P-II-22. Circulatory shock, Case 1

Case Presentation

A 63-year-old man was taken to the emergency department by ambulance, as he had been vomiting blood since the morning hours.

Medical history:

• Hypertension and coronary heart disease
• Coronary artery stent treatment 15 years ago
• Takes 100 mg of Aspirin daily
• Deep vein thrombosis (DVT) in 2018, on Warfarin since then
• Long-standing drinking problem; dismissed from his job
• Fails to take medications as prescribed, and usually makes an attempt to take the medication he missed taking earlier

Presenting complaint: This morning he was woken up by pain which developed in his stomach, and the pain radiated toward the midline of his abdomen. He has vomited several times since then — initially his vomit was rather dark in colour, and later he vomited fresh blood as well. He arrived at the emergency department at noon.

Laboratory results on admission:

• White blood cell count: 10.7 g/L
• Haemoglobin: 128 g/L (low)
• Haematocrit: 0.39 L/L (low)
• Thrombocyte: 132 g/L (low)

Imaging: The abdominal CT scan showed liver cirrhosis and an abnormal fluid accumulation in the abdominal cavity.

Course in the ICU

He was taken to the ICU immediately after the CT scan. The patient was alert and oriented to person, place, and time, however, he complains of intermittent headaches.

• Blood pressure 70/30 mmHg, pulse 120 beats/min
• Oxygen administration raised to 40% to maintain arterial oxygen saturation above 90%
• Central intravenous catheter inserted; rapidly given 3 litres of normal saline, 3 units of fresh frozen plasma, and vitamin K
• Only 50 ml of urine passed via the urine catheter

Laboratory results after fluid treatment:

• White blood cell count: 13.4 g/L (high)
• Hb: 89 g/L (low)
• Ht: 0.30 (low)
• Thr: 115 G/L (low)

Deterioration: The patient’s condition deteriorates. His skin is pale, cold, and clammy. His blood pressure is unmeasurable, his pulse rate is 150/min. He has heavy breathing, and his finger pulse oximetry result is 86%, despite the administration of 40% oxygen. The patient developed shock.

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Key Quotes & What They Tell Us

Quote / Value	Interpretation
Vomit “initially … dark in colour, and later … fresh blood”	Hematemesis from upper-GI bleeding; dark = partially digested blood, fresh red = active brisk bleed
CT: “liver cirrhosis and an abnormal fluid accumulation in the abdominal cavity”	Cirrhosis → portal hypertension → ascites and esophageal/gastric varices (the likely bleeding source)
“100 mg of Aspirin daily … on Warfarin”	Combined antiplatelet + anticoagulant therapy aggravates bleeding and impairs clotting
Hb 128 → 89 g/L; Ht 0.39 → 0.30	Progressive fall confirms significant ongoing blood loss (partly dilutional after saline)
BP 70/30 → unmeasurable; pulse 120 → 150/min	Hypotension with compensatory, then decompensated, tachycardia
Skin “pale, cold, and clammy”	Intense peripheral vasoconstriction (sympathetic compensation) → high SVR; hallmark of hypovolemic shock
“only 50 ml of urine”	Oliguria from renal hypoperfusion
SpO₂ 86% despite 40% O₂	Decompensated shock with tissue hypoperfusion and impaired oxygen delivery

Key Points

• Type of shock: Hypovolemic (hemorrhagic) shock from upper-GI variceal bleeding secondary to liver cirrhosis / portal hypertension.
• Aggravating factors: Chronic alcohol use, poor medication compliance, and combined Aspirin + Warfarin therapy.
• Pathophysiology: Loss of circulating volume → ↓venous return → ↓cardiac output → compensatory sympathetic vasoconstriction and tachycardia → eventual decompensation.
• Clinical signature: Cold, clammy, pale skin (high systemic vascular resistance) distinguishes hypovolemic shock from warm distributive shock.
• Course: Progressed despite aggressive resuscitation (3 L saline, 3 U FFP, vitamin K) — indicates severe ongoing hemorrhage requiring definitive source control.