Postural Hypotension

[thegreypilgrim]

You respond to a private residence for an "Unknown Medical".

83 year old male, generally ill in appearance, weighs about 140 lbs. (64 kg) and about 5'9" (170 cm), sitting upright in a chair. Multiple family members in vicinity as there was some sort of family party/event preceding this incident.

HPI: pt reports RUQ and RLQ abd pain x 1-2 hours, "dull" quality. Pt stood up to go home, then felt weak and dizzy accompanied by nausea, but no vomiting. Family reports a "glazed" look in his eyes and period of disorientation (not able to answer questions). Returning to a sitting position has not appeared to improve symptoms.

Vitals: BP - 70/40, P - 90, RR - 24, SpO2 - 92%, Skins - hot and dry, Temp. - 100.3 F (37.9 C)

ECG: NSR with no ectopy

Medical History: Renal Failure (recently placed on dialysis - Tues. Thurs. Sat. - today is Monday), chronic kidney infections, BPH, COPD, HTN (recently taken off HTN meds), chronic nephrolithiasis (mainly struvite, staghorn stones)

Allergies: Sulfa drugs - pt reports generalized edema and rash formation

Medications: Procrit, calcium acetate, phosphorous, citalopram, albuterol, and OTC stool softener

Physical Exam:
Constitutional - slightly febrile (not present this AM with home RN visit), reports general malaise all day, feels weak and dizzy
Head - normocephalic, atraumatic, equal facial symmetry, pupils PERRLA.
Neck - no JVD, no masses, no stomas, trachea midline
Chest - denies chest pain/discomfort, no palpitations, no accessory muscle use, breath sounds clear x 6, pt has a hickman catheter for dialysis
Abd - RUQ and RLQ pain, increases on palpation, no rigidity, no distention, no pulsatile masses, normal bowel movements. Positive for nausea, no vomiting.
Pelvis - pt has foley cath and 2 uretral stents which were placed 3 months ago after an exploratory surgery aimed at determining cause of chronic kidney stones and infections
Extremities - unremarkable

You are an ALS unit with all your typical capabilities and equipment. You have a general hospital (not a "doc-in-the-box" but not a teaching hospital either) with a 2 minute ETA, another general hospital with STEMI and Stroke capabilities with a 20 minute ETA, and a Level II medical center 35 minutes away. Have at it.

 

[EMTinNEPA]

Supplemental oxygen at 4lpm via nasal cannula.
Place patient supine and recheck blood pressure.
IV access.
250cc fluid bolus if hypotension persists after repositioning.
4mg Zofran IV push for the nausea.
Blood glucose level check
12-lead EKG... looking specifically for ST segment changes and/or peaked T waves indicative of hyperkalemia.
Any slurred speech, diplopia, unequal motor function?
He's mildly tachypneic, but are his respirations regular?
Does the patient still have his appendix and gallbladder?

I will make my transport decision once I have the information requested back. My working DDx includes UTI, hyperkalemia, acute MI, some other type of infection (the man has several tubes coming out of him, all portals for infection) with secondary sepsis, hypoglycemia, or orthostatic hypotension of as yet unclear etiology. It sounds like there may be a few things going on here.

 

[thegreypilgrim]

Blood glucose level check

BGL 160.

12-lead EKG... looking specifically for ST segment changes and/or peaked T waves indicative of hyperkalemia.

As of right now, 12-lead is nonspecific

Any slurred speech, diplopia, unequal motor function?

No neuro deficits.

He's mildly tachypneic, but are his respirations regular?

Indeed they are regular.

Does the patient still have his appendix and gallbladder?

Yes he does.

I will make my transport decision once I have the information requested back. My working DDx includes UTI, hyperkalemia, acute MI, some other type of infection (the man has several tubes coming out of him, all portals for infection) with secondary sepsis, hypoglycemia, or orthostatic hypotension of as yet unclear etiology. It sounds like there may be a few things going on here.

Yeah kind of a complicated case here, good choices for DDx so far.

 

[MrBrown]

I am thinking some sort of infection; a little oxygen, IV access, if nausea if severe we can give ondansetron PO (or IV if he wont take a tab) and go from there.

