# 76 y/o M - Hypotension



## LuvGlock (Jan 10, 2012)

Background: I just got my card, so if I did or said something stupid, laugh hysterically, but then tell me why I'm a moron. 

Picked up a 76 y/o M from a cancer center.  C/C hypotension after receiving 2 units of PRBC's.

History of Pancreatic CA, HTN.  Normally runs 140 systolic.  Has not taken his HTN meds in 3 days.  

VS: 82/38, 66bpm, 14RR, 97% RA, 98.8F
Pt has no complaints, states he feels fine.  CRT < 2 sec.
Skin P/W/D.
Initial exam reveals ascites, no other significant findings.
Pt has -s/s poor perfusion.  3 Lead shows NSR s ectopy.

I gave him a bolus (500cc), with no change.


My question is this:

How did he have such long standing hypotension without any signs or symptoms.  His heart rate was relatively low, so how is this guy managing to perfuse?

Help!


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## NYMedic828 (Jan 10, 2012)

LuvGlock said:


> Background: I just got my card, so if I did or said something stupid, laugh hysterically, but then tell me why I'm a moron.
> 
> Picked up a 76 y/o M from a cancer center.  C/C hypotension after receiving 2 units of PRBC's.
> 
> ...



Im as new as you are to this, but cancer centers usually give patients whatever they want to make them comfortable. Its very important to know FOR A FACT what meds he has been given by them. He may not have taken his HTN meds, but he may have 15mg of morphine in him for all we know when we get there.

Was the BP taken manually or by machine?

500cc without cardiac compromise or a significant bleed there should be some form of hemodynamic changes.

what was the PATIENTS chief complaint? Other than the hypotension, what was his actual signs and symptoms?

Just doesn't seem to add up. Hypotension aside, his other vitals seem to be pretty fantastic especially for someone sick enough to be removed in an emergent manor from a place who is supposed to be already providing him definitive care.


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## NomadicMedic (Jan 10, 2012)

What meds is he taking? Are you SURE he didn't take his beta blockers? Hypotension with a slower HR and HX of HTN always makes my nose perk up and start sniffing around for the BetaBlocker bottle.

Was he septic? What did his 12 lead look like?

And I'm sure you did the regular GI assessment? Any vomiting, stool changes? What was his abdomen like?

You said S/S of poor perfusion. Please explain what you saw and what he told you.


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## Veneficus (Jan 10, 2012)

NYMedic828 said:


> 500cc without cardiac compromise or a significant bleed there should be some form of hemodynamic changes.



Please recall that 500cc of isotonic fluid can easily be third spaced with no intravascular volume expansion. 

Even more if there has been long term compensation for fluid balance.


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## NomadicMedic (Jan 10, 2012)

Veneficus said:


> Please recall that 500cc of isotonic fluid can easily be third spaced with no intravascular volume expansion.
> 
> Even more if there has been long term compensation for fluid balance.



I didn't see "acites" in the original post. Curious about his liver.


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## NYMedic828 (Jan 10, 2012)

n7lxi said:


> What meds is he taking? Are you SURE he didn't take his beta blockers? Hypotension with a slower HR and HX of HTN always makes my nose perk up and start sniffing around for the BetaBlocker bottle.
> 
> Was he septic? What did his 12 lead look like?
> 
> ...



The original post says *-s/s poor perfusion*

The only problems stated are acites and hypotension at 82 systolic

Like I said im an amateur compared to 99% of the forum, but aside from the extremely rare occurrence of neurogenic shock, shouldn't any early hypotension have a compensatory increase in HR unless it is blocked by an outside force like medications? (Dysrhytmias aside)


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## NomadicMedic (Jan 10, 2012)

NYMedic828 said:


> The original post says *-s/s poor perfusion*
> 
> The only problems stated are acites and hypotension at 82 systolic
> 
> Like I said im an amateur compared to 99% of the forum, but aside from the extremely rare occurrence of neurogenic shock, shouldn't any early hypotension have a compensatory increase in HR unless it is blocked by an outside force like medications? (Dysrhytmias aside)



Ahhh... you used the world famous -. I really have to stop reading this on my freakin' iphone. 

