You and your partner are dispatched for a report of an unresponsive 77-year-old male in a senior’s apartment complex. The time of the call is 08:36 am. Upon arrival, a home health aide greets you at the apartment door and informs you the patient is in the bedroom. As she leads you towards the bedroom, the aide begins to tell you she arrived for work about an hour ago and found the patient in his bed. “He normally is awake when I get here, but today I found him still in his bed. I thought he was only wanting to sleep in so I decided I would give him a little time, but he didn’t respond when I tried to wake him a few minutes ago.” She tells you she routinely visits Mr. Oliveira twice a week to help with cleaning and cooking. She says, “The last time I saw him was 3 days ago and he was sick at the time. I thought he might have come down with a bad cold because he was coughing a lot and I tried to encourage him to see his physician.” As you approach the patient’s bedside, you observe a thin, older adult male who appears asleep. You hear audible respirations that sound congested, and his skin appears pale and mottled. You begin your assessment of the patient’s mental status, and he does not respond to verbal stimuli, but moans to a trapezius pinch without opening his eyes. You contact dispatch to request an ALS unit to the scene and continue with your primary assessment. As there is no evidence of trauma, your partner proceeds to open the airway using a headtilt, chin lift maneuver and observes thick but loose brown secretions in the airway. After suctioning his airway, you assess his breathing which is tachypneic at 24 – 26 per minutes, shallow and slightly labored with equal chest rise. The pulse oximeter is reading 92% on room air. You detect a weak tachycardic radial pulse at a rate of between 118 – 124 beats per minute and his skins are pale, mottled, cool and clammy to the touch. You contact dispatch to provide an update and are informed ALS has been rerouted to a pediatric cardiac arrest and is not available. You obtain a SAMPLE history from the health aide which is as follows: S: Terrible cough x 3 days and a temperature of 101° F. Per the health aide, the patient had reported feeling pain when taking a deep breath when she last saw him. A: Shellfish M: Lisinopril, Aspirin, Ventolin Inhaler and Furosemide. P: Hypertension, Chronic Bronchitis, and an AMI 5 years ago. L: Unknown. The health aide reports he refused to eat during her last visit. E: Unknown During your assessment of his lung sounds, you hear rales and rhonchi bi-laterally in all fields. You obtain a full set of vitals which are: RR: 24 breaths per minute, labored and shallow RR: 120 beats per minute, week and regular BP: 68 by palpation Skins: mottled, cool, and clammy Pupils: PERL (sluggish) SpO2 Reading: 92% 1. What conditions or factors lead you to label the patient as critical? 2. How are you going to manage and care for this patient? 3. Based on the history, what type of shock are you suspecting the patient is experiencing? 4. What are the Pathophysiologic changes associated with Distributive shock? 5. What stage of shock is the patient in?
CASE STUDY - SHOCK
You and your partner are dispatched for a report of an unresponsive 77-year-old male in a
senior’s apartment complex. The time of the call is 08:36 am.
Upon arrival, a home health aide greets you at the apartment door and informs you the
patient is in the bedroom. As she leads you towards the bedroom, the aide begins to tell
you she arrived for work about an hour ago and found the patient in his bed. “He normally
is awake when I get here, but today I found him still in his bed. I thought he was only
wanting to sleep in so I decided I would give him a little time, but he didn’t respond when I
tried to wake him a few minutes ago.”
She tells you she routinely visits Mr. Oliveira twice a week to help with cleaning and
cooking. She says, “The last time I saw him was 3 days ago and he was sick at the time. I
thought he might have come down with a bad cold because he was coughing a lot and I
tried to encourage him to see his physician.”
As you approach the patient’s bedside, you observe a thin, older adult male who appears
asleep. You hear audible respirations that sound congested, and his skin appears pale and
mottled. You begin your assessment of the patient’s mental status, and he does not
respond to verbal stimuli, but moans to a trapezius pinch without opening his eyes. You
contact dispatch to request an ALS unit to the scene and continue with your primary
assessment.
As there is no evidence of trauma, your partner proceeds to open the airway using a headtilt, chin lift maneuver and observes thick but loose brown secretions in the airway. After
suctioning his airway, you assess his breathing which is tachypneic at 24 – 26 per
minutes, shallow and slightly labored with equal chest rise. The pulse oximeter is reading
92% on room air. You detect a weak tachycardic radial pulse at a rate of between 118 –
124 beats per minute and his skins are pale, mottled, cool and clammy to the touch.
You contact dispatch to provide an update and are informed ALS has been rerouted to a
pediatric cardiac arrest and is not available.
You obtain a SAMPLE history from the health aide which is as follows:
S: Terrible cough x 3 days and a temperature of 101° F. Per the health aide, the patient
had reported feeling pain when taking a deep breath when she last saw him.
A: Shellfish
M: Lisinopril, Aspirin, Ventolin Inhaler and Furosemide.
P: Hypertension, Chronic Bronchitis, and an AMI 5 years ago.
L: Unknown. The health aide reports he refused to eat during her last visit.
E: Unknown
During your assessment of his lung sounds, you hear rales and rhonchi bi-laterally in all
fields.
You obtain a full set of vitals which are:
RR: 24 breaths per minute, labored and shallow
RR: 120 beats per minute, week and regular
BP: 68 by palpation
Skins: mottled, cool, and clammy
Pupils: PERL (sluggish)
SpO2 Reading: 92%
1. What conditions or factors lead you to label the patient as critical?
2. How are you going to manage and care for this patient?
3. Based on the history, what type of shock are you suspecting the patient is
experiencing?
4. What are the Pathophysiologic changes associated with Distributive shock?
5. What stage of shock is the patient in?
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