Treatment of a persistently hypotensive patient after maximal therapy can be a harrowing experience in the ED. The patient who has obvious trauma with ongoing hemorrhage, the reason is usually apparent, and the outcome is dismal if uncorrected. In medical cases of shock or in cases without ongoing hemorrhage, potential pitfalls should be rapidly reviewed. Is the patient appropriately monitored? Is there malfunctioning arterial blood pressure monitoring, such as dampening of the arterial line or disconnection from the transducer? Is the patient adequately volume resuscitated? The early use of vasopressor will falsely elevate CVP and disguise hypovolemia. Is the intravenous tubing into which the vasopressors are running connected appropriately? Are the vasopressor infusion pumps working? Are the vasopressors mixed adequately? Does the patient have a pneumothorax after that CVP placement? Has the patient been adequately assessed for an occult penetrating injury (a bullet hole or stab wound)? Is there hidden bleeding from a ruptured spleen or ectopic pregnancy? Does the patient have adrenal insufficiency? The incidence of adrenal dysfunction can be as high as 30 percent in this subset of patients. 20 Is the patient allergic to the medication just given (e.g., penicillin) or taken before arrival? Is the renal failure or cancer patient in cardiac tamponade?
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