That's why I asked about betablockers.


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## LuvGlock (Jan 10, 2012)

The pt himself had absolutely no complaints.  The sending doc opined that the ascites was from the pancreas, not liver related.

It's certainly possible he did take his meds.  I got that information from the facility, which got it from his daughter.

BP was manual.



> Was he septic? What did his 12 lead look like?



Temp was normal when I got him.  According to the cancer center, the daughter called the previous night to say pt wouldn't be in for a transfusion because he had a fever and didn't feel well.  

No 12 lead available.



> And I'm sure you did the regular GI assessment? Any vomiting, stool changes? What was his abdomen like?



Negative on everything.  Denied blood from either end.  Abdomen was soft, otherwise normal (except for the ascites).

The DDX is helpful, but I really want to know *why* he had the hypotension for so long without any apparent compensation and without s/s.


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## Fish (Jan 11, 2012)

It sounds like he needed more Fluid expansion than the 500cc to really start making a difference.

I am willing to bet he has either been taking something, or been giving something that is not allowing for his body to have "Normal" reactions to a low BP. I would of expected a faster Heart rate, so I would be suspicous that some"thing" some drug that you were unaware of, is limiting it.

I think given the situation and history, 500 with no changes definitly warrants the consideration and administration of a few more 500ml boluses while monitoring Lung Sounds and other Vital signs, then you might start to see the positive changes that you are looking for before you get to the hospital.


Just my two cents.


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## Handsome Robb (Jan 11, 2012)

Fish said:


> It sounds like he needed more Fluid expansion than the 500cc to really start making a difference.
> 
> I am willing to bet he has either been taking something, or been giving something that is not allowing for his body to have "Normal" reactions to a low BP. I would of expected a faster Heart rate, so I would be suspicous that some"thing" some drug that you were unaware of, is limiting it.
> 
> ...



Agreed.


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## johnrsemt (Jan 11, 2012)

Don't forget that there are people that can deal with low bp without any signs/symptoms:   I get headaches and slight dizziness when my bp hits above 130 systolic;   but am fine when it is 72/30.


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## exodus (Jan 11, 2012)

Why exactly wasn't a 12 lead available? You're an ALS unit. Or did you opt not to do one?


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## LuvGlock (Jan 15, 2012)

Believe me, I would have loved to do one.  I was not on a mainline bus that day, and they have all the 12 leads. Transfer squads only get LifePak 10s. Ugh.


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## medicsb (Jan 15, 2012)

Veneficus said:


> Please recall that 500cc of isotonic fluid can easily be third spaced with no intravascular volume expansion.
> 
> Even more if there has been long term compensation for fluid balance.



THIS.

I transported (IFT) a young septic woman who accepted 8L of saline over 8 hours with only 500ml of urine out during that time.  Systolic pressure steady in the 70s-80s until levophed brought it up to high 90s.


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## usalsfyre (Jan 15, 2012)

In the absence of signs of poor perfusion (i.e. he had no mentation changes, radial pulses, no tachycardia, was warm, dry and had good color) I really wouldn't worry about the pressure too much. 

Don't get too terribly tied up on numbers.


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## Dwindlin (Jan 15, 2012)

I tend to focus more on MAP than BP.  Though he doesn't show any signs of poor perfusion I would still take measures to improve his MAP as it is only about 52.


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## mycrofft (Jan 16, 2012)

Since there is an "AP" with %, I assume the pulse was by pulse ox and not palpation nor auscultation. No notation about regularity or strength either. A very irregular pulse, either inotropically (varying strengths) or chronotropically (especially irregularly-irregular ones) are not rationally reported by the poor pulse-ox. 
But besides that, as above all.


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## Veneficus (Jan 16, 2012)

medicsb said:


> THIS.
> 
> I transported (IFT) a young septic woman who accepted 8L of saline over 8 hours with only 500ml of urine out during that time.  Systolic pressure steady in the 70s-80s until levophed brought it up to high 90s.



