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Shock in the Emergency Department February 28, 2014

Posted by Andy Jagoda, MD in : Cardiovascular , trackback

March’s Case: You are working in the ED late one evening when an 82-year-old man is brought in by his son. His son reports that earlier today, his father had been in his usual state of health, but this evening he found his father confused, with labored breathing. On arrival, the patient has the following vital signs: temperature, 38°C; heart rate, 130 beats/min; blood pressure, 110/60 mm Hg; respiratory rate, 34 breaths/min; and oxygen saturation, 89% on room air. He is delirious and unable to answer questions. A focused physical examination demonstrates tachycardia without extra heart sounds or murmurs, right basilar crackles on lung auscultation, a benign abdomen, and 1+ lower extremity pitting edema. You establish intravenous access with a peripheral catheter and send basic labs. A further history obtained from the son reveals that his father has congestive heart failure with a low systolic ejection fraction, as well as a history of several prior myocardial infarctions that were treated with stent placement. As you consider this case, you ask yourself whether this patient is in shock, and if he is, what are the specific causative pathophysiologic mechanisms? You review which diagnostic tests are indicated to assist with the differential diagnosis of shock and you consider options for the initial management of this patient.

Tell us your diagnosis in the comments box below and check back regularly to see what other emergency physicians have said.  The correct diagnosis will be published on March 8!

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Comments»

1. ashok khanna - March 1, 2014

possible pneumonia /sepsis, Chest x-ray, EKf and cbc with diff and chemistry result and ekg for further differential diagnoses are needed.

2. Ryan - March 1, 2014

Definitely sounds like shock… however, not sure if purely cardiogenic in nature with the fever of 38.0 – would look for sources of infection as well…

3. alice knittel - March 1, 2014

CHF

4. Shravanti Halpern - March 1, 2014

The patient definitely comes under the criteria for sepsis. Given the signs, he probably has pneumonia/respiratory infection. He is not in septic shock yet (SBP <90mmHg) but definitely could be "cryptic shock". However, due to poor EF and already 3rd spacing, it would be difficult to give this patient the typical required initial fluid resuscitation (1-2L) without throwing him into pulmonary edema. This is someone who would require intubation, "gentle hydration" along with an ionotrope (Dobutamine or Milrinone) + a vasopressor (probably Norepnephrine or Phenyephrine) as part of the EGDT. Broad antibiotic coverage for respiratory infection most definitely needs to go in as well.

5. Cecilia cruz - March 2, 2014

He is in compensated septic shock. May have a component of cardiogenic decompensation, but likely secondary to sepsis.

6. suresh naidu - March 2, 2014

Going through ABC …obviously there is problem with breathing and maybe circulation. I will get a ECG …and a quick assessment for shock. I will use ultrasound going through RUSH (rapid ultrasound in shock) protocol.mainly focusing in quick echo and IVC …to look for the need to fluid resuscitation or inotropes. If patient baseline blood pressure is known …it can be assumed fall in 30% MAP is considered as shock. differntial diagnosis for this patient 1- pneumonia with severe sepsis TRO septic shock 2. ACS precipitated by pneumonia 3. acute on chronic heart failure precipitated by pneumonia ( with or without cardiogenic shock) 4. respiratory distress secondary to pulmonary embolism(less likely)

7. Laurel K - March 2, 2014

The abrupt onset of tachycardia, tacypnea, and fever in the presence of localized lung findings and hypoxia is suspicious for sepsis due to pneumonia. Although his underlying CHF certainly will make his response to sepsis more difficult, this seems to be a secondary rather than primary issue. If there was more suggestive physical exam info, for example JVD, hepatojugular reflux, or an S3–though I find them hard to hear in the ER–CHF would be a higher consideration. An ECHO would help to see the ventricular motion and to see if a pericardial effusion was present/contributing to the problem.

Other considerations include PE (always out there but I think less likely) and hypovolemia (also unlikely given his son’s observation of patient’s normalcy earlier in the day).

A portable stat CXR and bedside troponin and EKG will help make some immediate determinations (I’d know something about the state of failure within 15 minutes) In addition I would want to do cultures, give some antibiotics, and get some initial labs including lactic acid and ABG.

8. daniel - March 3, 2014

since he is febrile he most likely has compensated septic shock / sirs

9. rajesh - March 5, 2014

its obstructive shock with underlying LRTI, treated with antibiotics, diuretics and inotropes, if airway compromised then ventilation.

10. Zulkarnain AB HAMID - March 6, 2014

Taking shock as hypoperfusion, his altered mentation is already an indicator of altered perfusion. This patient likely has severe sepsis (sepsis + organ involvement) and while the BP is not low yet, a lactate of >4 would clinch the diagnosis of septic shock.

I agree that the the cardiac manifestation is likely secondary to the primary event (distributive shock) and manifests as a result of the heart not being able to cope with the increasing chronotropic response (the only way the body can respond acutely to decreased DO2 is to increase cardiac output –> tachycardia).

Issues:
1. Severe sepsis (possibly septic shock) from severe pneumonia (unilateral crackles + fever)
2. Early decompensated heart failure secondary to inadequate reserves for adequate cardiac response

Plan:
1. CXR
2. full blood count, renal panel (chek creatinine and electrolytes), lactate, ABG (low saturations – check P/F and even ventilation)
3. blood culture

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