Download Approach to the Hypotensive Patient

MKSAP Questions
Intern Report
General Internal Medicine – Question 72

A 47 y/o man is evaluated for right lateral shoulder pain. He has been pitching
during batting practice for his son’s little league baseball team for the past 2
months. He has shoulder pain when lifting his arm overhead and also when lying
on the shoulder while sleeping. Acetaminophen has not been helpful. On physical
exam, he has no shoulder deformities or swelling. Range of motion is normal. He
has subacromial tenderness to palpation, with shoulder pain elicited at 60 degrees
of passive abduction. He also has pain with resisted midarc abduction but no pain
with resisted elbow flexion or forearm supination. He is able to smoothly lower his
right arm from a fully abducted position, and his arm strength for abduction and
external rotation against resistance is normal.
 Which of the following is the most likely diagnosis in this patient?
A. Adhesive capsulitis
B. Bicipital tendonitis
C. Glenohumeral arthritis
D. Rotator cuff tear
E. Rotator cuff tendonitis
General Internal Medicine – Question 72

E. Rotator cuff tendonitis
•
inflammation of the supraspinatus and/or infraspinatus tendon that can also involve the
subacromial bursa, common overuse injury
– subacromial tenderness and impingement
– Pain occurs with overhead reaching and when lying on the side
– The passive painful-arc maneuver assesses the degree of impingement
– Pain with resisted midarc abduction is a specific finding for rotator cuff tendonitis
– Appropriate treatments include NSAIDs, ice, and exercise
• Adhesive capsulitis (frozen shoulder): decreased range of shoulder motion resulting
from stiffness rather than from pain or weakness
• Bicipital tendonitis: overuse injury, tender bicipital groove, and anterior shoulder pain
is elicited with resisted forearm supination or elbow flexion
• Glenohumeral arthritis: related to trauma and the gradual onset of pain and stiffness
over months
• Torn rotator cuff: arm weakness, particularly with abduction and/or external rotation
– A positive drop-arm test is a very specific but relatively insensitive method for
diagnosing rotator cuff tear
Approach to the Hypotensive
Patient
Etiologies of Shock
Hypovolemic
Cardiogenic
Distributive
Obstructive
Combined
“A significant reduction in tissue perfusion,
Resulting in poor oxygen delivery to these tissues”
SHOCK Physiology
Physiologic
Variable
Preload
Contractility
Afterload
Tissue
Perfusion
Clinical
PCWP
CI/CO
SVR
MV02
Hypovolemic




Distributive




Cardiogenic




Obstructive




COMBINED SHOCK PROBABLY MOST COMMON
SHOCK Management-Basics
Increase preload
Increase contractility
Increase/decrease afterload
Increase oxygen delivery
Oxygen Delivery= CO X ((1.34 x hemoglobin
concentration x SaO2) + (0.0031 x PaO2))
Initial Evaluation
 What are the vital signs?
 Check BP in both arms
 Is the patient mentating well or confused?
 What has their urine output been?
 What is the BP trend?
 Reason for admission?
 Do they have IV access?
 Does the patient look well?
Initial Evaluation-History
History: rarely useful in the acute setting
 Food/medicine allergies
 Medication changes
 Immunosupressed states
 Hypercoagulable conditions
 Prexisting illnesses
 Recent procedures
Initial Evaluation - Physical Exam
 Evidence of:







