For the Disease Summary for this case study, see the CD-ROM. PATIENT CASE
Ms. K.Z., a 22-year-old university coed, was rushed to the emergency room 35 minutes after sustaining multiple stab wounds to the chest and abdomen by an unidentified assailant. A witness had telephoned 911. Paramedics arriving at the scene found the victim in severe acute distress. Vital signs were obtained: HR 128 (baseline 80), BP 80/55 (baseline 115/80), RR 37 and labored. Chest auscultation revealed decreased breath sounds in the right lung consistent with basilar atelectasis (i.e., collapsed lung). Pupils were equal, round, and reactive to light and accommodation. Her level of consciousness 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 intravenous lactated Ringer’s solution at a rate of 150 mL/hr. Patient Case Question 1. With two words, identify the specific type of hypovolemic shock in this patient. Hypovolemic Shock
An electrocardiogram monitor placed at the scene of the attack revealed that the patient had developed sinus tachycardia. She was tachypneic, became short of breath with conversation, and reported that her heart was “pounding in her chest.” She appeared to be very anxious and continued to complain of pain. Her skin and nail beds were pale but not cyanotic. Skin turgor was poor. Peripheral pulses were absent with the exception of a thready brachial pulse. Capillary refill time was approximately 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 near where she was lying. Patient Case Question 2. Based on the patient’s clinical manifestations, approximately how much of her total blood volume has been lost? Hypovolemic Shock
During transport to the hospital, vital signs were reassessed: HR 138, BP 75/50, RR 38 with confusion. She was diagnosed with hypovolemic shock and IV fluids were doubled. Blood samples were sent for typing and cross-matching and for both chemical and hematologic analysis. Laboratory test results are shown in Patient Case Table 6.1 Patient Case Question 3. How many units of whole blood are minimally required? Patient Case Question 4. Is it necessary that sodium bicarbonate be administered to the patient at this time? Oxygen was started at 3 L/min by nasal cannula. Repeat arterial blood gases were: PaO2 82 mm Hg, PaCO2 38 mm Hg, pH 7.36, SaO2 95%. Patient Case Question 5. Are arterial blood gas results improving or deteriorating? ER physicians chose not to start a central venous line. An indwelling Foley catheter was inserted with return of 180 mL of amber-colored urine. Urine output measured over the next hour was 14 mL. Ms. Z’s condition improved after resuscitation with 1 L lactated Ringer’s solution and two units packed red blood cells over the next hour. Hypovolemic Shock
Patient Case Question 6. Based on urine output rate, in which class of hypovolemic shock can the patient be categorized at this time? Laboratory blood test results are shown in Patient Case Table 6.2 Hypovolemic Shock
Patient Case Question 7. Explain the pathophysiology of the abnormal BUN and Cr. Patient Case Question 8. Does the patient have a blood clotting problem? Patient Case Question 9. Explain the pathophysiology of the abnormal serum glucose concentration. The patient was taken to the operating room for surgical correction of lacerations to the right lung, liver, and pancreas. There, she received an additional six units of type B+ blood. Surgery was successful and the patient was admitted to the ICU for recovery with the following vital signs: HR 104, BP 106/70, RR 21, urinary output 29 mL/hr. A repeat BUN and Cr revealed that these renal function parameters had returned to near-normal values (23 mg/dL and 1.4 mg/dL, respectively). Patient Case Question 10. Based on clinical signs after surgery, in which class of hypovolemic shock can the patient be categorized at this time?
Bruyere, Harold J.. 100 Case Studies in Pathophysiology (Kindle Locations 824-828). Wolters Kluwer Health. Kindle Edition Hypovolemic Shock