Standard chief complaint - 8o-something guy sent from dialysis for a fever. He had just had a graft put in his arm a couple of weeks prior, but he also had a tunneled IJ catheter and several other potential sources for his fever. The patient denied any symptoms other than a productive cough and shortness of breath that he said was chronic and unchanged, however when his significant other arrived, she said that the cough and shortness of breath were new and worsening over the previous week, and that he also seemed a little confused over the last couple of days.
The patient was febrile, mildly tachypneic, tachycardic, and hypoxic, with an initial blood pressure 160s/70s. He was A&Ox4. Antipyretics were given, and the work-up was started. He didn't look overly toxic or in any distress. His fever resolved, HR returned to normal, and RR decreased to approximately 20. His initial lactate was 2.5.
What I want to reflect on in this case is the blood pressure. As the remainder of his vitals improved, his BP started to trend down, to SBPs of 100s, then 90s, 80s, then one in the 70s. I attributed the initial drop in BP due to resolution of his fever, but when it got into the 80s, I started to give him small fluid boluses totaling about 500 cc, plus he was getting antibiotics, and being that he was a dialysis patient, I wanted to go slow. His mental status never changed during this period of hypotension, and his HR stayed right around 100. His next couple of pressures were back in the 90s and 100s. Appropriate surgery and medicine consults were called, and he was signed out to the step down unit for admission. Subsequently a STEMI came in, so I was pulled away for about 20 minutes, and when I went back to the room the MICU resident was there and the patient had been started on dopamine. Apparently his SBP dropped back down, as low as 60s.
I've heard multiple lecturers and ED attendings say that Emergency Physicians aren't really good at recognizing shock. I'm not quite sure why this is, but I can postulate a couple of reasons. First, we see a broad range of vitals in a lot of different people, and maybe we just don't react to vital signs like we should. SBPs >200 in Philly are a dime a dozen, as are blood sugars >400. We also have ESRD patients that always run low after dialysis, and this patient had just been dialyzed. Second, I think that suspicion of shock is often based on the clinical appearance of the patent. This guy was awake, oriented, and without real complaint, looked well perfused, wasn't overly tachycardic, and I didn't really feel that he was in shock. His lactate was right on the cusp of abnormal, but he didn't look toxic.
I think that had I recognized that this patient was in septic shock earlier, and not just hypovolemic from dialysis, more aggressive initial fluid resuscitation may have been able to save this patient a central line, dopamine drip, and short MICU stay. The patient's BP improved with the dopamine and continued fluid resuscitation, and his mental status seemed to improve to better than when he had initially arrived with a hypertension. He ended up only being on the drip for a few hours and doing just fine, but still a good case for reflection.
No comments:
Post a Comment