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).

(b)        Please discuss the timing and nature of any investigations that you would perform.

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College Answer

Timing and the information expected is required. Immediate investigations should include ECG monitoring (for rhythm and ST segment assessment), arterial blood gases (oxygenation, carbon dioxide and acid base status), full blood examination (Hb, WCC) and electrolytes (including renal function and lactate). Blood cultures should be taken as soon as possible. Less urgent (minutes) investigations include chest and abdominal radiographs, ECG, and consideration of further abdominal investigations (eg. CT scan).

More specific investigations may be indicated according to the clinical suspicion. Consider exclusion of pulmonary embolus (CT angiogram, transoesophageal echo), severe myocardial dysfunction (PA catheter, echocardiography), baseline cortisol (before administer corticosteroids).

Discussion

Immediate investigations

  • ABG
  • CXR
  • FBC, EUC, CMP, LFT, group and screen, blood cultures (as well as any other relevant body fluid)
  • ECG

Investigations in the short-medium term

  • CTPA and CT abdomen (to look for major postoperative bleeding, as well as rule out PE)
  • Formal TTE to assess cardiac function in detail
  • random cortisol level