76 y/o M - Hypotension

[LuvGlock]

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!

 

[NYMedic828]

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!

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.

 

[NomadicMedic]

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.

 

[Veneficus]

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.

 

[NomadicMedic]

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.

 

[NYMedic828]

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.

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)

 

[NomadicMedic]

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.

 

[LuvGlock]

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.

 

[Fish]

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.

 

[Handsome Robb]

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.

Agreed.

 

[johnrsemt]

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.

 

[exodus]

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

 

[LuvGlock]

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.

 

[medicsb]

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.

 

[usalsfyre]

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.

 

[Dwindlin]

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.

 

[mycrofft]

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.

 

[Veneficus]

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?

 

[Sam Adams]

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.

 

[Veneficus]

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.