8L without pressors???!!!

Are you trying to give me GERD?


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## Sam Adams (Jan 16, 2012)

Do you have any idea what meds he was on? Further, was the ascites new onset or a chronic condition. We had a pt not long ago who was non-compliant w/ his diuretic and the "extra" fluid accumulated into his scrotum. (think basketball) Similar to this pt, he had no complaints (save when he sat on the twins) and presented hypotensive w/ baseline mentation.


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## Veneficus (Jan 16, 2012)

Sam Adams said:


> Do you have any idea what meds he was on? Further, was the ascites new onset or a chronic condition. We had a pt not long ago who was non-compliant w/ his diuretic and the "extra" fluid accumulated into his scrotum. (think basketball) Similar to this pt, he had no complaints (save when he sat on the twins) and presented hypotensive w/ baseline mentation.



But it is not cool until it ruptures a vein in the scrotum. 

Had one of those. A constant nonpulsating stream of blood that shoots about 4 feet across the room under pressure.

Nobody believed me until the next crew went to the same guy for the same thing. Eventually he got a DNR and died from it. 

I heard it looked like somebody killed a pig in the room when he finally cashed out.


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## mycrofft (Jan 16, 2012)

It's supper time in my time zone....

If considerable fluid goes in and neither goes out nor increases BP nor other signs, it's time to go to Page 2 of the Protocol.

Remember somewheres between 20k and 400k die annually from medical mistakes.


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## Veneficus (Jan 17, 2012)

mycrofft said:


> It's supper time in my time zone....
> 
> If considerable fluid goes in and neither goes out nor increases BP nor other signs, it's time to go to Page 2 of the Protocol.
> 
> Remember somewheres between 20k and 400k die annually from medical mistakes.



I guess it is the medical version of "how many people can we fit in the clown car?"


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## systemet (Jan 17, 2012)

LuvGlock said:


> Believe me, I would have loved to do one.  I was not on a mainline bus that day, and they have all the 12 leads. Transfer squads only get LifePak 10s. Ugh.



Just a thought here.  If you have the 10D, you can hit the "DIAG" button, and get diagnostic quality for leads I, II, III.  You can also fire it into lead one, use the foot lead, and get MCL1-6, or MCL4R, etc.

I'm not saying that you're going to get to ER bypass to cathlab based on a handful of MCL strips, or that you'll get orders for 'lytics -- but you may identify an acute MI and save your patient some valuable myocardium.

And yes, I know it's a pain in the *** trying to glue all those strips to a PCR.


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## Veneficus (Jan 17, 2012)

systemet said:


> Just a thought here.  If you have the 10D, you can hit the "DIAG" button, and get diagnostic quality for leads I, II, III.  You can also fire it into lead one, use the foot lead, and get MCL1-6, or MCL4R, etc.
> 
> I'm not saying that you're going to get to ER bypass to cathlab based on a handful of MCL strips, or that you'll get orders for 'lytics -- but you may identify an acute MI and save your patient some valuable myocardium.
> 
> And yes, I know it's a pain in the *** trying to glue all those strips to a PCR.



I appreciate the ingenuity, but you must really have some long transports times to go through all of that.


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## systemet (Jan 17, 2012)

Veneficus said:


> I appreciate the ingenuity, but you must really have some long transports times to go through all of that.



Haven't had to work without 12-lead since.... maybe 2003?  And even that was an exception, most places I was working had them from 2000 on.  I even remember using the LP11.

I agree, it takes a lot of time, and unless other people in your system are doing it on a regular basis, a lot of ER docs / RNs are going to ignore a big mess of paper and tape.  But it does work.  

Screening II / III for IWMI is pretty quick and easy, at least.  If you identified an MI, and got the patient reperfused quicker, I reckon the time savings would justify it.


