The Hypotensive Patient Flashcards

1
Q

A 50yr old male with no significant past medical history is day 2 admission for a community acquired pneumonia (CURB-65 = 3). He is currently receiving IV Co-Amoxiclav and Clarithyromycin, and slow IV fluids (12 hourly).
His current observations are: HR 109, BP 91/65, RR 22, Saturation 95% OA, Temperature 37.9
His NEWS score is: 6

a) Why is his blood pressure low?
b) What further details would you like to know?

A

a) Sepsis - peripheral vasodilatation leading to a distributive shock (almost)

b) General appearance
- unwell, clammy, cyanosed, etc.

Airway.
- Patency, secretions, abnormal sounds, etc.

Breathing.

  • Oxygen requirement
  • do they need a blood gas?
  • Abnormal sounds - wheeze (consider nebs), crackles (may be overloaded if bibasal)
  • PMHx of COPD/Asthma or chest sepsis

Circulation.

  • Baseline BP/ change from normal?
  • Fluid status
  • PMHx of CCF, or other CVD
  • Medications that may influence fluid status (eg. furosemide, antihypertensives)
  • Catheter required?

Disability.

  • Any new confusion/ reduced GCS
  • Glucose, pupils, neurology

Exposure.

  • Abdo, calves (?PE), wounds, sores, etc.
  • Do they need/ have they had cultures? (sepsis 6)
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2
Q

How would you investigate/manage patient with chest sepsis?

A

Sepsis 6. (BUFALO)

  • Blood cultures
  • Urine output - catheter
  • Fluids (NaCl bolus, then replacement/ maintenance)
  • Antibiotics - broad-spec (eg. tazocin in chest sepsis)
  • Lactate - VBG/ABG (>2 = pathological)
  • Oxygen - 15L/min via NRB, titrate down

Bedside.

  • Full A-E assessment and examination
  • Sputum sample
  • ECG - PE (sinus tachy, RBBB, S1Q3T3), sepsis-induced AF, etc.
  • Consider urine dip

Bloods.
- IV access - bloods (FBC, CRP, U+Es, clotting, LFTs, glucose), ABG, blood cultures

Imaging.

  • CXR
  • ?CTPA (?PE)

Special tests.

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3
Q

Sequential organ failure assessment (SOFA) score.

a) When should it be used?
b) Criteria

A

a) In patients with sepsis admitted to ITU, to calculate mortality risk
(NOT to diagnose sepsis, and not for ward level care)

b) - CV - MAP (or use of vasopressors)
- Resp - PaO2, FiO2, on ventilation (NIV or CPAP)
- Haem - platelet count
- Neuro - GCS
- Hepatic - Bilirubin
- Renal - Creatinine

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4
Q

qSOFA score.

a) When should it be used?
b) Criteria
c) What is a ‘positive’ score?

A

a) Outside ITU, to determine mortality risk at the bedside for patients with sepsis

b) - GCS < 15
- RR: 22 or more
- Systolic BP: 100 or less

c) - 2 - 3 = high risk (3 - 14x increase in mortality)
- 1 or less = not high risk

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5
Q

You are on call for medicine. It is 2am.

The nurse bleeps you, “ Hi Doctor, Mrs Smith in bed 10 has dropped her blood pressure, it is 85 systolic.”

A
  • What’s the rest of their obs, what are they scoring?
  • What is the trend of the BP?
  • Why are they in hospital?
  • Do they have IV access?
  • Are there fluids running?

Go and see the patient

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6
Q

67 year old patient admitted with ?urosepsis, on day 2 oral nitrofurantoin. BP 86/54 and bloods on admission show current AKI.
PMHx - HTN, T2DM
DHx - Ramipril 2.5 mg BD, metformin 1g BD

a) Management of this situation

A

a) - Sepsis 6
- Fluid bolus (consider fluid status) to bring BP up
- Consider switching to IV abx according to local policy (eg. IV tazocin; beware gentamicin due to AKI)
- Omit ramipril until BP and renal function improve
- Omit metformin until renal function improves

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7
Q

Why can furosemide actually help to INCREASE blood pressure in overloaded patients?

A

Frank-Starling curve.

  • In healthy patients, when preload (EDV) increases, stroke volume (SV) also increases
  • In patients with reduced cardiac function and/or those who are very overloaded, SV begins to DECREASE beyond a critical threshold of preload
  • Hence, in these patients actually offloading fluids with furosemide and reducing preload will increase SV
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