Hypotension

[Aussieaid]

Sounds most like a leaking AAA. With his liver failure he is at high risk of bleeding so even a small leak can be catastrophic. Only about 50% of cases of ruptured AAA present with the classic triad of severe acute pain, pulsatile mass and hypotension. He is most likely bleeding into his abdomen from somewhere or other possible diagnoses are a perforated bowel or even severe acute pancreatitis.

The mass in his RUQ is most likely his enlarged liver. The medication he was on was probably lactulose which scavenges the ammonia from the blood and into the colon in liver failure patients. It is more commonly used for constipation which is why he has chronic diarrhea.

Monitor, 2 large bore IV's, NRB with O2, titrate small fluid boluses to maintain normal GCS. Don't pour the fluids in wide open unless he has altered mental status and severe hypotension just in case it is a ruptured AAA. Treat the pain once you have adequate BP. Rapid transport to nearest surgical facility.

[Jaymazing]

No more walking him, if I can help it. There's a few things on the DDx, but the one that has me most worried is the potential AAA, which could be perpetuating his organ failure.

Can you describe the pain for me? localize? radiate? quantify?

Any mottling to the extremities?

​As far as I'm concerned, his pressure is low enough to warrent a 20cc/kg bolus. I'd like to get his BP above 80, and I'm titrating to 90. I also want another big bore IV, and I'll position him in trendelenburg.

I feel like correcting the BP will fix the nausea. If not I'd be thinking of Zofran.

Any changes?
Hold off on narcs, I wouldn't want to be chasing my tail fixing his BP.

[MariB]

I'm concerned about his weakened system and illnesses, dehydration from possible C diff. Pain very common. He needs fluids and fast

[DartmouthDave]

Hello,

Pressure typically runs on the low side for liver failure patients due to vasodilation. However, this is too low.

If the renal failure is due to Hepatorenal Syndrome things are not looking too good for this patient.

I do not like the low SpO2. Pleural effusions are common in liver failure as well. However, for some reason not well understood (more so by me) these patient can develop Hepatopulmonary Syndrome. Massive vasodilation of the pulmonary vessels causes a huge shunt. If I recall, laying these patient flat helps with oxygenation. BUT, I am not sure of this last statement.

Plus, as noted above, this risk of bleeding, infection et al.

I think I would give some fluid. I would start with a NS 500cc bolus. Plus, getting moving.

Cheers

[fakingpatience]

Aussiland: Thank you, yes the medication is lactulose which causes his chronic diarrhea.

You start asking the patient more about his pain, he says that it is in the center of his abdomen, radiating into his back; "feels like it is ripping me in half." Pain is 10/10. Try as you might, you cannot feel any pulsating masses. As mentioned before, his abdomen is extremely distended and rigid. No molting noted in his extremities, just very very pale.

Attempt to lay the patient flat, but he develops a panicked expression and tells you it is much more difficult to breath. You settle on a low semi-folwers position.

As DartmothDave suggested, when you ask this patient about his blood pressures, he says running in the mid 90s systolic is not unusual for him. His BP was last checked after dialysis treatment 2 days ago and was in the mid 90s; was 120s systolic pre dialysis.

You have your second IV, but all you could find is a 22G in his R hand (did I mention your partner was a wizard for finding the aforementioned 18?)

Place the patient on nasal cannula at 3 lpm and his spo2 improves to 99%

Start Normal Saline fluids running wide open and hit the road. Oh, did I mention you are ~45 mins away from the nearest hospital?

En route you go to take your next blood pressure using the autocuff and you hear a loud hissing noise from it; the autocuff just broke (gotta love technology!) Grab the manual blood pressure cuff, but you are unable to hear anything. No palpable radial pulses, no palpable brachial pulses. Patient is still Sinus tach ~110 on the monitor, AAOx4.

How much fluids do you give this guy?

Any pain medication? (you have morphine, dliaudid, and fentanyl at your disposal)

[Kaisu]

I'm going with a dissecting aorta and I am looking for a chopper. Fluid replacement needs to be balanced with the likelihood of increasing his already pretty nasty bleeding. I would titrate fluids to keep MAP at 60 and would start thinking about vasoconstrictors. Have you got an anxiolytic/amnesiatic agent on board?

[fakingpatience]

I'm going with a dissecting aorta and I am looking for a chopper. Fluid replacement needs to be balanced with the likelihood of increasing his already pretty nasty bleeding. I would titrate fluids to keep MAP at 60 and would start thinking about vasoconstrictors. Have you got an anxiolytic/amnesiatic agent on board?

Crappy weather, no ones flying, sorry!

For pain/ anxiolytic drugs you have fentanyl, morphine, dilaudid, ativan, valium, versed, and etomidate

Your pressor options are dopamine, levaphed, or mixing an epi drip

Out of curiosity, why are you wondering about an amnesiatic agent?

[island emt]

Because then the pt won't remember hearing me go OH SHIT ,OH SHIT :-]

I'm not sold on the AAA but it's always possible to not feel the pulsating mass with a distended abd. The description of " radiating into his back; "feels like it is ripping me in half." Pain does lead us down that path of DD.

Did you check femoral pulses by chance?

Whatever the cause this guys definitely circling the drain and someones already pulled the plug. It's going to be a long ride trying to keep him stable.

[mobey]

I am going to go at this another way.

If I can't get a BP, but I have tachycardia, Im gonna say it's critically low.

I'll start up a Dopamine drip and titrate for palpable pulses with warmish extremities if I cant get a BP.

Here is where I differ though.

I have had 6 ~ patients die in my care, a couple have been in agony, with one of those being a disecting AAA. The reality is, this guy probably isn't going to survive the next 24hrs (Is he even going to be a surgical candidate?). I would be heavy on the narcs.... i'd rather Ketamine..... But if I must, Fentanyl will be just OK.

Giving small doses (50mcg) at a time, and not stopping till he is half asleep. It will be like chemistry class... a little Dopamine/fluid, let the pressure come up - A little pain control. Repeat.

[ERDoc]

The differential on this guy is huge. Ruptured AAA is definitely on the list. With the guy's underlying liver pathology we also need to add varcieal bleeding from portal hypertension, SBP and relative intravascular hypovolemia secondary to third spacing.

I would say we also need to be very cautious about the fluid and drug use. I'd like to get his pressure up with pressors. I know we are thinking ruptured AAA as one of the possibilities, but I'd like to get his pressure a little higher so that we have some wiggle room once we start trying to titrate his pain meds. This is one of the few pts that needs diesel and lots of it.