# CHF, Pneumonia, Septic?



## Jciota (May 18, 2011)

Heres my pt info , wanna know what you guys would do?  56 y/o mentally retarded pt in nursing home with dyspnea. RR 30 B/P 88/40 102 fever ST @ 110 on monitor with audible rales. Nurse said she doesnt know anything she just got there, and her exact words were I heard crackles so Im giving albuterol. Pt was o2 sat 80%. No hx of CHF as far as i know. Let me know if you want anymore info... just want to see what people would do in this situation


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## JPINFV (May 18, 2011)

Jciota said:


> Heres my pt info , wanna know what you guys would do?  56 y/o mentally retarded pt in nursing home with dyspnea. RR 30 B/P 88/40 102 fever ST @ 110 on monitor with audible rales. Nurse said she doesnt know anything she just got there, and her exact words were I heard crackles so Im giving albuterol. Pt was o2 sat 80%. No hx of CHF as far as i know. Let me know if you want anymore info... just want to see what people would do in this situation



Standard H/P to the best of your abilities, then most likely CBC, chem 7, lactate levels, chest x-ray, oxygen titrated to SpO2, normal saline wide open, and see what the response is...


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## medicRob (May 18, 2011)

JPINFV said:


> Standard H/P to the best of your abilities, then most likely CBC, chem 7, lactate levels, chest x-ray, oxygen titrated to SpO2, normal saline wide open, and see what the response is...



Haven't heard it called a Chem-7 since ER. We call it a BMP 'round these here parts.


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## usalsfyre (May 18, 2011)

Sepsis. Two lines, pour the fluid on, high concentration oxygen, consider intubation and transport. If the B/P is unresponsive to fluids start norepi or neo (if norepi is unavailable). At a CCT level, draw cultures and start broad spectrum antibiotic coverage (a gram of ceftriaxone anyone?), if the pressure is still unresponsive consider vasopressin and/or hydrocortisone.


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## JPINFV (May 18, 2011)

medicRob said:


> Haven't heard it called a Chem-7 since ER. We call it a BMP 'round these here parts.




I've heard both terms, and I'm sure my vocabulary is going to change a bit once I start clerkships in a few months.


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## medicRob (May 18, 2011)

JPINFV said:


> I've heard both terms, and I'm sure my vocabulary is going to change a bit once I start clerkships in a few months.



Yeah, you'll see CMP/BMP and CBC on the majority of patients. I like to get a PTT on my older patients, collect a red top on females of child bearing age (not to mention, it is generally a good idea to have an extra non-additive chem tube collected and in the lab anyways).


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## abckidsmom (May 18, 2011)

medicRob said:


> Haven't heard it called a Chem-7 since ER. We call it a BMP 'round these here parts.



We called it a Chem-7. 

How was his color?  With his pressure being down, I wouldn't necessarily believe that sat was really 80.  

This is the kind of patient I will watch carefully, start some oxygen, get a couple of lines for access, bolus and reassess.  Assuming that he's perfusing better than that sat of 80 would suggest, he's got a little bit of wiggle room for us to take our time and wait and see how he responds.


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## usafmedic45 (May 19, 2011)

> her exact words were I heard crackles so Im giving albuterol



*facepalm*


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## Voodoo1 (May 19, 2011)

usalsfyre said:


> Sepsis. Two lines, pour the fluid on, high concentration oxygen, consider intubation and transport. If the B/P is unresponsive to fluids start norepi or neo (if norepi is unavailable). At a CCT level, draw cultures and start broad spectrum antibiotic coverage (a gram of ceftriaxone anyone?), if the pressure is still unresponsive consider vasopressin and/or hydrocortisone.



What makes you say that this pt is septic? What two lines? How would you admin the O2? Why would you consider intubation? If the SPO2 didn't improve and when would you make that decision? I'm asking not to offend, but to learn from others in the field.


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## Smash (May 19, 2011)

*I'll second usalsfyre*

Failing having all the info and gestalt that I would have if I was there myself... 

He fits SIRS criteria and he lives in nursing home; he has to die of sepsis secondary to pneumonia sooner or later.
Fluids +++, norepinepherine if no response to fluids.  Depending on time to hospital, ceftriaxone IV.  Cultures are nice, targeted antibugs are great, but we need to crack on to at least slowing down the bugs sooner rather than later.  Just wish I could draw some cultures first, then I wouldn't have to decide on way or the other.
Anyhoo, if poor response to norepinephrine, add some vasopressin.