 

[MonkeySquasher]

Hrm.

Well to start, IV access, bloods, trap it off. Preferably the side opposite the shunt. O2 via NC @ 2LPM, and then titrate from there.

As stated above, he's slightly tachypneic. I'd ask if it's normal for him recently. If not, it may show he's acidic. Which points me closer to a few certain problems. It's not cardiac. I doubt it's electrolyte related.

Poss Dx for ABD Pain + Fever:

Appendix
Gallbladder
Liver
Kidneys
Viral/Bacterial/Sepsis
Leaking Aneurysm
Cancer
Hypothalamus/Thyroid condition
Recent Vaccines/Medications
Toxins
Crohn's Disease

Seeing as how he's already having Renal and Urinary problems (kidney, prostate, UTIs, caths, etc), I would focus on that. Fever could be caused by another infection, early sepsis, or maybe cancer fever. (Cancer would explain a LOT of his problems in that area.)

However, the drop of BP suddenly points to either sepsis, or a problem with the pump/container/fluid triad. It's not the pump, and he's not bleeding externally. So either he's septic and the container suddenly got bigger, or the container has a hole in it and he's losing fluid internally. So to be honest, if his mentation is fine and he's perfusing okay on some Oxygen, I'm going to hold off on giving a bolus until I'm certain it's not going to just make kool-aid in his abdominal cavity.

Any pain into his back? Any Cullens or Greys signs? Any jaundicing? What does his output look like in the foley bag?

So load and drive to the closest hospital with a CT scanner and some surgical capabilities.

 

[EMTinNEPA]

BGL 160.

Ok, say goodbye to hypoglycemia

As of right now, 12-lead is nonspecific

Doesn't take AMI off the table, just not a STEMI. Without ST segment changes, AMI is a bit of stretch but I've seen stranger presentations. Also, does not rule out hyperkalemia.

No neuro deficits.

Indeed they are regular.

Thanks for playing, stroke.

Yes he does.

I'll put appendicitis and acute cholecystitis with gallbladder perforation on the table then. Any increase in pain on flexion or rotation of the right leg? Positive Murphy's sign? As asked above, any jaundice?

Also, does the patient's blood pressure or mentation improve when laid supine? If not, does a small fluid bolus help?

Yeah kind of a complicated case here, good choices for DDx so far.

Thank you, sir (or ma'am, whichever the case may be).

I'm gonna say transport to the facility 20 minutes away. If they have STEMI and stroke capabilities I'd be willing to say they have surgical capabilities as well, and I have a sneaking suspicion this gentleman is going to be opened up at some point.

Updated DDx: UTI, hyperkalemia, some other type of infection with secondary sepsis, appendicitis, acute cholecystitis with gallbladder perforation, orthostatic hypotension.

 

[MonkeySquasher]

Ok, say goodbye to hypoglycemia

Doesn't take AMI off the table, just not a STEMI. Without ST segment changes, AMI is a bit of stretch but I've seen stranger presentations. Also, does not rule out hyperkalemia.

Thanks for playing, stroke.

Any increase in pain on flexion or rotation of the right leg? Positive Murphy's sign?

...does a small fluid bolus help?

Updated DDx: UTI...

A) It was never a diabetic or glucose problem. Atleast, nothing pointed to it at all. I would have been very, very curious as to how anything with this could have been diabetic. But atleast you checked.

B.) It wasn't an MI, he already stated the ECG was RSR (I'm assuming Lead 2. He didn't state) Also, a BP that low would suggest R-sided failure, which suggests cardiogenic shock. In which case, fluids could be a bad idea, as it'll end up in the lungs. But, with semi-okay neuro and warm/dry skin, he's not in cardiogenic shock. It's a fluid/container problem, but nothing to do with the pump.

C) Hyperkalemia IS possible with the Hx of Renal Failure, weakness, and tachypnea. Possibly also explains the hypotension. However, seeing as he had just had dialysis the morning before, I would be skeptical of this. Especially with a RSR ECG - If it's far enough that you have hypotension, I believe you'd see the arrhythmias. Correct me if I'm wrong.

