# Severely Acidotic / Sepsis



## 18G (Dec 7, 2014)

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?


----------



## 18G (Dec 7, 2014)

There was consultation between the receiving Intensivist and sending ED physician and no mention of intubation. Yet, the Intensivist asks me why the ED didn't intubate.


----------



## luke_31 (Dec 7, 2014)

This patient was a train wreck from the beginning.  Intubation I don't feel would have made a significant difference in the beginning of her care.  Granted I could see it happening once she was seen by the ICU doc, but there are significant risks with intubation and the sedatives and paralytics that might be used with a patient that has such worrisome lab values.  Also with non-labored, effortless breathing I wouldn't want to take away her ability to breath on her own, and the pursed lip breathing could have been her way to try and help blow off more of the CO2.  Bicarb administration would have probably keep the patient in the ED for a while longer to see if the pH improved.  If I was there I would have asked about if it would be possible to further stabilize the patient with regards to the pH and best way to try and start warming the patient further.  It's possible that some of the lab values would improve once metabolism was improved with the body being normothermic.


----------



## StudMartin (Dec 7, 2014)

Yowzas.


----------



## Clare (Dec 7, 2014)

See how they go on CPAP first.

I'd refuse to transport this patient without the interhospital retrieval team coming with us.  I'd need be I'd get the Duty Intensivist from the Department of Critical Care Medicine on the phone about it.  I'm not experienced enough to manage somebody this sick.


----------



## Carlos Danger (Dec 8, 2014)

Bicarb would probably not have been helpful.

I can imagine why the ED doc wanted to avoid intubation - it sounds as though she was quite tenuous, and intubating someone that acidemic can be risky. But.....with that GCS and ABG, I think it's fair to say that it should have been done. Much better in the ED by a physician with plenty of help than in the back of an ambulance by a single medic.

A CPAP trial would have been a good option. I wonder why they didn't do that?

This is a transport for a dedicated CCT crew who deals with these scenarios regularly, not a sole paramedic.


----------



## Ewok Jerky (Dec 8, 2014)

Agreed this transport was not a fun for anyone involved.  I don't think death was probably avoidable in this case.  I can also understand why the sending facility didn't want to intubate, don't want to precipitate the ultimate outcome.  But then I don't know why the receiving intensivist didn't request it before transport.  If no intubation I probably would have sent CCT.  Heck, probably would have sent CCT regardless.  With calcium too, although again I don't think this level of acidemia is something one recovers from.


----------



## VFlutter (Dec 8, 2014)

Sounds like Rhabdo is playing a big role. I don't think Bicard would really do anything except for chasing a number. If they were hypotensive and poorly responsive to pressors then sure. This is the type of patient who dies during or shortly after intubation. Hopefully they ended up tubed and on CRRT once they got to the unit.


----------



## 18G (Dec 8, 2014)

The patient did get intubated as soon as they got moved into the ICU bed.


----------



## wanderingmedic (Dec 9, 2014)

Ouch! I do think that rhabdo is playing a big role here, and I'm not sure how much good bicarb would have done. Call me aggressive, but I would have liked to have tubed the pt. Intubation was inevitable. I think the pt could have benefited from some PEEP and increased tidal volume. A vent could also have provided benefits to the pt's acidosis by helping the pt do blow off CO2 more efficiently, even thought the pt was most likely in metabolic acidosis. A Tube could also give you access for some deep suction.


----------



## Rescue7RN (Dec 9, 2014)

So this is one of my first posts but here are my two pennies.  
1.  You are taking a critical patient out of one facility and traveling for greater than an hour.  Most people only count the drive time but there is time out of unit, loading, unloading and then up to the other unit.  She needs intubated now before you leave.  You need to have everything set up, and you need to do it with just a wiff of meds.  No paralytics then match her minute volume immediately after intubation. If you can't do it, ask the referring doc to do it.  

2.  This is for a critical care team to do.  Its ok to refuse these transports when they fall way out of your scope/knowledge level.  This is not a dig on you, this is for the patients benefit.  

3.  She needs the bicarb but not push just because the PH is so low. 

4.  IVF.  Now that you have controlled the airway, fill her up. with a liter or two.  Her acute liver failure looks to be from shock liver.  The renal failure looks to be acute on chronic because the BUN/CR ration is not greater than 20 but the IVF can help until you differentiate that.  