What is his conscious state?  He probably needs intubated and ventilated as well, take some load off, reduce some of that lactate production and O2 demand.

Find out if he has advanced directive or NFR, he's as sick as three hospitals and it wouldn't surprise me if he dies from this.


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## usafmedic45 (May 19, 2011)

> he has to die of sepsis secondary to pneumonia sooner or later.



....if sepsis from a poorly maintained urinary catheter or unnoticed/untreated bedsores doesn't get him first.


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## Aidey (May 19, 2011)

usafmedic45 said:


> ....if sepsis from a poorly maintained urinary catheter or unnoticed/untreated bedsores doesn't get him first.



Beat me to it.


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## socalmedic (May 19, 2011)

usalsfyre said:


> Sepsis. Two lines, pour the fluid on, high concentration oxygen, consider intubation and transport. If the B/P is unresponsive to fluids start norepi or neo (if norepi is unavailable). At a CCT level, draw cultures and start broad spectrum antibiotic coverage (a gram of ceftriaxone anyone?), if the pressure is still unresponsive consider vasopressin and/or hydrocortisone.



and what if the patient has a central line?


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## Smash (May 19, 2011)

Voodoo1 said:


> What makes you say that this pt is septic? What two lines? How would you admin the O2? Why would you consider intubation? If the SPO2 didn't improve and when would you make that decision? I'm asking not to offend, but to learn from others in the field.



I kind of covered a couple of these in my post above, must have been at the same time as you were posting.

This pt has severe sepsis because he is:
Febrile (temp >38 celsius)
Tachycardic (rate >90)
Tachypneic (rate >20)
(and I would presume he will have white cell abnormalities)

He also has hypotension.

So clinically, he fits the criteria for SIRS, and as he is in a nursing home he has a good chance of having a respiratory focus (and the rales of course point to that as well)

Need good, large bore IV access because first and foremost this patient needs aggressive fluid resuscitation.  Sepsis causes a number of problems (well, craploads actually, it's an incredibly complex beast) and leaky capillaries is a major one.  These patients lose and enormous amount of fluid from their capillaries, and the also tend to make enormous quantities of poor quality urine.  Added to this the fact that they will have likely had poor oral intake, possibly for some days, and you end up with a really crappily perfused, dry as hell patient.  These patients need multiple litres of fluid.  Many multiple litres.

This will be one of the few times that I give high concentration of O2.  Even if he had a relatively normal SpO2, I would still give O2, because septic patients have an enormously increased O2 demand at a tissue level.  This is why SCVO2 is measured to get an idea of perfusion (although there is some doubt about how useful it is)
Intubation is probably indicated (or is indicated, it's whether we do it there or at hospital that is the question) to maximise O2 delivery with high FiO2 if needed and to add some PEEP to ensure recruitment of alveoli (someone smarter than I am needs to explain that better, or correct me if I'm wrong)
It will also help relieve some of the workload, this patient is breathing up hard, burning a lot of energy with thei respiratory muscles, adding to the lactate production and sucking up O2.  Once tubed, head up 30degrees, careful suctioning of tube and oropharynx, try not to add more bugs to the stew.

I forgot to mention the mineralcorticoids if/when vasporessin is started.  If we get to that point it suggests a relative adrenal insufficiency so steroids are indicated.  100mg for a start, repeated 8 hourly (not that I'll have him for that long)


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## usalsfyre (May 19, 2011)

socalmedic said:


> and what if the patient has a central line?


What type of central line? I highly doubt the guys sitting in a normal LTC with a triple lumen CV catheter conveniently emerging from his chest. Meaning your looking at a PICC or implanted device, which vary in usefulness depending on capacity and whether you have the equipment to properly access it.

Unless you know the specifics on any central access device be very careful accessing them.


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## usalsfyre (May 19, 2011)

Voodoo1 said:


> What makes you say that this pt is septic? What two lines? How would you admin the O2? Why would you consider intubation? If the SPO2 didn't improve and when would you make that decision? I'm asking not to offend, but to learn from others in the field.



Smash covered my thoughts on this pretty well.


