18G
Paramedic
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I had a patient recently from a small community hospital that leaves me shaking my head so I wanted to seek other opinions on the case.
Patient was in her 70s, found at home alone on the floor after several days with no heat. Patient came into the ED hypothermic with rectal temp of 95.4F, after blanket warmer core temp trended downward to 93F and remained 93.1F on arrival at the ICU. Initial ABG was pH: 7.06, PCO2: 56, PO2: 54, HCO3: 16. O2 sat: 71% (4lpm-N/C). Lactic acid was like 6 or 7. WBC: 18.2. Troponin: 5.4, CK and CK-MB both grossly elevated. ALT and AST were in the thousands range. Potassium was 5.7. BUN: 35, Creatinine: 4.32.
Patient was determined to be septic w/ acute renal failure and acute liver failure. Bedside assessment of resp status - resp rate was 28, non-labored, effortless. Audible congestion was noted w/ cough. Patient had course crackles throughout. Chest x-ray only showed atelectasis. Pulse ox 82%. Poor pleth due to poor distal perfusion, unable to palpate radial pulses. Hands and forearms are cool. Patient was reported with distal cyanosis on ED arrival. Patient had some mottling starting to show in lower extremities. B/P wasn't bad. No hypotension. B/P maintained 108/50s to 129/80. HR maintained in the 80s (no beta blocker use).
Patient was semi-responsive w/ GCS of 7. The patient was not a DNR. The patient didn't really look all that bad all things considered initially. But soon after we loaded the patient increased resp rate to 32-35 and was pursed-lip breathing.
This patient should have been intubated in the ED and prob had some bicarb to boost the pH to at least 7.2. Granted the trajectory of this patient was death but in hindsight this patient should have been intubated.
The patient was maintaining the airway ok and my management was a warmed liter NSS bolus and passive warming of the patient, NRB, and an antibiotic was infusing during transport. I contemplated intubation but am not able to RSI or use drug-assisted intubation. I also thought about CPAP but figured the patient was maintaining and had a relatively short ETA (<35mins). I informed the ICU RN and RRT that the patient needed intubated as soon as we arrived in the ICU.
In hindsight I wish I would have had the ED physician intubate the patient prior to transport and administer bicarb. Regardless, I knew it wouldn't have changed the patient's outcome and maybe that's why I wasn't all that aggressive about it. But I always strive to do the right thing and not be biased in my treatment decisions.
What do others think about this case and the patient not being intubated in the ED and no addressing of the critically low pH?
Patient was in her 70s, found at home alone on the floor after several days with no heat. Patient came into the ED hypothermic with rectal temp of 95.4F, after blanket warmer core temp trended downward to 93F and remained 93.1F on arrival at the ICU. Initial ABG was pH: 7.06, PCO2: 56, PO2: 54, HCO3: 16. O2 sat: 71% (4lpm-N/C). Lactic acid was like 6 or 7. WBC: 18.2. Troponin: 5.4, CK and CK-MB both grossly elevated. ALT and AST were in the thousands range. Potassium was 5.7. BUN: 35, Creatinine: 4.32.
Patient was determined to be septic w/ acute renal failure and acute liver failure. Bedside assessment of resp status - resp rate was 28, non-labored, effortless. Audible congestion was noted w/ cough. Patient had course crackles throughout. Chest x-ray only showed atelectasis. Pulse ox 82%. Poor pleth due to poor distal perfusion, unable to palpate radial pulses. Hands and forearms are cool. Patient was reported with distal cyanosis on ED arrival. Patient had some mottling starting to show in lower extremities. B/P wasn't bad. No hypotension. B/P maintained 108/50s to 129/80. HR maintained in the 80s (no beta blocker use).
Patient was semi-responsive w/ GCS of 7. The patient was not a DNR. The patient didn't really look all that bad all things considered initially. But soon after we loaded the patient increased resp rate to 32-35 and was pursed-lip breathing.
This patient should have been intubated in the ED and prob had some bicarb to boost the pH to at least 7.2. Granted the trajectory of this patient was death but in hindsight this patient should have been intubated.
The patient was maintaining the airway ok and my management was a warmed liter NSS bolus and passive warming of the patient, NRB, and an antibiotic was infusing during transport. I contemplated intubation but am not able to RSI or use drug-assisted intubation. I also thought about CPAP but figured the patient was maintaining and had a relatively short ETA (<35mins). I informed the ICU RN and RRT that the patient needed intubated as soon as we arrived in the ICU.
In hindsight I wish I would have had the ED physician intubate the patient prior to transport and administer bicarb. Regardless, I knew it wouldn't have changed the patient's outcome and maybe that's why I wasn't all that aggressive about it. But I always strive to do the right thing and not be biased in my treatment decisions.
What do others think about this case and the patient not being intubated in the ED and no addressing of the critically low pH?