5.  What's everyones thoughts on anticoagulation and going direct to a cath lab?  What was the 12 lead like?  She's definitely having an NSTEMI and seeing what an echo is like would also be a  benefit?

Tim


----------



## VFlutter (Dec 9, 2014)

Rescue7RN said:


> 4.  IVF.  Now that you have controlled the airway, fill her up. with a liter or two.  Her acute liver failure looks to be from shock liver.  The renal failure looks to be acute on chronic because the BUN/CR ration is not greater than 20 but the IVF can help until you differentiate that.



Shock Liver in a normotensive patient? Why does this patient have elevated liver enzymes? Why is she in acute renal failure?



Rescue7RN said:


> 5.  What's everyones thoughts on anticoagulation and going direct to a cath lab?  What was the 12 lead like?  She's definitely having an NSTEMI and seeing what an echo is like would also be a  benefit?



This is not a NSTEMI. Do NOT coagulated her. She will likely end up in DIC. Why are here "cardiac" enzymes elevated? What else could elevated Trop/CK indicate?

You are looking at this as individual concurrent problems. Is there one reason for the whole constellation of issues?


----------



## 18G (Dec 9, 2014)

Rescue7RN said:


> So this is one of my first posts but here are my two pennies.
> 1.  You are taking a critical patient out of one facility and traveling for greater than an hour.  Most people only count the drive time but there is time out of unit, loading, unloading and then up to the other unit.  She needs intubated now before you leave.  You need to have everything set up, and you need to do it with just a wiff of meds.  No paralytics then match her minute volume immediately after intubation. If you can't do it, ask the referring doc to do it.
> 
> 2.  This is for a critical care team to do.  Its ok to refuse these transports when they fall way out of your scope/knowledge level.  This is not a dig on you, this is for the patients benefit.
> ...



Intubation was indicated and in hindsight should have made it happen but for whatever reason, all that were involved in the patient's care opted not to intubate at that stage in the game. I think we all have the coulda, shoulda moments. Again, the trajectory was death at this point so I wasn't too aggressive with pushing it... if the patient deteriorated I would have intubated the patient but they remained baseline with a patent airway. It's a case that provides emphasis for going forward in the future. 

This acuity level of patient is often transported by a single Paramedic and is what we are accustomed to and comfortable with. I work for a hospital affiliated inter-facility company. We have out own ventilators, etc. 

The patient had two liters of fluid infused. 

I did not suspect an NSTEMI at all and neither did the ED doc. Enzyme elevations like these come from more than cardiac muscle and given the history and overall condition, the elevations seemed more likely from another cause. 

All good thoughts.


----------



## SeeNoMore (Dec 10, 2014)

Good discussion. Personally if I was not allowed to RSI, I would not have taken this patient. But hindsight is 20 / 20 right? I also was not thinking NSTEMI, but assumed the elevated enzymes were secondary to Sepsis. Given a lack of other options CPAP or Bipap , depending on your vent might have been an option. I know you considered it. Was there ever a repeat ABG? I assume not or you would have included it. Thanks for sharing.


----------



## Carlos Danger (Dec 10, 2014)

While I agree that this patient should probably have been intubated for transport, I also understand the ED doc's reluctance. This is not a routine patient and thus routine decision making and risk/benefit analyses do not necessarily apply. "GCS <8 = intubate" is not always true. This is the kind of patient who arrests on induction if. Attempting to improve things without intubation may have been the wiser choice. Discretion is sometimes the better part of valor.


----------



## VFlutter (Dec 10, 2014)

Chase said:


> Attempting to improve things without intubation may have been the wiser choice. Discretion is sometimes the better part of valor.



We frequently have these type of crash intubations upon arrival to our unit since we are a tertiary hospital with frequent transfers from rural areas. Unfortunately, many of these rural EM Docs are just not comfortable or competent with these types of patients. Even though they need to be intubated they are usually better served by our CC/Pulm Intensivist then the moonlighting ER doc who has not intubated in month. 

The worst situations are the ones who do not get intubated in the ED, crump en route, and arrive with a LMA/King and a bloody hypotensive mess after multiple airway attempts. The back of an ambulance, or helo, is not the place you want to tube these trainwrecks. Unfortunately, it happens.


