You are called to see a 49-year old female in the general surgical ward who has become profoundly hypotensive (75/40 on auscultation). She is now 5 days after palliative surgery for a perforated malignant gastric ulcer. She is barely rousable and the pulse oximeter saturation is 85% on face mask oxygen (10L/min).
(a) Please outline your initial management of this patient.
Obvious initial priorities are airway, breathing and circulation, but aware of the fact that there may be some limitations placed on the resuscitative efforts. If no formal documentation is immediately available, it is appropriate to aggressively resuscitate (as usual, without delay) until appropriate information is obtained.
Endotracheal intubation is almost certainly indicated (immediately if unable to protect airway, or after a short period of cardiovascular resuscitation). Rhythm assessment is required to rapidly exclude reversible rhythm disorder. Fluids should be administered (type and amount over time should be discussed), and a vasopressor (bolus ± infusion) may be appropriate when hypovolaemia has been excluded.
Major differential to be considered includes hypovolaemia and sepsis (abdominal, respiratory) but other causes must be considered (including pulmonary embolus, myocardial infarction, anaphylaxis, adrenal insufficiency etc.).
Early administration of broad spectrum antibiotics &/or corticosteroids should be considered.
...Should this patient even come to ICU?
Oh well, you can work that out after you have violently resuscitated her, amiright?
Initial assessment, with attention to ABCs with simultaneous brief history and rapid focused examination
1) Ensure personal safety
2) Perform a basic peri-arrest primary survey