saying that they wanted to set up for a CVP, or central venous pressure monitoring, and also to get a lactate test. And so in a patient with sepsis, what lactate level is a marker of severe sepsis versus a lactate level that would be reassuring or considered normal? Explain this again. I don't understand. My wife is healthy. Alright.

Calm down. Honey, it's okay. Now look, a bacteria could have seeded the blood stream through the lungs, a cut in the skin, her intestines. Second liter's in.

Goal-directed resuscitation for septic shock is so easy. It's so difficult for you ED types. She's in shock? Systolic is only 82. That would be a yes. The key is to preserve affected tissue perfusion while avoiding excessive myocardial oxygen consumption. Translation. Get oxygen to the body without stressing the hear.

We need CVP monitoring and continuous intravenous access to keep track of that. See that? He's learning already. That requires ICU level monitoring. We're too busy down here. We can't do that. Really? You can't? You can and you will, watch.

We don't have the nursing capacity. The patient's come in. We stabilize them. Then we send them up. That's how it works. Yeah. You forgot about that eight hours that they sit around in triage. And wait another five to get a bed.

Hey, look, it's not great, OK? But it's the reality. Reality is nothing more than a persistent illusion. Einstein said that. I'm physicist. Memorized everything that guy ever wrote. See that? Even more reason not to sit around and let your organs rot away like rancid meat.

Nobody's organs are rotting. Free air under the diaphragm. Probably a perfed diverticulum.

What's that mean? What that means is an infection in your intestines has eroded through the wall. We need to get in there, clean up, and repair the hole. Lucian.

Don't you get tired of ER docs waiting around for the surgeons to come down and save the day? Give them a break, Kevin. You know what it's like down here. I'm going to call the OR, tell them we're bringing her up. So the ICU physician has begun a series of interventions. In these interventions, focus around fluid resuscitation, and the patient now has gotten 2 liters of normal saline bolus, and has instituted, something they called early goal-directed therapy. And there's a discussion about whether early goal-directed therapy can be done in the emergency department. What are the indications according to the surviving sepsis campaign guidelines for early goal-directed therapy. And does this patient qualify? Why or why not? Well, let's see what happens to our patient.

They managed to repair her damaged intestine, but her blood pressure dropped very low. It will be a while before we know anything. Six hours ago she was giving a talk in front of hundreds of people. How did she end up here? Mmm, sometimes things just happen.

And there's really no way to make sense of it. She's not in pain? I'll make sure she has a morphine order. How is she doing? She still needs the dopa to keep her systolic above 85. And I think she's third spacing. She had a touch of DIC, last 2 liters in the OR.

So unfortunately, our patient's taken a turn for the worse after surgery. And the surgeon says that during the surgery, the patient lost a lot of blood and went into DIC. What changes in this patient's laboratory values would we expect to see because of her DIC, or disseminated intravascular coagulation status? Next, we have a 64-year-old presenting-- Pratt. We need a room. This is Alison MacKenzie, our septic with a bowel perf.

Lost a lot of blood. Having some ectopy, and didn't tolerate the trip down the hall too well. Tacky, on two pressors.

CVP is only six. Run of V-tach. Can I ask you a question? Why didn't you stabilize the patient in postop instead of bringing us this shocky, fragile mess? Well, she got 4 units of blood. Look, I'm not an idiot. I know about the postop audit that Dubenko's doing. He doesn't want this patient in his PACU because it will mess up his data. No, that's not what's happening here. He'd rather have her code and die in the ICU than on his watch.

Die? Yeah, well, we'll try to avoid that. You tell Lucien this can't happen again. You know, this wasn't his idea.

Yeah, right. You know, I thought she was ready to move. [BEEP ALARM] No pulse. Starting compression.

Oh, no. This can't be happening. Oh no, please. Charge to 200. Nice job, Neela. Let's just stay focused on the patient, shall we? Clear. Please help her.

Katey, someone on the phones says they've got to talk to you right now. It's an emergency. I'm in the middle of a code. No go. Just go. Just go. And there's a guy outside begging to come in to see this patient.

He's not family. He can't be here. You might want to rethink that. What? Look, your wife is doing everything she can not to die right now.

She could probably use all the support she could get. Epi's in. Ok.

Going again. Clear. [DEFIB PADDLES] So unfortunately this patient took an even more significant turn for the worse and had a cardiac arrest. Let's see what happens next. Well, her heart is beating in a normal rhythm, but her blood pressure is still dangerously low. Isn't there something you can do about that? We've maxed out on the medications.

They're not helping. It's possible that the part of her brain that controls the blood pressure isn't functioning properly. What? Why not? Because she received 45 minutes of CPR.

Her brain was deprived of oxygen during that time. And when that happens, we often see some degree of neurologic injury. She walked in here today with a stomach ache. And now you're telling me her brain is damaged. Look, I don't want to take away all hope. But I want to be realistic here.

If she survives, there most likely will be neurologic deficits. So our patient had 45 minutes of pulseless down time, or 45 minutes of cardiac arrest, but they were able to bring the patient back and get spontaneous circulation. Unfortunately, the physician is now telling the family, the husband, that even though this lady, this scientist, came in very healthy. At this point, they're worried that she might have neurologic dysfunction due to her prolonged infection, downtime, and cardiac arrest. So post her cardiac arrest, what would you, as the provider, shoot for as a goal temperature where you would want this patient's temperature to be? That concludes our Shock Case Discussion.

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