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Definition: A life-threatening state of adrenocorticosteroid hormone deficiency leading to hypotension and hemodynamic shock.

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Clinical Features

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  1. Hypotension/shock, orthostatic hypotension

  2. Anorexia, nausea/vomiting

  3. Abdominal pain

  4. Fever

  5. Lethargy/weakness

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Differential Diagnosis

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  1. Shock: septic, cardiogenic, spinal

  2. Anaphylaxis

  3. Other causes of hypotension (see Hypotension)

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Management

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  1. Ensure adequate airway and gas exchange

  2. Administer high-flow oxygen/100% oxygen

  3. Expand the circulating volume rapidly with dextrose in normal saline (D5NS) → up to 2 to 3 L may be required

  4. Draw blood for random cortisol and ACTH levels

  5. Immediately following this, administer IV glucocorticoid: hydrocortisone 100 mg (and continue q6h as needed)

  6. Support systemic blood pressure with vasopressors

  7. Correct any of the following common electrolyte disturbances:

    • hypoglycemia
    • hyponatremia
    • hyperkalemia
    • hypercalcemia

  8. Identify precipitating cause (eg, iatrogenic adrenal insufficiency due to exogenous corticosteroid administration)

  9. Rule out other causes on the differential diagnosis (especially those that are rapidly correctable):

    • anaphylaxis
    • tension pneumothorax
    • massive hemorrhage
    • syringe swap
    • myocardial ischemia/infarction

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Definition: Physiologic response to a noxious chemical, thermal or mechanical stimulus; associated with invasive procedures, trauma, and disease; generally time-limited until injury heals.

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Clinical Features

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  1. Pain varies greatly—mild to severe (0-10 scale)

  2. Onset—acute

  3. Location—site of injury, radiation, or referred pain

  4. Duration—continuous, intermittent, relapsing

  5. Characteristics—sharp/stabbing, cramping

  6. Associated features tachycardia, tachypnea, hypertension, diaphoresis

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Differential Diagnosis

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  1. Acute pain:

    • surgical/procedural
    • trauma
    • disease process

  2. Chronic pain:

    • nociceptive:
      • somatic—muscles, bones, skin, connective tissue, blood vessels
      • visceral—viscera (organs)
    • neuropathic:
      • peripheral nervous system
      • central nervous system
      • CRPS I/II

  3. Acute on chronic pain

  4. Anxiety, panic attack

  5. Drug-seeking behavior

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Management

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  1. Treat pain and determine underlying cause:

    • acute surgical pain typically requires intravenous opioids (consider bolus, infusion, or patient-controlled analgesia as appropriate)
    • pain out of proportion to surgery/procedure or new onset pain requires history, physical exam, and appropriate laboratory investigations, imaging, and surgical consultation

  2. Adjust therapy if patient is tolerant to analgesic medications:

    • chronic opioid use for chronic pain/addiction

  3. Consider multimodal analgesia as clinical situation permits:

    • nonopioid analgesics (acetaminophen/paracetamol, NSAIDs)
    • α2 agonists (clonidine, dexmedetomidine)
    • gabapentin
    • NMDA antagonists (ketamine, methadone)
    • local anesthetics
    • peripheral nerve blockade (single shot or indwelling catheter)
    • neuraxial blockade

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Definition: Passage of amniotic fluid into the maternal circulation typically resulting in sudden, profound, and unexpected shock, and cardiopulmonary collapse.

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Clinical Features

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  1. Hypotension, cardiopulmonary arrest

  2. Fetal distress

  3. Pulmonary edema/ARDS

  4. Cyanosis, dyspnea

  5. Coagulopathy

  6. Seizures

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Differential Diagnosis

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  1. Obstetric causes:

    • acute hemorrhage
    • placental abruption
    • uterine atony
    • peripartum cardiomyopathy
    • eclampsia

  2. Anesthetic causes:

    • high/total spinal
    • aspiration
    • local anesthetic systemic toxicity

  3. Other causes:

    • pulmonary thromboembolism
    • venous air embolism
    • anaphylaxis
    • sepsis
    • intracranial hemorrhage
    • transfusion reaction

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Management

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  1. Call for assistance (another anesthesiologist) and inform obstetrician:

    • prompt delivery of the fetus improves maternal resuscitation outcomes

  2. Ensure adequate oxygenation and ventilation:

    • intubate trachea and ventilate with 100% ...

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