1. Jiraporn sri-on Emergency medicine Bangkok metropolitan administration and vajira hospital

23. 53-year-old female with Hx of hyperthyroidism At 15.20 น . 4/8/52 Case discussion

33. Differential diagnosis

35. Fluid Challenge Test Initial CVP <8 8-15 >15 cm H 2 O PAOP <12 12-16 >16 mm Hg Volume & Rate 200 mL/10 min 100 mL/10 min 50 mL/10 min During infusion, CVP rises >5 cm H 2 O or PAOP rises >7 mm Hg Yes No Stop challenge Complete the volume Wait 10 min Wait 10 min CVP change >5 3-5 < 2 3-5 < 2 PAOP change >7 4-7 < 3 4-7 < 3

38. Inotropic use:Commonly used First-Line Agents Michael M . Givertz James C . Fang :Irwin and Rippe’s Intensive care medicine 6 th edition 2008 pp 335 Cause of Hypotension Pulmonary Capillary Wedge Pressure Cardiac Output Systemic Vascular Resistance Preferred Agent(s) Unknown ? ? ? Dopamine Hypovolemia ↓ ↓ ↑ None a Decompensated heart failure ↑ ↓ ↑ Dopamine, dobutamine Cardiogenic shock ↑↔ ↓ ↑ Dopamine Hyperdynamic sepsis ↓↔ ↑ ↓ Norepinephrine, dopamine Sepsis with depressed cardiac function ? ↓ ↓ Dopamine, norepinephrine plus dobutamine Anaphylaxis ? ? ↓ Epinephrine Anesthesia-induced hypotension ? ? ↓ Phenylephrine, ephedrine b a Volume resuscitation with intravenous fluids and/or blood products recommended. b For obstetric patients.

39. Ultrasound:Estimation of central venous pressure Robert F.reardon and Scott A.joing : Emergency ultrasound pp 129 IVC size (cm) Respiratory change RA pressure (cm) <1.5 Total collapse 0-5 1.5-2.5 > 50% collapse 5-10 1.5-2.5 <50% collapse 11-15 >2.5 <50% collapse 16-20 >2.5 No change >20

40. IVC measurement demonstrating normal IVC collapse. IVCDmax (expiration) 17.9 mm; IVCDmin (inspiration) 8.9 mm. IVC-CI : IVCDmax– IVCDmin/IVCDmax: (17.9 – 8.9)/17.9; 50% collapse.