The transiently hypotensive patients can be some of the weirdest patients you face in the emergency department. They may come in with a list of hypotensive readings from home only to be normotensive at triage. It’s easy to look at a patient’s long list of medications and anchor on his or her antihypertensives as the cause of the symptoms. But before you do that it is important to have a stepwise approach to ensure that you are not missing any of the life threats.
When you face these patients the first question you should ask yourself is if there are any wild cards. For example, Is the patient immunosuppressed and hiding an infection. Or has the patient recently undergone a surgery and the low blood pressures as are a sign of a post operative bleeding? (for more on wild cards check out our lecture on the subject at https://www.blog.numose.com/emed-basics/wild)
Now that you took the second to consider wild cards, let’s now consider each of the possible causes of shock.
Cardiogenic Shock: Is the patient presenting with new onset heart failure secondary to an atypical MI? Did the patient have a recent URI and now is presenting with myocarditis?
Distributive Shock: Whenever you think of infection think of the 3 most common places for infections to develop. Lungs, Urine, Skin. Be especially vigilant about this cause of shock in your patients that are immunosuppressed or super old.
Obstructive Shock: Did your patient have a PE? Is the patient a dialysis or chemo patient that now has a pericardial effusion?
Hypovolemic Shock: Is the patient hemorrhaging from somewhere? Did the patient eat a bad burrito and now has massive diarrhea and cannot keep up with his/her fluid losses.
Neurogenic Shock: Did the patient sustain some type of trauma that disrupted his/her sympathatetic chain?
Now that you have your differential you can now focus your history and physical. You know what things to ask in your history and what things to look out for on the physical exam. For example to assess for cardiogenic shock you will remember to ask your patient if they had DOE or PND. On physical exam you will specifically look for JVD, auscultate the lungs for crackles, and look at the legs for edema.
You are also ready to Initiate a work up based on the differential:
Cardiogenic shock: Order an EKG and a troponin. Consider doing an ultrasound looking at EF, pericardial effusion, and the status of the IVC. Do a bedside ultrasound so see if the EF is ok or bad.
Distributive shock: Get a Chest Xray and a UA to assess for infection. Be sure to do a full skin exam, including looking at the perineum. Look at every square inch of your patient to make sure you are not missing a cellulitis, abscess, or necrotizing fasciitis.
Obstructive shock: Consider calculating a Well’s score and getting a D Dimer if there is concern for a PE. Do a bedside ultrasound to see if your patient has a massive pericardial effusion.
Hypovolemic shock: Order a CBC and a PT/INR/PTT in order to make sure that the patient is not anemic or at increased risk of bleeding.
Neurogenic shock: Consider getting imaging of the spine if there is the right trauma history.
You don’t always have to order a multimillion dollar work up on these patients but it all comes down to the patients history, physical, and whether or not there are any wild cards. These features will either raise or lower your threshold to order tests (review the ED Mindset for more on this topic https://www.blog.numose.com/emed-basics/mindset).
To Admit or Discharge:
This is always the hardest question to answer especially in a patient that has had a negative work up. If the patient has any wild cards you should consider admitting the patient for observation. These patients have a higher rate of adverse outcomes when discharged home. It is important to also weigh in what the follow up with the patient will be. If the patient can be seen by his or her pmd the next day then that can make it easier to discharge the patient home. Finally have a conversation with the patient. Most patient’s don’t want to be admitted to the hospital. Tell them the results and explain to them your concerns and see if the patient wants to stay or be dced home. If the patient doesn’t want to stay in the hospital then you have your answer and be sure to document in your MDM the shared decision making.
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