Pharmacotherapy Case: Hypovolemic Shock Management By Dr. Nehad Ahmed

Age: 58 years

Gender: Female

Subjective Data

Chief Complaint:
“I’ve been vomiting blood and feel like I’m going to pass out.”

History of Present Illness:
Ms. Thompson is a 58-year-old female with a history of peptic ulcer disease and chronic NSAID use for osteoarthritis. She reports 24 hours of recurrent vomiting with “coffee-ground” material and bright red blood, accompanied by dizziness, weakness, and palpitations. She denies recent trauma, melena, or abdominal pain but admits to non-adherence to her pantoprazole regimen.

Medical History:

• Peptic ulcer disease (diagnosed 2 years ago).

• Osteoarthritis (chronic ibuprofen use).

• Hypertension.

• Iron-deficiency anemia (baseline Hgb 10.5 g/dL).

Family History:

• Father: Gastric cancer at age 65.

• Mother: Hypertension.

Social History:

• Smokes 1 pack/day for 30 years.

• Occasional alcohol (2–3 glasses of wine/week).

Medications:

• Ibuprofen 400 mg PO TID (self-prescribed for pain)

• Pantoprazole 40 mg PO daily (non-adherent)

• Lisinopril 10 mg PO daily

Allergies:

• No known drug allergies.

Adherence:

• Poor adherence to pantoprazole; frequent NSAID use.

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Objective Data

Vital Signs:

• BP: 88/50 mmHg (supine), 70/40 mmHg (standing)

• HR: 120 bpm (sinus tachycardia)

• RR: 24 breaths/min

• SpO2: 94% on room air

• Temp: 36.8°C (oral)

• Weight: 65 kg

• Capillary refill: 4 seconds

Physical Exam:

• General: Pale, diaphoretic, lethargic.

• Cardiovascular: Tachycardic, weak radial pulses, no murmurs.

• Abdomen: Soft, non-tender, no guarding or rebound.

• Skin: Cool, clammy extremities; dry mucous membranes.

Laboratory Results:

• Hemoglobin: 7.2 g/dL (↓ from baseline 10.5 g/dL)

• Hematocrit: 22%

• BUN: 48 mg/dL (creatinine 1.3 mg/dL; BUN/Cr ratio 37)

• Lactate: 4.8 mmol/L (↑)

• INR: 1.1 (normal)

Diagnostics:

• Nasogastric tube aspirate: Coffee-ground material with bright red blood.

• ECG: Sinus tachycardia, no ischemic changes.

• CT abdomen/pelvis: No active bleeding identified; gastric wall thickening.

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Assessment

1. Hypovolemic Shock (Stage III):

   • Secondary to acute upper gastrointestinal bleed (likely NSAID-induced ulcer).

   • Hemodynamic instability (tachycardia, hypotension, lactic acidosis).

2. Risk Stratification:

   • Glasgow-Blatchford Score: 12 (high risk for rebleeding/mortality).

3. Comorbidities:

   • Anemia exacerbating tissue hypoxia.

   • Chronic NSAID use contributing to ulcerogenesis.

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Plan

1. Immediate Resuscitation:

   • IV Fluids: Bolus 2 L 0.9% NaCl, then titrate to MAP ≥65 mmHg.

   • Blood Products:

     • Type and crossmatch for 4 units packed RBCs.

     • Transfuse 2 units PRBCs stat (goal Hgb ≥7 g/dL).

   • Vasopressors: Initiate norepinephrine (4–8 mcg/min) if BP remains <90/60 mmHg post-fluids.

2. Pharmacotherapy:

   • Proton Pump Inhibitor (PPI): Pantoprazole 80 mg IV bolus, then 8 mg/hr infusion (reduce rebleeding risk).

   • Antiemetic: Ondansetron 4 mg IV (for nausea/vomiting).

   • Antibiotics: Ceftriaxone 1 g IV daily (prophylaxis in cirrhotics if suspected varices; not indicated here but included for completeness).

3. Monitoring:

   • Continuous telemetry, hourly vital signs, urine output (goal >0.5 mL/kg/hr).

   • Repeat Hgb q4–6h, lactate clearance in 6 hours.

4. Education:

   • Discontinue NSAIDs; transition to acetaminophen for pain.

   • Adhere to PPI therapy and smoking cessation counseling.

5. Follow-Up:

   • Urgent esophagogastroduodenoscopy (EGD) within 24 hours for definitive management.

   • GI consultation for ulcer treatment and H. pylori testing.

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Rationale:

• Fluid resuscitation with crystalloids restores intravascular volume, while PRBCs improve oxygen-carrying capacity.

• IV PPI reduces gastric acid secretion, stabilizing clots in upper GI bleeds.

• Norepinephrine is reserved for refractory hypotension despite fluids/blood.

• Early EGD is critical to identify and treat the bleeding source.