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## Smash (May 19, 2011)

Sorry for all the typing mistakes in my last post.  I was trying to type faster than my fingers could keep up with to get out the door to the gym to meet my training partner. 

And I should also apologize for the terrible grammar in this post!


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## usafmedic45 (May 19, 2011)

socalmedic said:


> and what if the patient has a central line?



All the better?


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## usafmedic45 (May 19, 2011)

> This pt has severe sepsis because he is:
> Febrile (temp >38 celsius)
> Tachycardic (rate >90)
> Tachypneic (rate >20)
> ...



Pop quiz: what common over the counter medication can induce all of those findings and should always be included among the differentials for "sepsis of unknown origin"?


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## usalsfyre (May 19, 2011)

usafmedic45 said:


> Pop quiz: what common over the counter medication can induce all of those findings and should always be included among the differentials for "sepsis of unknown origin"?



Psuedoephedrine?


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## medicRob (May 19, 2011)

usalsfyre said:


> Psuedoephedrine?



You've got my attention. 

</Forum meth Chef>


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## usafmedic45 (May 19, 2011)

usalsfyre said:


> Psuedoephedrine?



Nope.


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## mycrofft (May 19, 2011)

*Ignorant question now the likely culprit is named*

1. What's the optimal IV fluid for impending septic shock? Oddly, the word "albumin" leapt to mind, but so did "French Toast"...


2. Second the Albuteral facepalm. Nice try nurse, now how about some medicine? Was it even ordered? 
3. Central line in a nursing home: the tip probably looks like the bottom of a shower curtain in a frat house.
4. Common OTC med...dunno, with both raised pulse and lowered BP. "Mah-wong"?B)
5. Agree with drawing labs (red top, tiger top, purple top) before dumping meds onboard, other than volume expanders and O2. If you have a ridealong, have her get a urine spec too.

A good case to make sure they send lots of documentation along. If possible, call the ER and tell them you have the specimens after giving the pt heads-up, they can have the lab slips waiting.

PS: YAY for "rales", I hate "crackles" as I've heard rhoncii called crackles too.


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## usalsfyre (May 19, 2011)

mycrofft said:


> 1. What's the optimal IV fluid for impending septic shock? Oddly, the word "albumin" leapt to mind, but so did "French Toast"...



Of the commonly available pre-hospital fluids Ringers is a better choice than NS.


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## mycrofft (May 19, 2011)

*CaCO3 OD can cause drop in BP due to arrythmia, and IV fluid*

Don't know if that consitutes a rapid pulse, though.


Yeah, SNS is a placesaver for other stuff.


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## usafmedic45 (May 19, 2011)

> Don't know if that consitutes a rapid pulse, though.



Nope.  It also doesn't induce fever either.


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## mycrofft (May 19, 2011)

*Your avatar is appropriate.*

By the way, interestig article I googled about IV resuscitation of septic patients:
http://www.ivteam.com/fluid-resuscitation-in-septic-shock/
I loved the Gatorade ad banner on the top.

ADDIT: "To answer your question more explicitly, there is no clear evidence on which to base the choice of intravenous fluid resuscitation agent in patients with septic shock. Colloids have physiologic advantages in maintaining colloid osmotic pressure, but suffer from higher acquisition cost and a variety of adverse effects. Gelatin solutions have been associated with anaphylactoid reactions, as have dextran solutions. Hydroxyethyl starches and dextrans may increase bleeding by induced coagulopathy and altered blood viscosity. Without clear evidence to guide the choice of intravenous solution, they should be chosen based upon solution-specific and patient-specific factors."   Gregory S. Martin, MD, MSc    http://www.medscape.com/viewarticle/448198


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## medicRob (May 19, 2011)

usafmedic45 said:


> Pop quiz: what common over the counter medication can induce all of those findings and should always be included among the differentials for "sepsis of unknown origin"?



Iron poisoning?

It is the only differential that comes to mind at the moment involving an OTC.


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## usafmedic45 (May 19, 2011)

medicRob said:


> Iron poisoning?
> 
> It is the only differential that comes to mind at the moment involving an OTC.



Nope.  It's even more common than iron poisoning.


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## mycrofft (May 19, 2011)

*Salicylates*

Back off the Pepto.


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## usafmedic45 (May 19, 2011)

mycrofft said:


> Back off the Pepto.



Bingo.


