In the ED, we often see a discrepancy between a blood pressure and the clinical exam, both in medical cases and trauma cases. Most commonly, the BP is low and the patient looks perfectly fine. There are three possibilities. (1) The BP is real and the patient is sick. (2) The BP is false and the patient is well. (3) The BP is real and the patient is well, i.e. it’s the patient’s baseline BP.
By far, the most common outcome is (1) – the patient is deceptively sick. It is compensated shock. Residents often blow off a single low BP reading and live to regret it later. The patient transitions into decompensated shock and then it’s obvious that the low BP measurement was a warning of things to come.
The residents’ reaction to the low BP was perfect despite the initial “what the?!?” reaction. The junior immediately FASTed the patient and saw a sliver of free fluid. The pre-attending repeated the BP himself and verified that it was low. The pulse was weak, btw. The residents started giving blood and put the patient in for a pan-scan. In the meantime, a repeat FAST showed increasing fluid in the RUQ. CXR and Pelvis XR were normal.
Once the patient was stabilized, the patient went to the CT where a bad splenic lac was seen. Surgery took the patient to IR then SICU. The patient’s initial Hct was 43. His second Hct was 46. The patient was a small guy and we may have overfilled his gas tank a little.
Kudos to JS and MM, who ran the show alone.
