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RAPID RESPONSE

RAPID RESPONSE. Hypotension. Hypotension. 79 year old female from nursing home admitted with cellulitis. Rapidly Triage. Get to the bedside! Will this patient be dead in … . One minute One hour or One day. Initial Assessment. ABC Stable vs. Unstable Initiate ACLS protocol?

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RAPID RESPONSE

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  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

  12. Objective Data • Physical Exam • Laboratory Data • Imaging

  13. Laboratory Data • In ER: • WBC – 14, H&H 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

  16. Treatment

  17. 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

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