Shock

Yes. She has clear evidence of end-organ dysfunction (decreased LOC, hypoxemia, oliguria)

inadequate tissue perfusion to meet cellular requirements of oxygen and nutrients. Manifested in this patient by hypotension, decreased LOC, hypoperfusion of skin and oliguria.

Yes - still evidence of end-organ dysfunction

normal blood pressure in this scenario is not reassuring, considering his history of HTN. Clinically, the patient has inadequate tissue perfusion (poor peripheral tissue perfusion and oliguria).

Given the ECG findings (that you haven't seen because I am too lazy), this patient is having an acute MI. He needs definitive therapy as quickly as possible.
Dependingo n what resources are available in the centre you are practicing, thrombolysis or percutaneous coronary intervention (PCI) should be arranged urgently. In the meantime, the usual therapy for an ACS should be undertaken: 160 mg ASA chew, nitro spray or SL nitro, heparin IV, beta-blocker if pulmonary edema, ACE inhibitors and statin (later). Once the underlying etiology has been addressed, potentially modifiable variables (content, contractility, rate, rhythm, afterload, preload) must be addressed; then complications (pulmonary edema, acute renal failure)

The correct answer is "all of the above" because when a patient presents with a right upper-lobe infiltrate on a chest x-ray, it indicates a possible lung infection. In order to manage this patient, it is important to administer crystalloids in boluses to maintain fluid balance, initiate broad-spectrum antibiotics to target the infection, find the source of the infection to prevent further spread, and draw cultures as soon as possible to identify the causative organism and guide targeted treatment. Therefore, all of the mentioned actions are necessary for the initial management of this patient.

low JVP, cool extremities, history of blood loss, lack of history suggestive of decompensated distributive shock - suggest that this is most likely hypovolemic shock.

You would do all of the above, but you would do the ABCs (Airway, Breathing, Circulation) first.

The patient's symptoms, such as fever, lethargy, productive cough, and yellow sputum, along with her vital signs, including high heart rate, low blood pressure, and low oxygen saturation, suggest an infection. The fact that she has not urinated in 24 hours indicates possible kidney dysfunction. These findings are consistent with septic shock, which is a type of distributive shock caused by a severe infection leading to systemic inflammation and organ dysfunction.

You would do all of the above, but you would do the ABCs (Airway, Breathing, Circulation) first.

A mild elevation in lactate in this patient signifies both end-organ hypoperfusion and anaerobic metabolism. End-organ hypoperfusion refers to inadequate blood flow to organs, which can be caused by various conditions such as shock or heart failure. Anaerobic metabolism occurs when there is insufficient oxygen supply to tissues, leading to the production of lactate. Therefore, a mild elevation in lactate suggests that the patient may be experiencing both inadequate blood flow to organs and anaerobic metabolism, which can be indicative of impending respiratory failure.

During the CIRCULATION portion of ABC, checking for evidence of end-organ function is important to assess the overall perfusion and function of vital organs. This helps in determining if the circulation is adequate or if there are any signs of organ dysfunction. Obtaining IV access is also crucial during this phase as it allows for the administration of fluids and medications to support circulation and maintain blood pressure.

The most likely source is from the GI tract, but a coagulopathy with hemoptysis and bleeding from hemorrhoids is also a remote possibility. From this information, we can begin to narrow the DDx for the etiology of her shock state.

Given the warm extremities, the hypotension and the end-organ dysfunction, this is distributive shock.

The highest considerations on the DDx are cardiogenic and obstructive shock. Given his history, his cardiac risk factors and his physical exam (cool extremities, high JVP, S3, crackles), this is most likely cardiogenic shock. Although the initial presentation of abdominal pain may make some students consider hypovolemic shock initially, the elevated JVP makes this unlikely.

The ABG results indicate a low pH (7.26) and low bicarbonate (HCO3-) level (13), which suggests metabolic acidosis. The anion gap is elevated (30), indicating the presence of unmeasured anions in the blood. The respiratory compensation is evident by the low partial pressure of carbon dioxide (PCO2) of 30, which is in the expected direction to compensate for the metabolic acidosis. Therefore, the correct answer is "wide anion gap metabolic acidosis with resp compensation." This suggests that there is an underlying metabolic acidosis with an elevated anion gap, and the respiratory system is compensating by decreasing the PCO2 levels.

During the BREATHING portion of ABC, it is important to check for adequate O2 saturation and apply oxygen to the patient. This is because ensuring the patient has sufficient oxygen levels is crucial for their respiratory function and overall well-being. By checking the O2 saturation and providing oxygen if necessary, you can help support the patient's breathing and prevent further complications.

When a patient is acutely bleeding and no fluid resuscitation has been undertaken, the hematocrit (and measure Hb levels) will remain relatively unchanged. It is only after fluid resuscitation is underway, or there is time for equilibration of extravascular fluid to the intravascular space, that a drop in Hb will become manifest on a CBC. The important point ot stress is that a normal Hb level cannot be used to rule out hemorrhagic shock.

DO2 = CO x [(1.34 x Hb x SaO2) + (0.003 x PaO2)]

Hb: an "adequate" Hb level is needed to carry oxygen to the tissues.
SaO2: maximize oxygen saturations in the short-term (increase FiO2, intubate if necessary)
PaO2: does not make a significant contribution given the very small value.

Currently, contractility is maintained in this patient (high cardiac output state - warm extremities). However, the patient is inappropriately vasodilated leading to the hypotension. If this patient progresses to decompensated septic shock, then an agent to increase contractility may be needed.

Evidence of end-organ dysfunction: confusion, decreased level of consciousness (CNS); hypotension, tachycardia, poor pulses, poor peripheral perfusion, decreased capillary refill (CV); tachypnea (resp); decreased bowel sounds, hepatic dysfunction (GI); decreased urinary output, anuria (GU); decreased perfusion, livedo reticularis (skin). Evidence of an underlying etiology for the shock state.

During the AIRWAY portion of ABC, you would check for adequate level of consciousness, cough, and gag reflex. These assessments are important to determine if the patient's airway is patent and if they are able to protect their airway. If the level of consciousness is decreased, it may indicate a compromised airway. Adequate cough and gag reflex are signs that the patient can effectively clear their airway and protect against aspiration. These assessments help ensure that the patient's airway is open and functioning properly.

The potentially modifiable variables for every patient in shock include blood content, cardiac contractility, heart rate, heart rhythm, afterload, and preload. These variables can be adjusted or manipulated to improve the patient's condition and stabilize their vital signs. By addressing issues such as low blood volume, poor cardiac contractility, abnormal heart rate or rhythm, increased afterload, and inadequate preload, healthcare providers can work towards restoring the patient's hemodynamic stability and improving their overall prognosis.