This 79 year old lady presented to emergency with abdominal pain, nausea and vomiting. On examination, she appeared shocked, with cool mottled extremities and a weak thready pulse. The heart rate was 150 (in AF, but apparently that is long-standing) and the non-invasive blood pressure cuff generated improbable numbers (Pfft, 52/35mmHg? Really?).

A CT of the abdomen was ordered, which revealed the following findings:

  • Free gas and fluid in the peritoneum;
  • Loops of thickened bowel with intramural gas pockets;
  • Bilateral small pleural effusions with overlying atelectasis.

Shortly after returning from CT, the surgical team were disappointed to find her breathless and semicomatose. A rapid sequence induction and intubation were carried out, and a post-intubation blood gas was collected.

References

Siegel, John H., Ivo Giovannini, and Bill Coleman. "Ventilation: perfusion maldistribution secondary to the hyperdynamic cardiovascular state as the major cause of increased pulmonary shunting in human sepsis." Journal of Trauma-Injury, Infection, and Critical Care 19.6 (1979): 432-460.

Fischer, Stefanie R., et al. "Nitric oxide synthase inhibition restores hypoxic pulmonary vasoconstriction in sepsis." American journal of respiratory and critical care medicine 156.3 (1997): 833-839.