Under pressure

Phone running out of juice with no charger in sight during a busy night on call? That sinking feeling isn’t so different from managing a crashing hypotensive patient at 4 am, when every second counts. Take 10 minutes to work through this module and leverage your AMBOSS resources to build a systematic approach to diagnosing and treating hypotension—before your patient's perfusion hits 0%.

You are the night-call intern cross-covering the general surgery service. It’s late—so late it’s almost early, and you’ve been running on adrenaline and muscle memory all night. The list of post-op checks, order clarifications, and rapid responses has been endless, and your last real meal is a distant memory.

You lean against the nurses' station in the ED and pull out your phone to update your senior resident. Phone battery at 2%, just like you. You're just starting your treasure hunt through the work area for a charger cord...when your pager vibrates against your hip.

Click the pager icon to reveal the message.

Honestly? Same. But there’s no time to wallow; you have a decision to make.

Question: How urgently do you want to assess the patient?

Make your choice, then click on the explanation bubble to reveal the answer.

• Right now
• Once you plug in your phone for a quick charge
• Once you’ve updated orders for the rest of your patient list. You've already had enough 3 am calls about discontinuing senna.

You put your phone on power-saving mode and make your way across the bridge. They're all the way across the hospital, so you have a minute to collect your thoughts (and an extra 1000 steps).

Question: What information is most crucial to know, and how will you find it?

Your signout sheet is your lifeline when you're on call. You can review it to get critical information quickly.

• Age
• Code status
• Admission diagnosis or reason for hospitalization
• Past medical history, procedures, and interventions
• Medications
• Allergies
• Recent remarkable labs

Don’t overlook “stable” patients during signout! They still require monitoring and attention. Ignoring them can come back to bite you.

If a signout mentions an allergy, always clarify what type of reaction the allergy causes. A mild rash may be manageable, but if an allergen triggers anaphylaxis or severe hypotension, knowing the severity of the allergic response can make all the difference in how urgently you treat the patient.

The air is buzzing with activity—nurses scrambling to cover multiple patients, monitors beeping in the background, and someone shouting across the hallway about a code brown. Your patient's nurse is at the counter, balancing a phone call while scanning through a stack of papers, looking just as frazzled as you feel. Your phone's still threatening to die at any moment, and you're hoping to get through this quickly so you can find a charger.

Question: When you speak with the patient’s nurse, which of the following should you do?

Make your choice, then click on the explanation bubble to reveal the answer.

• Get a quick report about the patient’s symptoms, then ask the nurse if she knows where you can find a charger.
• Ask the nurse to come with you to the patient’s bedside and to give you a quick report as you go.

  In critical situations, the patient’s well-being comes first, so don’t let a dying phone distract you. There are always workarounds, like using a landline or asking a nurse for help paging your senior resident. But losing focus on the patient’s care can have serious consequences.

You and the nurse power walk to the patient's room.

Question: Which of the following can you immediately assess from the doorway?

Make your choices, then click on the explanation bubbles for more information.

• Position of the patient
• Mental status
• Respiratory rate and pattern
• Signs of respiratory distress
• Vital signs
• Presence of IV lines

That's right—all of the above!

The first 60 seconds at the patient's bedside are crucial, so use your eyes and ears to quickly assess for signs of shock. Look for signs of poor perfusion (pale, cool skin, altered mental status), respiratory distress, and abnormal vital signs. This rapid evaluation can guide your immediate treatment decisions and help prioritize interventions.

Pulse oximetry measurements are unreliable in patients with shock due to peripheral hypoperfusion and/or vasoconstriction.

“If you can keep your head when all about you are losing theirs...”

Question: Which clinical scenario would you like to explore?

Choose an option to continue the module.

• Option 1: Impending cardiovascular collapse
• Option 2: Hypotension responsive to IV fluids

Your patient's back in the game. Now you can recharge too…and hopefully find a way to juice up your phone's battery!

• You did a great job:
  • Quickly triaging a potentially critically ill patient
  • Recognizing when to call for help (Option 1)
  • Prioritizing initial management over diagnostics (Option 1)
  • Remembering common causes for the four main categories of shock (Option 2)
  • Ordering basic tests appropriate for most patients with hypotension (Option 2)
• Of course, further management will depend on the specialist (in this case, the on-call acute care surgeon). Here is a graphic you might find useful for understanding the different types of shock the next time you're under pressure.

Congratulations on completing this module. Hopefully you now feel more comfortable assessing a patient with shock!

Personal story from an AMBOSS clinician

It was a Friday night during my first few weeks of intern year, and the day shift resident was eager to hand off their patients and head home. We breezed through a list of NTDs (nothing-to-dos), patients considered stable enough to not require further attention.

Later that night, in between level 1 trauma alerts, I received a page about a hypotensive patient. I checked my list and saw it was an elderly man who had been admitted earlier in the day with a retroperitoneal hematoma and had been deemed stable. An NTD. I quickly ran up to assess him. I started fluids and ordered labs, including a type and screen. And then I noticed something odd: The patient had a documented allergy to blood products—but there was no further information. No details in the H&P, nothing in the chart.

So, of course, his hematocrit and hemoglobin had dropped from earlier measurements, and he now needed a transfusion. The patient was minimally responsive and couldn't tell me about this allergy to blood products. I had to call his wife in the middle of the night, and she wasn’t sure what the allergy was. She said it had been 20 years ago, and she thought the allergic reaction might have been caused by a platelet transfusion. Meanwhile, the blood bank couldn't advise me on whether giving any blood product would be safe since there was a documented allergy.

There was a lot of yelling because my senior resident wasn’t pleased that I hadn't asked more about the allergy during signout. Now he was stuck making calls to specialists and to our attending while the floor nurses advocated for the patient to go to the ICU. I don’t remember much else from that night. Ultimately, we gave the patient a unit of blood, under specialist advisement and close monitoring, and his condition improved.

The lesson I learned: A stable patient is only stable until they're not. Don’t get comfortable with a list full of NTDs. Ask questions, always reassess, and be prepared for the unexpected.