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

Clinical Features

  1. Hypotension/shock, orthostatic hypotension

  2. Anorexia, nausea/vomiting

  3. Abdominal pain

  4. Fever

  5. Lethargy/weakness

Differential Diagnosis

  1. Shock: septic, cardiogenic, spinal

  2. Anaphylaxis

  3. Other causes of hypotension (see Hypotension)


  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

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

Clinical Features

  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

Differential Diagnosis

  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


  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

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

Clinical Features

  1. Hypotension, cardiopulmonary arrest

  2. Fetal distress

  3. Pulmonary edema/ARDS

  4. Cyanosis, dyspnea

  5. Coagulopathy

  6. Seizures

Differential Diagnosis

  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


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

    • prompt delivery of the fetus improves maternal resuscitation outcomes

  2. Ensure adequate ...

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