D) Wasn't a stroke. Ischemic would have deficit and no fever, and Pons bleed would have fever but severely decreased LOC and decreased respiratory rate.

E) Good call on the Murphy's sign, didn't even think of that. While elderly may have a marked reduction in the sign, it'd still be a good sign. -thumbs up-

F) UTI wouldn't cause the BP problem. It WOULD cause a septic problem which would cause the BP problem.

 

[EMTinNEPA]

A) It was never a diabetic or glucose problem. Atleast, nothing pointed to it at all. I would have been very, very curious as to how anything with this could have been diabetic. But atleast you checked.

B.) It wasn't an MI, he already stated the ECG was RSR (I'm assuming Lead 2. He didn't state) Also, a BP that low would suggest R-sided failure, which suggests cardiogenic shock. In which case, fluids could be a bad idea, as it'll end up in the lungs. But, with semi-okay neuro and warm/dry skin, he's not in cardiogenic shock. It's a fluid/container problem, but nothing to do with the pump.

C) Hyperkalemia IS possible with the Hx of Renal Failure, weakness, and tachypnea. Possibly also explains the hypotension. However, seeing as he had just had dialysis the morning before, I would be skeptical of this. Especially with a RSR ECG - If it's far enough that you have hypotension, I believe you'd see the arrhythmias. Correct me if I'm wrong.

D) Wasn't a stroke. Ischemic would have deficit and no fever, and Pons bleed would have fever but severely decreased LOC and decreased respiratory rate.

E) Good call on the Murphy's sign, didn't even think of that. While elderly may have a marked reduction in the sign, it'd still be a good sign. -thumbs up-

F) UTI wouldn't cause the BP problem. It WOULD cause a septic problem which would cause the BP problem.

My theory is that there could be multiple pathologies at work here. My goal is to rule out as much as possible. As the OP stated, this is a complex case. The hypoglycemia, MI, and stroke are common things which could be presenting at the same time with another pathology. I wanted to rule out the most common things it could possibly be (even if they are a stretch). It could have been a silent MI and the only way to rule that out would be a 12-lead (which is why I removed MI from the DDx after the 12-lead came back negative). Also, with right-sided heart failure the fluid would back-up into the peripheral vasculature and you would have edema and JVD, which the OP mentions nothing of in the physical exam he typed out. I'm also aware of hypotension being caused by sepsis SECONDARY to a urinary tract infection... like I said, I have a suspicion that there are multiple pathologies.

EDIT: Also, he did not have dialysis the morning before... he gets Tuesday, Thursday, Saturday, and per the OP this scenario takes place on a Monday.

Forgive me if I'm not entirely coherent, just getting off a 16 with no sleep...

 

[reaper]

A) It was never a diabetic or glucose problem. Atleast, nothing pointed to it at all. I would have been very, very curious as to how anything with this could have been diabetic. But atleast you checked.

B.) It wasn't an MI, he already stated the ECG was RSR (I'm assuming Lead 2. He didn't state) Also, a BP that low would suggest R-sided failure, which suggests cardiogenic shock. In which case, fluids could be a bad idea, as it'll end up in the lungs. But, with semi-okay neuro and warm/dry skin, he's not in cardiogenic shock. It's a fluid/container problem, but nothing to do with the pump.
C) Hyperkalemia IS possible with the Hx of Renal Failure, weakness, and tachypnea. Possibly also explains the hypotension. However, seeing as he had just had dialysis the morning before, I would be skeptical of this. Especially with a RSR ECG - If it's far enough that you have hypotension, I believe you'd see the arrhythmias. Correct me if I'm wrong.

D) Wasn't a stroke. Ischemic would have deficit and no fever, and Pons bleed would have fever but severely decreased LOC and decreased respiratory rate.

E) Good call on the Murphy's sign, didn't even think of that. While elderly may have a marked reduction in the sign, it'd still be a good sign. -thumbs up-

F) UTI wouldn't cause the BP problem. It WOULD cause a septic problem which would cause the BP problem.

Yes, please study up on that chapter!

