Shock by

julierobinson3 — 2021-05-03 16:27:34 UTC

Your patient (male, 73 years old) has been admitted following an emergency laparotomy secondary to a small bowel obstruction. He has a medical history of T2DM, obesity and hypertension. He takes metformin, lingaliptin and ramipril.
He is a retired bus driver.

There are ECG changes (see snapshot below) which could indicate a myocardial event has occurred recently.

The patient is intubated and mechanically ventilated.

HR 120 in ST, Temp 35.9
His blood pressure is 70/40, MAP of 50

Urine output 10 ml/hr x 3 hours.

Cool peripheries, CRT 4-5 secs.

Recent ABG: pH 7.32, PaCO2 4.3, HCO3 18, BD -5, PaO2 11.1 on 0.5 FiO2, Hb 98, SaO2 96%, lactate of 3.1, K+ 3.0, Glucose 12.8.

Abdomen closed, soft and mildly distended

Sedated via Propofol and a Fentanyl infusion.

Assess his haemodynamics using Problem, Objectives, Plan....

julierobinson3 — 2022-02-16 15:40:12 UTC

Metabolic acidosis

2023-07-04 12:53:20 UTC

Lactate >2

2023-07-04 12:53:43 UTC

Reduce lactate

2023-07-04 12:56:39 UTC

Improve pH/acidosis status

2023-07-04 13:02:17 UTC

Fluids, Sodium Bicarbonate

2023-07-04 13:02:56 UTC

oliguria

2023-07-05 12:48:41 UTC

increase intravascular volume

2023-07-05 12:49:18 UTC

vasopressors

2023-07-05 12:49:49 UTC

low BP and MAP

2023-07-07 09:33:53 UTC

higher HR

2023-07-07 09:33:59 UTC

low potassium

2023-07-07 09:34:28 UTC

high blood glucose level

2023-07-07 09:34:46 UTC

electrolyte replacement

2023-07-07 09:35:56 UTC

insulin +/- fluids for BGL

2023-07-07 09:36:11 UTC

filter if poor renal function/diuretics if appropriate (FB dependent)

2023-07-07 09:38:05 UTC

T wave inversion in the lateral leads potentially due to acute ischaemia. In this ECG T wave inversion occurs in contiguous leads 1, AVL, V5 and V6

2023-07-09 13:54:05 UTC

prevent further ischaemia and reperfuse heart

2023-07-09 14:09:29 UTC

review for ? PCI or conservative management

2023-07-09 14:09:57 UTC

replace pottasium

2023-07-09 17:15:21 UTC

stabilise bp

2023-07-09 17:16:13 UTC

troponin/echo

2023-07-09 17:17:43 UTC

low temp

2023-07-10 12:44:57 UTC

?antibiotics if septic

2023-07-10 12:45:35 UTC

Bloods incl cultures

2023-07-10 12:48:05 UTC

low blood pressure, leading to reduced prefusion of the organs, causing potential AKI

2023-07-10 14:36:06 UTC

moderate amount of FIO2

2023-07-10 14:36:45 UTC

vasopressors

2023-07-10 14:40:37 UTC

control glucose levels, insulin infusion

2023-07-10 14:41:07 UTC

Cool peripheries and prolonged CRT

2024-03-05 17:08:20 UTC

Formal blood result to determine renal function

2024-03-05 17:10:27 UTC

Give blankets or potentially warming blanket to help peripheral and core temperature

2024-03-05 17:11:40 UTC

2024-03-10 16:50:05 UTC

Anticoagulation review if safe to use after surgery

Provide nutrition parenterally

2024-03-10 16:50:55 UTC

Judicious fluids and inotropic support

2024-03-10 16:51:11 UTC

Post op hypovolemia (no EBL)

2025-03-24 21:17:44 UTC

Review sedation

2025-11-26 12:24:18 UTC

2025-12-01 16:51:04 UTC

might need CRRT

Abdo mildly distended with lactate of 3.1 - to monitor this closely

2026-03-17 14:11:54 UTC

Low U/O with low map - fluid status?

2026-03-17 14:12:11 UTC

Look at full bloods - consider RRT

2026-03-17 14:12:27 UTC

Administer/rationalise Abx

2026-03-17 14:13:01 UTC

Fluid resuscitation - inc K+ top up +/- Mg top up if required.

2026-03-17 14:14:08 UTC

Imaging such as CT Chest and Abdo Pelvis

2026-03-17 15:54:18 UTC

Temperature Control

2026-03-17 15:57:42 UTC