Intravascular volume depletion
Obstructive symptoms (RV heave, pulsus paradox)
Irregular rhythm, murmurs, rubs, gallops
Peritoneal signs, ascites
Peripheral vasodilation (hyperemic skin)
Peripheral vasoconstriction (cold, clammy skin)
Decreased breath sounds
While your neurons are firing…
Get appropriate IV access
 Large bore IV vs. Central access
Crash cart close by with:
 Levophed (Norepinephrine)
 Dopamine
 Vasopressin
 Atropine
 Amiodarone/BB
How do we investigate this?
 All must be sent STAT
 CBC, Coag panel - evidence of blood loss
 BMP - evidence of lactic acidosis from tissue
hypoperfusion
 Troponins
 ECG
 Echo - evidence of pump failure, RV dysfunction,
pericardial tamponade
Case 1
JB is a 75 y.o WM with hx of CAD, DM2,
HTN admitted for chest pain/ischemic
evaluation
 Initial ECG shows sinus bradycardia with
1st deg AVB (PR=200msec), no ST/TW∆es
 Beta blocker held, receives ASA/Lovenox
 HD # 1, nurse calls you with BP of 68/44
This is not what I signed up for!!
Patient is oriented but lethargic
Repeat BP is 65/42, HR 45 bpm
Exam: no JVD, intravasc vol. depletion,
obstructive sx
IVF NS: wide-open
Tele Review: sinus pauses 4 sec
What is the diagnosis?
COMPLETE HEART BLOCK
To Pace Or Not..
Atropine 1 mg IV given
 HR increased to 65, BP increased to 85/55
Place TLC catheter
Pacing pads applied
 Transcutaneous pacing at 65 bpm
Transfer to CCU
Dopamine
Complete Heart Block - Summary
 Assess hemodynamics
 Look at escape rhythm
 Width of the QRS complex predicts location in AV node and
response to atropine
 Narrow = higher location, better response to atropine
 Evaluate for ischemia-usually vagal mediated
 Anterior MI
 Inferior MI
 Are there any reversible etiologies such as medications,
electrolytes, etc.
Case 2
 A.B is a 67 y.o AAM with hx of CKD, CHF,
HTN, COPD admitted for cough, fevers
 CXR c/w LL PNA, initials vitals stable
 Treated with Rocephin + Azithro
 Sputum/blood cx pending
 On HD # 3, while on rounds, you notice
patient to be somnolent and confused
Should I run away now?
 STAT Vitals
 BP 85/50. HR 115. O2 sat = 89% RA
 Review of previous vitals show BP decreasing
gradually during past 12 hours
 Fever up to 103.1 F o/n
 Exam c/w decrease BS at R base, warm
hyperemic peripheral extremities
 ECG: Sinus tachy. No ST/TW changes
WHAT IS THE LIKELY DIAGNOSIS?
SEPSIS/SIRS
Management
 IVF NS (wide-open) with TLC in place
 Repeat BP in 10 min:
 BP 75/60 after 1 liter NS, more lethargic
 Start pressors:
 Levophed (Norepinephrine) - increase SVR
 Let nursing staff know of likely ICU transfer
 Repeat BP on pressors
 BP 90/55, 85/55, 93/60
 Send blood and urine cultures
 Send STAT labs including ABG, CBC, BMP, coag panel
Which Antibiotics?
Broaden coverage to include
Pseudomonas, MRSA
 CTX:Cefepime :: GNB:GNB+Ps
 Unasyn:Zosyn :: GP/An/GN:GP/An/GN + Ps
 So…start with Vanc and Cefepime
(Vancopime)
Transfer to MICU
Sepsis Protocol
 Applicable to ICU patients
 Goal directed resuscitation
 IVF guided by CVP – at least up to 10 mmHg
 Assess MAP – 65 mmHg
 Pressor support – usually levophed
 Vasopressin useful in profound acidemia
 Avoid dopamine in excessive tachy states
 Assess perfusion – Mixed Venous SV02 (70%)
 Transfusion of pRBCS to Hct >30%
 Addition of inotropic support (dobutamine)
Read Early goal directed therapy or Sepsis guidelines
Prior to MICU
Case 3
J.R. is a 45 y.o. WM with hx of Crohns,
being treated with TNF- therapy, and
prednisone
Admitted for increased N/V/D for 1 week
No infectious precipitant identified
You go the ER to see him and you note
that his BP is 65/40, HR 115
 He is mentating well though
Evaluation
Exam c/w dry mucous membranes,
decreased skin turgor
Repeat BP shows the same value
What should you do?
Fluids….fluids…fluids..
 IVF NS: Aggressive rescucitation
 Pan-culture (risk of infection is high 2/2
concurrent immunosuprressive therapy)
 Ask about history of glucocorticoid tx
 Check for adrenal insufficiency
 Dosing stress-dose steroids:
 Hydrocortisone 100 mg IV q6h OR
 Dexamethasone 4 mg IV q6h – does not affect cortisol
assay
Case 4
 D.F is a 54 y.o. WF with history of
scleroderma, and secondary pulmonary
hypertension, admitted for worsening ascites
 Being treated with diuretics and antibiotics for
SBP
 On HD#4, nurse calls stating:
 “BP is 80/55, and she is complaining of chest pain
and her breathing has become more labored”
Based on this…
What is the most likely diagnosis?
Pulmonary Embolism
What next?
 Vitals are same on repeat
 Exam c/w incr JVP, RV heave, mild facial
plethora
 IVF/Access established
 Heparin gtt initiated for suspecting PE
 Repeat BP in 10 minutes - still 80/50
Transfer To ICU
 Is it ever “too much” fluid during resuscitation?
 Concept of LV/RV interdependence
 Pressor support
 Which one?
 Levophed preferred - less likely to cause tachy
 Dopamine - easily available
 Dobutamine – NOT A PRESSOR
 Can consider using thrombolytics in this case for
refractory:
 Hypoxemia
 Hypotension
Case #5
P.W. 52 y/o AAF with pmh of ICM here
with dyspnea and presumed HF
exacerbation.
Called for “altered mental status” HD#2
BP 106/74, HR 120, RR 30
Pt lethargic on exam
What do you want to look for?
Case #5
Exam
 Cool, dry extremities
 Sinus tach
 500ml in last 24hrs—depsite IV lasix
Labs
 AST/ALT 800/900
 Lactate 3.0
 Cr up to 3.0
Based on this…
What is the most likely diagnosis?
Cardiogenic Shock
Now what….
IV access, airway, crash cart and
oxygen.
Assess for ischemia
Dobutamine 2.5mcg
CCU and PA catheter
Calcium IV if hypocalcemic
Pressors if need be
Cardiogenic Shock
SHOCK MI
 Early, open artery
Assess for end organ perfusion
 BP not good enough
Mechanical Support
 IABP, Tandem heart, impella, LVAD
Mortality is high
 50-80% in hospital mortality
Summary Points: Hypotension
 Assess patient’s mental  Are you covering your
status/rapidity of onset
bases – 5A’s
 Is it one of these:
Arterial Support
Cardiogenic
Antibiotics
Distributive
Antithrombotics
Hypovolumic
Anticoagulants
Obstructive
Adrenal Support
 Make sure you have
adequate access
 Do you need other
 Make sure you have
studies urgently:
recent labs checked
Echo
 Keep a close eye on
CT Abd/Chest
their respiratory status