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## Veneficus (Jan 17, 2012)

systemet said:


> Haven't had to work without 12-lead since.... maybe 2003?  And even that was an exception, most places I was working had them from 2000 on.  I even remember using the LP11.
> 
> I agree, it takes a lot of time, and unless other people in your system are doing it on a regular basis, a lot of ER docs / RNs are going to ignore a big mess of paper and tape.  But it does work.
> 
> Screening II / III for IWMI is pretty quick and easy, at least.  If you identified an MI, and got the patient reperfused quicker, I reckon the time savings would justify it.



No doubt it works. It is brilliant.

If ever pressed I am going to use it and pretend like I thought of it.


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## systemet (Jan 17, 2012)

Veneficus said:


> No doubt it works. It is brilliant.
> 
> If ever pressed I am going to use it and pretend like I thought of it.



That's what I did.

Can't remember who taught me to do it though.  And sadly, I don't think I ever found anything using this method.  It would have been pretty MacGyver.


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## Veneficus (Jan 17, 2012)

systemet said:


> That's what I did.
> 
> Can't remember who taught me to do it though.  And sadly, I don't think I ever found anything using this method.  It would have been pretty MacGyver.



NO it would be MacGyver if you found something and then purposefully induced an allergic reaction in the patient to cause degranulation of histamine and heparin thereby resolving the acute pathology.

(Never did that, but damn straight I would take credit for it if it worked.)

If not, I'll just blame it on austere environment.

Better still use morphine or PCN to cause an anaphylactoid reaction...


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## d_miracle36 (Jan 18, 2012)

n7lxi said:


> What meds is he taking? Are you SURE he didn't take his beta blockers? Hypotension with a slower HR and HX of HTN always makes my nose perk up and start sniffing around for the BetaBlocker bottle.
> 
> 
> My first thought was this guy may need some glucagon.


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## Veneficus (Jan 18, 2012)

d_miracle36 said:


> n7lxi said:
> 
> 
> > What meds is he taking? Are you SURE he didn't take his beta blockers? Hypotension with a slower HR and HX of HTN always makes my nose perk up and start sniffing around for the BetaBlocker bottle.
> ...


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## systemet (Jan 18, 2012)

A few questions:

* What was his blood pressure prior to transfusion?

* Why is he receiving PRBCs?  
* What prompted this?  
* How anemic was he?  
* Do they know why?
* Do we have H&H for post- or pre- transfusion?

* Do we have any idea of his baseline labs?
* Does he have urine output?
* How's his renal panel?
* How are the 'lytes?  In particular the K+?

* Why does the doctor want him to go to the hospital?  What pathology is he/she concerned in ruling in/out?  What are they worried about?


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## Dwindlin (Jan 18, 2012)

Veneficus said:


> d_miracle36 said:
> 
> 
> > What are the risks of acutely reversing a B-Blocker?
> ...


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## Veneficus (Jan 19, 2012)

Dwindlin said:


> [ Typically I see rate/BP support and up to ICU to wait out the BB.



Because it is a really bad idea to acutely reverse a beta blocker. 

I was trying to be nice and educational like.


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## jjesusfreak01 (Jan 19, 2012)

systemet said:


> A few questions:
> 
> * What was his blood pressure prior to transfusion?
> 
> ...



Same questions, but I think the primary reason for referral is the hypotension post infusion. They probably expected better than 82/38 after two units. Seeing as he's being transferred from an infusion center, they may have transferred due to protocol rather than on a doctors specific orders.


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## d_miracle36 (Jan 19, 2012)

Ok maybe glucagon isn't the appropriate treatment for this pt. What circumstances would it be good for? And why do we not want to give glucagon? I'm still learning but everything I have read has it as the mainstay treatment/antidote. For pts who are symptomatic of course. Our protocols allow 2-5 mg.


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## d_miracle36 (Jan 19, 2012)

I just spoke with our er doc and he was curious as to why you wouldn't want to give it.


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## Veneficus (Jan 20, 2012)

d_miracle36 said:


> I just spoke with our er doc and he was curious as to why you wouldn't want to give it.



A couple of reasons actually, 

In this scenario, the patient is neither bradycardic nor mentally altered, and there are likely other pathologies in play.

