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 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 1. Why does this patient have cool skin?
Question 2. What is the pathophysiologic sequence of events for shock?
Question 3. What type of shock does this patient seem to have? What is your rationale?
Question 4. Does this patient need a blood transfusion? Provide rationale for your answer.
Question 5. Explain the pathophysiology of the patient’s altered mental status.
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?