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Hypotension in a Patient With Progressive Neurological Decline


Case Study

A rapid response was called for a patient because of new-onset hypothermia and hypotension. Upon the rapid response team's arrival, the patient was noted to be a 78-year-old female with a known history of hypertension treated with amlodipine and osteoporosis. She was admitted earlier in the day as a direct admission from the clinic for failure to thrive. Her daughter had found her unable to care for herself at home because of progressive fatigue, lethargy, somnolence, and dyspnea on exertion. She had also been unsteady on her feet and had had a few near falls.

Vital Signs

  • Temperature: 93.7 °F, rectal

  • Blood Pressure: 80/62 mmHg

  • Heart Rate: 48 beats per min (bpm), sinus bradycardia on telemetry ( Fig. 58.1 )

    Fig. 58.1, Telemetry strip showing sinus bradycardia with a heart rate of 48 bpm.

  • Respiratory Rate: 8 breaths per min

  • Pulse Oximetry: 97% on room air

Focused Physical Examination

A quick exam revealed a somnolent older woman in no apparent distress. She was opening her eyes only to painful stimuli and was responding in a garbled voice. Her responses were incomprehensible. She could move all limbs spontaneously but could not follow simple commands. Cardiac and pulmonary exams were unremarkable. The abdomen was benign.

Interventions

A cardiac monitor and pacer pads were attached to the patient's chest. A 1 L bolus of normal saline was ordered stat. Point-of-care glucose level was checked and noted to be 65 mg/dL. Then, 25 g of 50% IV dextrose was administered, which improved the blood glucose but had no effect on the patient's mental status. Stat complete blood count (CBC), comprehensive metabolic panel (CMP), arterial blood gas (ABG), and lactate were obtained, which came back unremarkable except for mild hyponatremia of 131. Blood cultures were drawn, and broad-spectrum antibiotics were initiated. A review of labs from admission showed a thyroid-stimulating hormone (TSH) of 125 mIU/L. Free T4 was undetectable. The patient was given 100 mg IV hydrocortisone. Stat consult was called to endocrinology, who recommended 200 mcg IV levothyroxine which was initiated. Given worsening altered mentation, there was a concern for the protection of the airway. The patient was intubated and transferred to the intensive care unit for further care.

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