Outside of this, the Beta blocker (BB) reversal with glucagon is not always a first-line agent, though it usually is.

It is administered IV, and often with Chloride. (While fine in the hospital, that is an aweful lot of chemistry for prehospital EMS) The dosage is listed starting at 5mg IV with follow up bolus as needed and then an infusion of 9mg/hour, until the effects of the BB wear off.

Potential side effects: arrythmia (with side effects common to those), rebound HTN, induced attack of angina, N/V, worsening of baseline cardiac function. 

From the practical point, most EMS agencies don't carry that kind of dose, use it IM and not IV, and even if you were to give an IV bolus, what is the likelyhood this patient would be brought into the ED and they would automatically set up a drip on your word?

Furthermore, when you are talking about an infusion over hours, the ED is not going to sit on that patient and perform serial labs.

It makes more sense for EMS to provide supportive therapy, with definitive reversal started in the ED, continued in a unit or floor, or simply admitted there to begin with and allow those people to do their job.

An arrest or peri-arrest situation would of course be a bit different, but I am thinking so rare that therapy like transcutaneous pacing or IV fluid therapy might be a but more prudent out of the hospital as well.


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## systemet (Jan 20, 2012)

jjesusfreak01 said:


> Same questions, but I think the primary reason for referral is the hypotension post infusion. They probably expected better than 82/38 after two units. Seeing as he's being transferred from an infusion center, they may have transferred due to protocol rather than on a doctors specific orders.



The OP states he was coming from a "cancer center".  Maybe that means something specific in their region, but it seems pretty vague.  I've been to places I'd consider a "cancer center" that were associated with a large universty hospital / trauma center, were centers for basic research, had their own CT, MRI, etc. and ran mini-ICUs.  So, to me, "cancer center" means something a little more than a basic infusion clinic.  But perhaps that's all it is.

I understand completely if the information isn't available --- sometimes that's just how it is.  But this seems more like a transfer than a scene call.  I would assume some of this stuff would have been available.  

In all likelihood the patient's a train wreck of acute and chronic multisystem pathology.  I was just wondering if there was anything specific to the blood product use like hyperkalemia or citrate toxicity.  These are probably just zebras though.


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## d_miracle36 (Jan 20, 2012)

Veneficus said:


> A couple of reasons actually,
> 
> In this scenario, the patient is neither bradycardic nor mentally altered, and there are likely other pathologies in play.
> 
> ...






That all makes sense. I am new and have yet to come upon a situation requiring glucagon(for bbod). I did have a suspected pt. that was brady yet very stable so no treatment was renderd except for supportive. Im not one to give drugs just to give them but I believe if presented with a unstable brady/hypo pt. I wouldnt hesitate to give my initial 2 mg of glucagon along with fluids and prepare for more agressive treatment if needed. I also learned that along with a bb od esophageal spams are likely and the glucagon can also reverse thouse. The ED doc said he has given it about twice in the past 10 years for esophageal obstruction which i was like mmhmmm....thinking thats awesome ive never heard of it!


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## NomadicMedic (Jan 21, 2012)

Esophageal spasm is a a rare complication of a Betablocker overdose, however Glucagon is often used to relax the smooth muscle of the esophagus following a foreign body obstruction, helping to free a stuck food bolus. I'd gather that's what the doc may have used it for.


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## Digger (Jan 23, 2012)

If a beta blocker OD is unstable- Bradycardic, altered, hypotensive- would atropine be less effective than glucagon in increasing HR and better perfusing the pt? I know glucagon is the antidote, but at least where I am glucagon is only indicated for hypoglycemia and we don't necessarily carry enough for that BB overdose.


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## Veneficus (Jan 23, 2012)

http://www.medscape.com/viewarticle/430202_6

ask, and you should receive.

However, in another article i read on the subject in pubmed but cannot relocate, it mentioned that high dose glucagon has been the antidote of first resort since the 1980s.

I think this article assumes bradycardia with an unknown etiology. But it doesn't specify that.


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## Digger (Jan 24, 2012)

Hey thanks! That was really informative!


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