Also, never look at a lead II for anything other then a rate. It will fool you over and over!

 

[MonkeySquasher]

Also, with right-sided heart failure the fluid would back-up into the peripheral vasculature and you would have edema and JVD, which the OP mentions nothing of in the physical exam he typed out.

EDIT: Also, he did not have dialysis the morning before... he gets Tuesday, Thursday, Saturday, and per the OP this scenario takes place on a Monday.

haha Well, foot in mouth. Yeah, I meant Left-sided failure. I always look at it the wrong way. =(

And good point with the dialysis, I was thinking in terms of every other day, and forgot that over the weekend he'd go 2 days. =x

 

[Akulahawk]

Yes, please study up on that chapter!

Also, never look at a lead II for anything other then a rate. It will fool you over and over!

I had a supervisor that once told me that Lead 2 told her everything she needed to know... It's kind of a sad story, that she was my boss and right out of Medic school, I was a better medic than she was. For all intents and purposes, she was also a new medic. :wacko:

 

[Veneficus]

You respond to a private residence for an "Unknown Medical".

83 year old male, generally ill in appearance, weighs about 140 lbs. (64 kg) and about 5'9" (170 cm), sitting upright in a chair. Multiple family members in vicinity as there was some sort of family party/event preceding this incident.

HPI: pt reports RUQ and RLQ abd pain x 1-2 hours, "dull" quality. Pt stood up to go home, then felt weak and dizzy accompanied by nausea, but no vomiting. Family reports a "glazed" look in his eyes and period of disorientation (not able to answer questions). Returning to a sitting position has not appeared to improve symptoms.

Vitals: BP - 70/40, P - 90, RR - 24, SpO2 - 92%, Skins - hot and dry, Temp. - 100.3 F (37.9 C)

ECG: NSR with no ectopy

Medical History: Renal Failure (recently placed on dialysis - Tues. Thurs. Sat. - today is Monday), chronic kidney infections, BPH, COPD, HTN (recently taken off HTN meds), chronic nephrolithiasis (mainly struvite, staghorn stones)

Allergies: Sulfa drugs - pt reports generalized edema and rash formation

Medications: Procrit, calcium acetate, phosphorous, citalopram, albuterol, and OTC stool softener

Physical Exam:
Constitutional - slightly febrile (not present this AM with home RN visit), reports general malaise all day, feels weak and dizzy
Head - normocephalic, atraumatic, equal facial symmetry, pupils PERRLA.
Neck - no JVD, no masses, no stomas, trachea midline
Chest - denies chest pain/discomfort, no palpitations, no accessory muscle use, breath sounds clear x 6, pt has a hickman catheter for dialysis
Abd - RUQ and RLQ pain, increases on palpation, no rigidity, no distention, no pulsatile masses, normal bowel movements. Positive for nausea, no vomiting.
Pelvis - pt has foley cath and 2 uretral stents which were placed 3 months ago after an exploratory surgery aimed at determining cause of chronic kidney stones and infections
Extremities - unremarkable

You are an ALS unit with all your typical capabilities and equipment. You have a general hospital (not a "doc-in-the-box" but not a teaching hospital either) with a 2 minute ETA, another general hospital with STEMI and Stroke capabilities with a 20 minute ETA, and a Level II medical center 35 minutes away. Have at it.

I think there are likely multiple etiologies going on.

Sepsis is a major issue, especially with all of the invasive medical hardware involved. Recurrent UTIs that make it to the Bladder are extraordinarily tough to treat. (worse if it is a gram (-) or resistant)

It is important to point out that a standard 12 lead EKG shows only the left side of the heart. Is does not rule out NSTEMI or Right sided MI without Changing the precordial leads to the right. Which I would most certainly run a v1-6 R look.

While the sudden drop in BP is indicative of a right sided MI, in my experience with right sided MI I have usually saw bradycardia with it. So while I would look for it, I am not really convinced right sided MI is going to be on the menu.

Endocarditis with valvular malfunction or failure is definately a possibility.

Peritonitis certainly is a possibility, but without rebound tenderness, it is not obvious if it is.

