What's Your Diagnosis? Treating Hypotensive Patients in the ED

Welcome to this month’s What’s Your Diagnosis Challenge!

But before we begin, check to see if you got the previous case on Evidence-Based Emergency Department Management of Methamphetamine Toxicity correct.

Case Presentation: Evaluation and Management of Hypotensive Patients in the Emergency Department

A 60-year-old woman with fever and flank pain is brought in by EMS…

The patient reports that she has been experiencing flank pain for the last 2 days and called EMS today because she had a fever and felt so weak that she was unable to walk.
The patient appears tired, tachypneic, and in mild distress. Her vital signs are: temperature, 38.5ºC; heart rate, 145 beats/min; blood pressure, 87/33 mm Hg; respiratory rate, 31 breaths/min; and oxygen saturation, 96% on room air. Her pulse is thready and irregular, and the monitor shows that she is in atrial fibrillation. She is delirious and has right costovertebral tenderness.
You suspect the patient is septic from a urinary tract source, but you wonder whether the atrial fibrillation is also contributing to her hypotension. What additional diagnostic tests could be performed at the bedside to evaluate for urinary tract obstruction and help guide hemodynamic management?

Case Conclusion

You performed a POCUS, which demonstrated right-sided hydronephrosis, and follow-up CT scan demonstrated a 9-mm obstructing calculus. Cardiac POCUS demonstrated a flat, collapsing inferior vena cava with hyperdynamic left ventricular ejection fraction and no evidence of pulmonary edema. The patient was given a 1.5-L crystalloid fluid IV bolus and started on a norepinephrine infusion, and broad-spectrum IV antibiotics were initiated, with improvement in her blood pressure to 110/70 mm Hg and heart rate to 120 beats/min. The patient was subsequently admitted to the medical ICU and urology was consulted, and they ultimately took the patient for emergent retrograde ureteral stent placement.