----------



## Brandon O (Dec 10, 2014)

You're in good company thinking it would be smart, but both the data and the physiology is pretty sure that bicarb does not help these people. Any more than fanning away the smoke helps with housefires.

It sounds like calling this patient stable for transfer was a bit of a, erm, judgement call. Scary stuff. It's one thing when they're going to necessary care (e.g. a cath lab) but... well, I dunno. In particular, avoiding the airway issue (because of acidosis or hemodynamics or whatever) is really just punting it to the transporting crew (i.e. you).


----------



## EMT11KDL (Dec 11, 2014)

Here is the issue, ABG was bad, Mixed Acidodic while in a hypoxic state with being Hypothermic.  Resp Rate increased because the body was trying to blow of the CO2 do hopefully get back to a normal Ph, but this guy is going to need help with that.  Do you happen to Remember what his BE was on the ABG?   I am guessing somewhere around -3.5.  I am guessing (with out seeing more of his labs like Na, K, Cl) the acidodic state is because of a metabolic issue.  But you also have to think that his ABG and lab values will be off because of his temp, so rewarming is another thing that needs to happen, bicarb will not work with patients that are hypothermic so that is why bicarb was not given, at least that is my best guess.  Also with Hypothermic Patients, you are more likely to develop hyperchloremic Meta. Acidosis especially with prolonged hypothermia. 

he was maintaining his own airway, plus with the elevated resp rate, he is able to blow of some CO2, The patient has been sick for a long time and he is very sick. He should have been seen by someone way before this, but some patients it takes an act of congress to get them into an ER. 

I would be torn on tubing this guy and most likely would not do it because he was not having a resp issue, my main goal would rewarm him to about 96 degrees, than bicarb and intubated probably than.  

Also to fix the Acid issue, we need to deal with the underlying causes which is going to be 
1. Temp issue
2. Septic

until those are fixed, he will not get better.  

This is a CCT, and you should not have been put into this situation, a specialty team should have handled this, but i do not know about your area, you might not have a CCT available.  

Very good case study!!!!


----------



## EMT11KDL (Dec 11, 2014)

EMT11KDL said:


> Here is the issue, ABG was bad, Mixed Acidodic while in a hypoxic state with being Hypothermic.  Resp Rate increased because the body was trying to blow of the CO2 do hopefully get back to a normal Ph, but this guy is going to need help with that.  Do you happen to Remember what his BE was on the ABG?   I am guessing somewhere around -3.5.  I am guessing (with out seeing more of his labs like Na, K, Cl) the acidodic state is because of a metabolic issue.  But you also have to think that his ABG and lab values will be off because of his temp, so rewarming is another thing that needs to happen, bicarb will not work with patients that are hypothermic so that is why bicarb was not given, at least that is my best guess.  Also with Hypothermic Patients, you are more likely to develop hyperchloremic Meta. Acidosis especially with prolonged hypothermia.
> 
> he was maintaining his own airway, plus with the elevated resp rate, he is able to blow of some CO2, The patient has been sick for a long time and he is very sick. He should have been seen by someone way before this, but some patients it takes an act of congress to get them into an ER.
> 
> ...



So I just re looked at the ABG, I thought the O2 was PO2.  Do we have a Po2?


----------



## Akulahawk (Dec 11, 2014)

EMT11KDL said:


> So I just re looked at the ABG, I thought the O2 was PO2.  Do we have a Po2?


Indeed we do...


18G said:


> 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.


----------



## EMT11KDL (Dec 11, 2014)

Akulahawk said:


> Indeed we do...



So I was originally right anyways with Hypoxia on that side, I just just way over looked it when I replied.  Do you have anything else you would like to add to this case?


----------



## Akulahawk (Dec 11, 2014)

EMT11KDL said:


> So I was originally right anyways with Hypoxia on that side, I just just way over looked it when I replied.  Do you have anything else you would like to add to this case?


Nope. Here's what I see: A hypoxic, hypothermic, septic patient that's in renal failure, liver failure and has an amazing case of rhabdo going on. I'm amazed the patient lived that long.


----------



## NomadicMedic (Dec 11, 2014)

I just read those ABG values to my wife, the emergency vet. Her response was, "somebody should start digging a hole."

Hahahaha.