Medication toxicity, procrit can cause a host of probelms, common side effects include: Nausea, Constipation, Fatigue, Vomiting, Fever, Pain, Infection.

There could also be problems with anemia normally which might not be correctable with diminished iron stores/metabolism.

There is also the possibility of bleeding/leakage from damaged urethra or extravasiation of the dialysis catheter.

There could also be a clotting problem from chronic depletion of clotting factors.

The stones are caused from infection usually, so sepsis is a very likely pathology here in addition to other issues.

On an ALS squad, 2-4L NC, (I have outgrown NRB for conditions nonspecific) A large bore IV, Probably 2. (in an 83 year old emaciated, probably an 18G) 12 lead, 12 lead v1-6 R, continue to monitor, If mental status or BP decreased I would consider some dopamine or epi drip whatever I had. No response to it would point to a bleed. It could also help with valvular insufficency. I would be very careful about adding fluid. If pressed I would start small probably 250. Destination for such a complex case, we are going 35 minutes to the academic center. Stroke and stemi may not have a urologist, nor emergent dialysis. This may also require some very capable intensive care.

 

[EMTinNEPA]

It is important to point out that a standard 12 lead EKG shows only the left side of the heart. Is does not rule out NSTEMI or Right sided MI without Changing the precordial leads to the right. Which I would most certainly run a v1-6 R look.

Excellent point! A right-sided 12-lead didn't even cross my mind.

 

[thegreypilgrim]

Outcome

Well thanks very much to everyone who replied. Everyone seemed to have interesting and valid points to make.

Ultimately this pt was brought to the closest facility, where upon arrival his BP had improved substantially - up to around 140/70 seemingly spontaneously.

This pt had a relatively positive outcome (I say "relatively" because he has not been discharged yet), was ultimately diagnosed with a new UTI, was dialysed upon admission and started on IV antibiotics. As it turned out there was no cardiovascular or neurological component to this particular presentation, but was simply another complication of his ongoing renal problems.

Thanks again to everyone.

 

[mycrofft]

No one looked at the belly?

Description, palp and ausc X 4 quadrants, percuss to differentiate gas from other soft expansion, and coincidentally do a McBurney's point rebound. Bruits at midline or (go to posterior belly) kidneys? And oral temp, or just a "mom-ometer" back of hand to forehead or posterior neck checking for heat and perspiration.
Glad he made it, three points for the team.

 

[Aidey]

Everyone should google "dialysis disequilibrium syndrome". Not that it applied in this case, but it could have.

Honestly, if a dialysis patient presents as septic. They're septic. It may seem like I'm over simplifying things, but dialysis patients have very high rates of sepsis. They may absolutely have something else going on (or a few something elses), but if it looks like sepsis you can bet good money it is.

Think about the dialysis process, the blood is taken out of a body and run through a machine causing anything local to become systemic. The dialsyis treatment can actually induce sepsis because it causes the infection to spread rapidly. I've seen patients come into treatment totally fine, and end up leaving 3 hours later in an ambulance with a temp of 105, altered LOC and crappy vitals.

Where I worked we checked the pts temp on a regular basis, and if their temperature was too high at the start of their treatment they either were sent to the hospital, or the RN would get orders for antibiotics and tylenol from the doc.

Something else to keep in mind is that the patients with the catheters have much higher rates of sepsis than the ones with fistulas or grafts. A large majority of them have MRSA, and rising numbers have VRE and other resistant organisms.

Also, a dialysis catheter is a type of central line. If you have protocols for central lines and the pt is critical, forget the IV and just use the catheter. You can even draw labs from it if you evacuate the heparin first.

 

[Veneficus]

Something else to keep in mind is that the patients with the catheters have much higher rates of sepsis than the ones with fistulas or grafts. A large majority of them have MRSA, and rising numbers have VRE and other resistant organisms.

Read up on biofilm in any microbiology text. Nasty stuff, likes to attach to indwelling medical devices.

Like I said, if the infection is in the bladder, it is going to be a long hard fight to get rid of it.

ab do not readily penetrate. Whatever is growing can hang on a very long time.