critical Scenarios

Working in critical care medicine is about constantly having to critically think. Each organs way of reacting to an insult intercedes within another; this, along with the fact that we can’t perfectly monitor hemodynamics/volume status/perfusion with a magic number makes some clinical scenarios particularly difficult to interpret. Think about the situations below and what you would do; how you would manage these situations. Use the evidence you’ve learned throughout training to guide you. Remember, sometimes its not about making the right choice, it’s about making a choice.

Scenario 1

You have a patient in septic shock from C. Diff on the ventilator. He is from a nursing home and at baseline is non-functional. The nurse reports that he has gone from 0.3 mcg/kg/min of levophed to 1.0 mcg/kg/min; at bedside, the patient has an arterial line placed with a slightly dampened waveform correlating with the heart rate. The a-line pressure reads 84/30 with a MAP of 59 while the cuff pressure reads 120/72 with a MAP of 88.

Does this patient have worsening shock? By definition shock is organ hypo-perfusion, and although it often correlates it is not necessarily low blood pressure. How can you tell this patient is hypo-perfusing with your physical exam?

Why would he go up on vasopressors if this were not an issue with blood pressure cuff reading? What are some common physiologic changes that cause you to increase your vasopressor requirement?

What is more reliable at this point, the cuff (which inherently can be inaccurate) or the arterial line (known to be much more accurate, but is affected by things such as SVR)?

What are some things you can do to the arterial line to ensure it is a correct waveform?

At this point, would you treat the blood pressure cuff reading or the arterial line reading? If you went of the blood pressure cuff reading and the patient were to lose a pulse, how would you justify going off the cuff?

SCENARIO 2

You hear a code blue overhead. Being the connoisseur you are, you check the EPIC app on your phone as you are running towards the room; it states the patient is DNR. You arrive to the room and compressions/ACLS are actively being performed. Another provider (a MD) is running the code. You see a 400 lb 6’5” man at bedside, aggressively screaming to continue. You see another woman sobbing outside the room; she states she is his wife, and he had wanted to be DNR.

Would you stop compressions at this point? How do you ensure the safety of the staff if you were to do this?

Since you are not the provider running the code, are you obligated to stop it? Since he is an MD - would you be overstepping your bounds? Since it is not your patient, and you do not know the situation, would stopping it be overstepping your bounds?

How do you know this woman is his wife? Who is this man at bedside, and how do you find out in a chaotic situation?

critical Scenarios

Scenario 1

SCENARIO 2

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