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## mycrofft (May 19, 2011)

*I was running out of candidates.*

Sen-sen, Proctosil, TigerBalm, Dr Scholl's Gel from the shoe inserts...


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## usafmedic45 (May 19, 2011)

mycrofft said:


> Sen-sen, Proctosil, TigerBalm, Dr Scholl's Gel from the shoe inserts...


Nah, you got it with salicylate.


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## fma08 (May 21, 2011)

Thanks for that note usafmedic. I wasn't aware of that. Did some research on salicylate poisoning, interesting reading.


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## Smash (May 22, 2011)

It never ceases to amaze me that I don't see more salicylate toxicity, given how ubiquitous it is and how tasty the chewable aspirin is. 

Any update on this patient? How did he do? Was he septic?


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## rhan101277 (May 22, 2011)

Jciota said:


> Heres my pt info , wanna know what you guys would do?  56 y/o mentally retarded pt in nursing home with dyspnea. RR 30 B/P 88/40 102 fever ST @ 110 on monitor with audible rales. Nurse said she doesnt know anything she just got there, and her exact words were I heard crackles so Im giving albuterol. Pt was o2 sat 80%. No hx of CHF as far as i know. Let me know if you want anymore info... just want to see what people would do in this situation



Any pitting edema?  If not does the patient appear dehydrated (is mucosa dry, skin turgor? etc.).  CHF is something that happens over a couple days, if its acute onset, it is not CHF.  15L NRB to improve sats, if no improvement albuterol x 1, keep in mind pneumonia can also cause crackles, not every crackle is a CHF case.  250cc fluid bolus and re-asses the need for further fluids.  Just because the cause seems obvious, I would infuse fluids cautiously since patient cannot reliably report symptoms.

Many possibilities here but I would say pneumonia.

If at any point during treatment I become unsure about the cause of respiratory distress or the patient deteriorates further despite my best abilities, I will contact med control for further assistance.

It is not like we are out here cooking breakfast.


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## FLdoc2011 (May 22, 2011)

Look up and read about the "Surviving Sepsis" early goal directed guidelines.    Will give you specifics on initial fluid resuscitation, and goals to meet before moving on to things such as pressors, steroids, etc...  

In the hospital setting we're doing SCVO2 monitoring which combined with other labs can point us to which intervention we want to do.... such as giving blood, inotropic support, oxygen, etc... 

And if they come in with a central line then in all likelihood that line is getting pulled (and cultured) when they hit the hospital and another one put in.


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## Trevor (May 22, 2011)

Im all for intubating these people for decreasing demand and work load, but dont they have a propensity to die after being being tubed? Doesnt it have to do with setting a "normal" resp rate and them not being able to compensate for Acidosis anymore? SO, just be careful of your vent settings! USAF maybe you can correct me if thats not correct.


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## usafmedic45 (May 22, 2011)

> Im all for intubating these people for decreasing demand and work load, but dont they have a propensity to die after being being tubed?



Some studies have shown increased mortality associated with intubation, but it most likely has to do with the increased severity of the underlying condition rather than a direct complication of being intubated or mechanically ventilated.  If you're already far enough up :censored::censored::censored::censored: Creek to need tubed, chances are decent that the currents going to continue to carry you to that final destination you were headed for to begin with.



> Doesnt it have to do with setting a "normal" resp rate and them not being able to compensate for Acidosis anymore?



You do know that we adjust ventilator settings to compensate for the patient right?  There is no "normal" (see the other thread) but rather it's guided by blood gas findings.  Unless the RT and doc are total morons, inadequate compensation (within reason) should not be a major factor.  The lack of ABGs in the field is the main reason why I don't like to see people put on vents by medics.



> SO, just be careful of your vent settings!



Exactly.


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## Trevor (May 23, 2011)

Absolutely agree with ya about being FUBARed... 
ya, i know that you can and do adjust vent settings... I vaguely remember an EMRAP discussion about patients dying post intubation due to sepsis and inability to continue to compensate after being tubed. I think they were talking about it during the very short time between ED intubation and first ABG...


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## mycrofft (May 23, 2011)

*USAF, your comment deserves framing and stickying here!*

"Some studies have shown increased mortality associated with intubation, but it most likely has to do with the increased severity of the underlying condition rather than a direct complication..." 

 You can substitute any invasive or painful measure for "intubation", and add "when truly necessary".


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