# Hypothetical scenario



## rhan101277 (Jun 14, 2011)

I realize not breaking clots bleeding is why we like to use permissive hypotension.

What about those cases where they are dehydrated from N/V/D?  We have protocols for fluids for hyperthermia though. 

Does anyone have protocols that would allow a fluid bolus under this scenario?  Thoughts on how you would treat?

Take this scenario, which is purely hypothetical.

You have a 45 y/o male N/V/D x 2 days, severe abdominal pain (umbilicus region) and feels weak while standing, reports no other pain anywhere.

CBG is normal and blood pressure sitting down is 130/90; HR 90; Sinus Rhythm; 12 lead ok; RR 24; pulse 99% on RA; PT is AAOx3

You decide to perform orthostatic vitals to assess for volume depletion now the vitals are 130/90; HR 115

At this point you think he could be dehydrated or bleeding internally, abdomen is soft-non tender.


Still the protocols define hypotension to be systolic BP below 90; but if someone is volume depleted they need a bolus.

The syncope and shock-medical protocol addresses checking orthostatic vitals, but nothing about what to do if you have a positive.


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## 605medic (Jun 14, 2011)

The pt still appears to be fine. I would start a saline lock and monitor for changes. If the pt is volume depleted it isn't bad enough to need aggressive therapy at this point.


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## NomadicMedic (Jun 14, 2011)

605medic said:


> The pt still appears to be fine. I would start a saline lock and monitor for changes. If the pt is volume depleted it isn't bad enough to need aggressive therapy at this point.



^This. I would gain access, but not bolus the patient. However, if things change, you've already got a line established and you're ready to act. 

And before I start thinking internal bleeding, I'm looking for signs. Blood in the emesis or stool? On Coumadin? Recent trauma? Not everyone with a bellyache is bleeding internally. There's not really enough PMHX/RX background to go off of here. He's stable, CAOx4. Get a good, solid history and get back to me.

(And is that standing BP correct? Did you have him stand for a minute or two before you took another?)


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## truetiger (Jun 14, 2011)

Our protocols allow for a bolus for n/v/d. There are no signs of internal bleeding. You take into account his n/v/d x 2 days and your positive othostatics, you bet he's dehydrated. 500cc bolus and another set of orthostatics.


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## Melclin (Jun 20, 2011)

Just going by what you're saying, it seems unlikely this bloke is bleeding internally. Depending on the rest of my exam and his social situation, I might leave him at home with a care plan involving some antiemetics, perhaps something to firm up his squirts, and some PO fluid & electrolyte. Maybe have a LOCUM come out and see him.

Again, depending on the rest of the exam and hx, I'd happily give him some fluid and an antiemetic. 

20mls/kg NS over say...30 mins, should do the trick.

What's the issue with giving this chap fluid? Do you actually have to wait for the SBP to drop bellow 90? That's pretty late in the whole process.


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## usalsfyre (Jun 20, 2011)

Unlikely to be bleeding internally, start a line, if he's an average size male I'd probably give him a liter then reevaluate. Anti-emetics PRN. 

Has he been making urine? How much, and what did it look/smell like?


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## MrBrown (Jun 20, 2011)

If you are not allowed to give somebody who is fluid depleted some fluid then the fail is strong in your protocol


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## usalsfyre (Jun 20, 2011)

MrBrown said:


> If you are not allowed to give somebody who is fluid depleted some fluid then the fail is strong in your protocol



I wonder a lot of times how much questions like this are because of poor protocols, and how much of it is poor interpretation of the protocols.

I see situations that don't exactly fit the protocols as "it's not expressly forbidden, and it's good medical care, so let's go ahead and do it. Many others, unwilling to accept the smallest inkling of responsibility or liability in their care think "it's not expressly permitted, therefore forbidden". 

rhan101277, please don't take this as a personal slam. If that's the only environment you know, it's hard not to think that way.


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## Melclin (Jun 20, 2011)

MrBrown said:


> If you are not allowed to give somebody who is fluid depleted some fluid then the fail is strong in your protocol



This.


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## MrBrown (Jun 20, 2011)

usalsfyre said:


> I see situations that don't exactly fit the protocols as "it's not expressly forbidden, and it's good medical care, so let's go ahead and do it. Many others, unwilling to accept the smallest inkling of responsibility or liability in their care think "it's not expressly permitted, therefore forbidden".



One of the Senior Officers on watch told Brown "if it doesn't say you can't do it, then there is nothing to say you cant do it"

All in line with good praxis of course


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