Can you be in shock and HYPERtensive?

I think so. Our patients teach us many lessons

#FOAMed
#FOAMcc
@UVMEmergencyMed

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A patient presents with 7 days of dyspnea, LE edema and fatigue. They have run out of all meds 2 weeks ago #COVID. They had an MI with ishcemic cardiomyopathy EF ~30%, also has a-fib.

Exam:
Afebrile, BP consistently >160/110, HR 110 afib, RR 30, POx 86%-> 94% 4LNC

Mild confusion
JVD+
Mild resp distress, crackles BL
No murmur
Hands, legs COLD and mottled to knees, toes and fingers purple, cap refill delayed
Pitting LE edema

Labs with Cr 2x baseline
Trop 0.4
AST/ALT ⬆️
BNP⬆️
Dark & minimal urine in foley
Lactate 5

ECG afib no acute ischemia

POCUS LVEF ~20%, RV diminished function, IVC 2.5 cm, BL b lines and small effusions

CXR c/w pulmonary edema

What's the problem?

Impaired tissue perfusion=shock

Low output, "cold and wet" cardiogenic shock with incredibly high SVR

⬆️MAP= CO⬇️ x SVR⬆️⬆️

Treatment?

Afterload reduction:
In this case used a high dose nitro gtt

CPAP helps ⬇️ resp effort and positive pressure ⬇️afterload and ⬆️CO in those w/ systolic dysfunction.

High dose diuretic therapy

Few hours later...

Urine output way up

Extremities warm and pink

Lactate normal

On 2 L NC

Tips:

Shock = hypoperfusion

Shock is NOT a blood pressure

Examine distal extremities as it might be the first clue

Afterload reduction to improve forward flow & ⬆️ CO in high SVR cardiogenic shock

POCUS helps