Ultrasounds as a guide in the diagnose of shock in a 33-year-old woman suffering an abortion, is it volume the answer? A case report

J Sanahuja, A Calvo, MJ Carretero, X Borrat, J Mercadal

BACKGROUND

The diagnose of shock may be difficult at the Emergency Department (ED). Functional ultrasound (FU) has taken prominence in the last years as a non invasive tool to treat and monitor these patients once the information is integrated in a mind map, that is an algorithm which integrates echo measurements in order to obtain the hemodynamic shock pattern i.e. ( cardiogenic, hypovolemic…).


CASE REPORT

We present a 33-year-old woman, pregnant of 15 weeks, who was admitted at the ED with hypotension and tachycardia after intense vaginal bleeding. Her blood pressure was 60/30mmHg and the heart rate 120 per minute, capillary refill longer than 2 seconds.

At first, we orientated the case as an hypovolemic shock secondary to abortion, starting the initial resuscitation with intense fluidotherapy. No hemodynamic response was found, persisting hypothense and tachycardic, being norepinephrine started to maintain blood pressure.  Labs showed hemoglobin of 11.7mg/dl, with acute kidney failure and coagulopathy, no leucothytose at that moment with CPR of 9mg/dL. The vaginal ultrasound showed embryonic remains that had to be removed at the operating room.

After the intervention, she was admitted at the intensive care unit, under perfusion of norepinephrine at dose of 0,2mcg/kg*min. There was performed a FU that let us estimate a cardiac output of 4 L/min, E/A ratio of 1.56 and an inferior vena cava that didn’t collapse with breathe. After integrating this information in our mind map we arrived at the conclusion that the patient had a distributive shock with a certain component of myocardial disfunction secondary to a septic abortion. Treatment was antibiotics, vasoactive drugs and volume restriction, being discharge from the ICU after 4 days.


DISCUSSION

FU lets us classify the shock after analyzing the different variables of perfusion. It detects those relevant alterations in the shock and it guides us in the treatment once we have integrated the information in a mind map. 

We first calculate the CO, then we analyze if it is a problem of low resistance, right ventricle pathology, hypovolemia and finally a left ventricle problem or valvulopathy; allowing us to classify the shock we are facing and optimizing the treatment we do in a dynamic way.


LEARNING POINTS
In this case, we could have avoided the volume overload and a premature initiation of vasoactive drugs if we had had the ultrasound at the ED, optimizing the perfusion from the beginning and avoiding the overresuscitation syndrome.

10 / Functional ultrasounds as a guide in the diagnose of shock in a 33-year-old woman suffering an abortion, is it volume the answer? A case report.