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.

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College Answer

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.

Discussion

...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

  • Immediate assessment to diagnose cardiac arrest
    • Are they awake?
    • If they appear unconscious, shake them and ask "Are you alright?"
    • If they are unresponsive, look listen and feel for respiratory effort.
    • If the patient is unconscious, unresponsive, and is not breathing, call for help and start CPR.
      Otherwise, move on with the structured approach to prevent cardiac arrest
  • Airway:
    • Assess patency: best done by interrogating the patient. If he provides coherent answers to your questions, his ABCs are unlikely to be desperately compromised. If he does not, one should secure his airway - initially usig unsophisticated techniques (jaw thrush, chin lift), progressing through airway adjuncts to intubation as needed.
    • Look for presence of vomit or foreign body
    • Prepare to progress to intubation
  • Breathing
    • Observe respiratory rate
    • maintain oxygenationintially with high flow oxygen via tight-fitting reservoir mask. A high flow nonrebreather mask not only delivers around 75% FiO2, it also allows one to assess respiratory function by observing the expiratory fogging of the clear plastic, and one can hook up an end-tidal capnometer to it to detect expired CO2.
    • progress to bag-mask ventilation if respiratory arrest occurs
    • Auscultate the chest, percuss it, palpate for surgical emphysema
    • Investigate with ABG and urgent CXR
    • Specific differentials to consider before moving on with the survey:
      • Massive PE (distended neck veins, cyanosis, tachycardia and hypotension)
      • Acute severe asthma (silent hyperexpanded chest, the hint of wheeze)
      • Tension pneumothorax (unequal air entry, deviated trachea, hyper-resonant chest)
      • Massive haemothorax or effusion (unequal air entry, deviated trachea, dull percussion note over the hemithorax)
      • Pulmonary oedema (pink frothy sputum, coarse gurling creps)
  • Circulation
    • Ensure large-bore IV access
    • Measure the blood pressure non-invasively and attach ECG leads for monitoring
    • administer IV fluids as bolus
    • administer readily available vasopressors, eg. metaraminol in order to maintain cerebral perfusion
    • assess for sources of bleeding
    • ABG or FBC to assess Hb, and need for transfusion
    • rapid bedside TTE to assess cardiac chamber volume and contractility
    • Specific differentials to consider before moving on with the survey:
      • Extremes of hypovolemia (collapsed veins, empty chambers, slow capillary refill, dry mucosae, cool extremities, weak rapid pulse)
      • Haemorrhagic shock ( exactly as above but also deathly pallor)
      • Cardiac tamponade (distended neck veins, muffled heart sounds, electrical alternans on ECG)
      • Peri-arrest arrhythmia (eg. VT or SVT)
      • Severe sepsis (mottled skin, fever, hyperdynamic circulation with hypotension)
    • A fluid bolus would be an appropriate reaction in any case. A hand-operated pump giving set with a litre of crystalloid should be set up. Ideally, one should prepare for invasive arterial blood pressure monitoring.
  • Disability/neurology
    • Assess for signs of intracranial catastrophe by performing a brief neurological examination, including pupils and muscle tone/reflexes
    • Test BSL: ensure normoglycaemia
    • Specific differentials to consider before moving on with the survey:
      • Intracranial catastrophe (pupils, focal signs)
      • Seizure (increased tone, exaggerated reflexes, gaze deviation, clonus)
      • Extreme hypoglycaemia
      • Hyperglycaemic coma
      • Extremes of electrolyte derangement (eg. a sodium of 90 or 190)
      • Hepatic encephalopathy
  • Exposure/examination
    • Assess for sources of bleeding
    • Examine for features of anaphylaxis
    • Check temperature; ensure normothermia