Shock Case Study 15 pts HPI Mrs K is a 22 yo college student

Shock Case Study (15 pts)

HPI. Mrs. K is a 22 y/o college student, rushed to the ED 35 minutes after sustaining multiple stab wounds to the chest and abdomen by an unidentified assailant. A witness called 911. Paramedics arriving at the scene found the victim to be in severe acute distress.

Vital signs were as follows: HR 128 (baseline 80), BP 80/55 (baseline 115/80), RR 37 and labored. Chest auscultation revealed decreased breath sounds in the R lung consistent with basilar atelectasis (ie. collapsed R lung). Pupils were equal, round, reactive to light, and accommodation. Her LOC was reported as “awake, slightly confused, and complaining of severe chest and abdominal pain.” Pedal pulses were absent, radial pulses were weak, and carotid pulses were palpable. The patient was immediately started on IV Lactated Ringer’s solution at a rate of 150 mL/hr.

An ECG monitor placed at the scene of the attack revealed that the patient has developed sinus tachycardia. She was tachypneic, became short of breath with conversation and reported her heart was pounding out of her chest. She appeared to be very anxious and continued to c/o pain. Her skin was cool and nail beds were pale but not cyanotic. Skin turgor was poor. Peripheral pulses were absent with the exception of a thread, brachial pulse. Capillary refill time was 7-8 seconds. Doppler ultrasound had been required to obtain an accurate BP reading. The patient’s skin was cool and clammy. There was a significant amount of blood on her dress and on the pavement where she was lying.

Question 5. Explain the pathophysiology of the patient’s altered mental status. (2pts)

During transport to the hospital, vital signs were reassessed: HR 138, BP 75/50, RR 38 with confusion. Patient was diagnosed with hypovolemic shock and IV fluids were doubled. Oxygen was started at 3L/min by nasal cannula. ER physicians chose not to start a central venous line. An indwelling foley catheter was inserted with return of 180mL of amber colored urine. Urine output measured over the next hour was 14mL. Patient was taken to the OR for surgical correction of lacerations to the right lung, liver and pancreas. In total, patient received 1L of Lactated Ringers.

Question 6. Based on the urine output rate, is this patient at risk for renal failure? (2pts)

Question 7. Is hypovolemic shock a medical emergency? State why or why not? (2pts)

Question 8. Based on the American College of Surgeons classification tool (Table 1) for estimating blood loss, how much blood loss (%) has this patient experienced and what class of blood loss does the patient fall into? (2pts)

Table 1.

Class

Parameter

III

Blood loss (ml)

<750

750–1500

1500–2000

>2000

Blood loss (%)

<15%

15–30%

30–40%

>40%

Pulse rate (beats/min)

<100

>100

>120

>140

Blood pressure

Normal

Decreased

Respiratory rate (breaths/min)

14–20

20–30

30–40

>35

Urine output (ml/hour)

>30

20–30

5–15

Negligible

CNS symptoms

Normal

Anxious

Confused

Lethargic

Class

Parameter	I	II	III	IV
Blood loss (ml)	<750	750–1500	1500–2000	>2000
Blood loss (%)	<15%	15–30%	30–40%	>40%
Pulse rate (beats/min)	<100	>100	>120	>140
Blood pressure	Normal	Decreased	Decreased	Decreased
Respiratory rate (breaths/min)	14–20	20–30	30–40	>35
Urine output (ml/hour)	>30	20–30	5–15	Negligible
CNS symptoms	Normal	Anxious	Confused	Lethargic

5. loss of consciousness (LOC) occurs at the time of trauma, lasting from a few minutes or hours to several weeks or even months. Lengthy LOC is known as coma. In this type of serious injuries the starting few days or immideately after trauma or injury may also produce negative changes in breathing and motor functions in the body. The observation of LOC at the time of concussion must be viewed as or it shows a potentially worrisome traumatic brain injury which will lead to coma also. LOC is followed by more severe acute mental status abnormalities and carries a greater risk of intracranial pathology. it might be chnaces of concussion without LOC. Prolonged LOC represents a neurologic emergency it is due to destctive phenomena of the nurons, which may require neurosurgical treatment as searly as possible. the concussion containing, Lingering symptoms even without LOC should be controlled or monitored carefullly and it is diagnised and treated according to established guidelines for safe return from the LOC

In the neurologic unconscious state, responses to the external stimmuli are reflexic or primary type. it may be absent altogether. Only in the somewhat higher level of function known as the minimally conscious state do we see the beginning of neurologic consciousness and higher-level behaviors indicating an awareness of the external stimuli.
It is important to diffrienties between unconsciousness from a neurologic cause and other uses of the term unconsciousness in psychology. Whereas psychological unconsciousness means to a state of unawareness or repressed ideas,

This kind of neurologic state shows a form of brain functioning not well or dysfunctioning which involve either the hemispheres or the deep structures of the brain. it also including the system, which governs sleep and wake cycles

LOC can occur from External forces that affect head movement cause mechanical stress within the brain tissue, producing a sudden electric discharge or depolarization of nerve cells throughout the brain. This electric depolarization leads to an outpouring of neurotransmitters in the brain, and a cascade of neurochemical changes results in excitatory and damaging effects on the nerve cells. The subsequent metabolic rearrangement can be measured by sophisticated functional neuroimaging techniques such as positron emission tomography (PET) scanning

The Glasgow Coma Scale is important for the identification of the seviarity of brain trurma. for the recovery r

Diffuse axonal injury (DAI)

Widespread axonal damage occurring after a mild, moderate, or severe TBI

Process takes approximately 12-24 hours

Clinical signs:

lowering of LOC

induction in ICP

Decerebration or decortication

Global cerebral edema

Complication can also be seen in this type of truma like subdural hemtoma, subacute subadural hematoma, periphral hematoma.

6. for the diagnosis of the kidney failure we must know the glomerular filtratin rate, which is not given in above problem

normal urine volume in helathy human is between 33 to 83 mi per hour, here the patient shows only 14 ml it suugest that their is something wrong. so it might be chances of kidney damage. or it may be also due to excessive blood loss.

7. yes it is hypovolemic shock certain strong evidence is as below, Hypovolemic shock is an emergency condition in which severe blood and fluid loss make the heart unable to pump enough blood to the body. This type of shock can cause many organs to stop working.

cool and clmy skin it is due to excesssive blood loss from the body

the othe factor which leads to the conclusion is breathing problrrm, lower blood pressure,confusion, anxiexy, LOC, decresed urin output.

8. blood pressure is 80/55

urine output is 14ml/hr

pulse rate is 128

RR is 37

so accroding to above data it belongs to class-III

so blood loss is from classs-III means it losses 1500-2000ml.