CHF / Hypercapneic / Hypotensive pt

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Patients drop their BP after intubation all the time.

 
The common ddx of hypotension is hypovolemic / bleeding, cardiac, or sepsis.  We were not sure why this patient became hypotensive.  While we were putting a cv line in the patient and on sono, we saw that his IJ was huge, the heart looked sort-of ok; leaving sepsis to be our leading dx.  We started levo.

 
A bnp of 522 is not definitive in ruling in or out acute pulmonary edema.  It didn’t help us.

 
We left the trop alone.  We didn’t think that the patient was having acs.

 
There are two options to sedating a patient with a low BP – (1) use a BP-stable drug such as etomidate or ketamine, (2) take your chances with a drug that may lower the BP  – benzo, fentanyl, etc.  We chose to start him on a versed drip.  The BP didn’t drop any further, but the levo was on board.

 
We scanned the patient’s abd wall.  In very obese patients, abd wall cellulitis may hide a massive collection.  I don’t know whether you can see it on sono, but I know you can see it on CT.  The scan should be done because it may lead to a trip to the OR or sicu.  The patient’s CT was negative for collection, it looked like all cellulitis.

 
The patient went to micu.  Everything got better.  He left the hospital after about a week, only to return a few days later with the same thing and was re-admitted to the micu.

One Comment

  • Andrew Shannon

    So, an abdominal wall abscess _should_ be able to be visualized on POCUS. Find the area of cobblestoning that is concerning to you for cellulitis, then maximize your transducer for penetration into the soft tissue until you are able to see the deepest level (i.e. the peritoneum). This may mean taking your “Depth” all the way out, switching from “Gen” to “Pen” on the first soft key to selectively utilize the lower-frequency range of your transducer, and possibly switching from the linear to the curvilinear transducer. Once you’re sure you’re not missing the “deeper action,” fan methodically through the area of interest in two orthogonal planes. Be on the look out for fluid collections, a “swirl sign,” and of course, air (bright echogenic linear densities with “dirty shadowing” deep) in the sub Q.

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