RAPID RESPONSE

1
RAPID RESPONSE

• Hypotension

2
Hypotension

• 79 year old female from nursing home admitted
  with cellulitis

3
Rapidly Triage

• Get to the bedside!
• Will this patient be dead in.
• One minute
• One hour or
• One day

4
Initial Assessment

• ABC
• Stable vs. Unstable
• Initiate ACLS protocol?
• Artifact??
• What is the baseline?

5
Artifact

• Manual BP
• Check both arms
• Palpate Pulses

6
Artifact

7
Immediate Interventions

• IV Acces
• Airway management
• ACLS Protocol

8
Historical Information

• Past Medical History
• Medications
• E.R./Hospital Course

9
Medications

• Prophylactic Lovenox
• Coreg
• Aspirin
• Combivent
• Lipitor
• MVI
• Protonix
• Prozac
• PRN Percocet
• Metformin
• SSI

10
ER/Hospital Course

• ER Vital Signs T 100.7, HR 115, BP106/80, RR 20
  SPO2 91 on 2L nc
• Pt noted to be pleasant and mildly confused, had
  an indeterminate troponin. Given Ancef, NS at
  85cc/hr. Admitted to telemetry. U.O. past 12
  hrs 200cc

11
PMHx

• CAD s/p RCA stent 2004
• COPD on home O2
• HTN
• DM II
• Diverticulosis
• CEA 2008
• Appendectomy, hysterectomy

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Objective Data

• Physical Exam
• Laboratory Data
• Imaging

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Laboratory Data

• In ER
• WBC 14, HH 12/39, PLT 140
• Na 142, K 4, Cl 105, HCO3 14, BUN 40, Creat 1.5
  (1.1 2008), Gluc 175
• Bedside
• EKG inverted Ts inferior leads, No ST changes, S.
  Tach 135
• PCXR Small lung vol. no obvious infiltrate
• Gluc 220

14
Bedside Workup

• Vital Signs
• EKG
• PCXR
• Finger Stick
• ABG
• Labs (lactate, chemistries, cbc, cortisol, type
  and screen, cardiac enzymes)

15
Differential Diagnosis

• Cardiogenic Shock
• Hypovolemic Shock
• Hemorrhagic Shock
• Septic Shock
• Adrenal Insufficiency
• Medication Effects
• Artifact

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Treatment

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Treatment

• Fluids, Fluids, Fluids
• Crystalloid vs. Colloid vs. Blood Products
• Vaspopressors
• Steroids
• Central line insertion
• Transfer to higher level of care

18
Summary

• Initial rapid assessment ABCs
• Equipment IV, O2, monitor, suction etc..
• Determine need for immediate interventions
• Rule out artifact
• Restore intravascular volume
• Stabilize then transport