----------



## triemal04 (Dec 12, 2014)

Remi said:


> While I agree that this patient should probably have been intubated for transport, I also understand the ED doc's reluctance. *This is not a routine patient and thus routine decision making and risk/benefit analyses do not necessarily apply.* "GCS <8 = intubate" is not always true. This is the kind of patient who arrests on induction if. Attempting to improve things without intubation may have been the wiser choice. Discretion is sometimes the better part of valor.


They don't, but when moving a patient out of the hospital, a whole new set of considerations comes up that make it even more convoluted.  

This one had a shortish transport time (<35 drive time apparently), but when faced with something longer, or shorter sometimes, it often may be better to perform the procedure (higher risk though it may be) than to put the patient into a lower level of care with an unsupported/underperforming whatever and hope that the same thing won't have to be done on the road. 

It probably would have been beneficial for the OP to ask the sending doc what his thoughts on intubation were, and why it wasn't performed.


----------



## Carlos Danger (Dec 12, 2014)

triemal04 said:


> They don't, but when moving a patient out of the hospital, a whole new set of considerations comes up that make it even more convoluted.
> 
> This one had a shortish transport time (<35 drive time apparently), but when faced with something longer, or shorter sometimes, it often may be better to perform the procedure (higher risk though it may be) than to put the patient into a lower level of care with an unsupported/underperforming whatever and hope that the same thing won't have to be done on the road.
> 
> It probably would have been beneficial for the OP to ask the sending doc what his thoughts on intubation were, and why it wasn't performed.



All truth.

It also comes down to clinical perspective, though. 

As transport folks, we tend to look at every patient care situation from the angle of the transport. "I'm alone in the back of ambulance. The patient will be safer if their airway is secured before we go" is (nearly) always a true statement. But as with every rule, there are exceptions. 

We are taught to be hyper-aggressive with airway management, and in most really sick patients, that is the right approach. What we _aren't_ taught however, is the downsides of invasive airway management in certain populations, or the nuance of analyzing the risk:benefit of intubating certain people who, if you only look at one side of the clinical picture, clearly should be tubed. We are great at identifying people who should be RSI'd, but not so experienced with choosing who maybe should not.  

In reality, a 30 or 60 or even 90 minute transport is a very small window in the course of a patient who is going to require perhaps weeks of intensive care. So when non-EMS folks look at these situations, they don't always rank priorities the same way that we do. EM docs and others tend to be better are looking at the bigger picture and viewing the transport is simply a brief phase in the overall course of the patient. 

So as a sending physician, you might look at the OP's scenario something along the lines of this:

If the ambulance crew has to tube her during transport, it likely won't go well.
But if I tube her, it likely won't go well, either.
She's best off not having to be intubated at all, and that's the goal here. But if the DOES have to be tubed, the best place for that is probably in a tertiary ICU by intensivists and/or anesthesia.
She's been holding her own since she's been here, and while that could change in the next 30 minutes or so, I really have no reason to believe that it will.  
When you look at it that way, you can maybe see why an EM doc in that situation would try to send the patient without intubating first.


----------



## JPINFV (Dec 12, 2014)

Rescue7RN said:


> 5.  What's everyones thoughts on anticoagulation and going direct to a cath lab?  What was the 12 lead like?  She's definitely having an NSTEMI and seeing what an echo is like would also be a  benefit?
> 
> Tim



There's a half a dozen different things that's going on with this patient that can cause elevated cardiac enzymes, especially the renal failure and the sepsis. Furthermore, even if it was an NSTEMI, then a cath would do nothing in this case except cause even more renal failure from contrast induced nephropathy. 

http://circ.ahajournals.org/content/124/21/2350.full.pdf+html


----------



## triemal04 (Dec 13, 2014)

Remi said:


> In reality, a 30 or 60 or even 90 minute transport is a very small window in the course of a patient who is going to require perhaps weeks of intensive care. So when non-EMS folks look at these situations, they don't always rank priorities the same way that we do. EM docs and others tend to be better are looking at the bigger picture and viewing the transport is simply a brief phase in the overall course of the patient.
> 
> So as a sending physician, you might look at the OP's scenario something along the lines of this:
> 
> ...




This is where it get's more problematic though, and where both the sending doctor, and the transporting team need to both be involved and aware of what the other is thinking and capable of.  

Even 30 minutes can be to long for some patients to go if they continue to decompensate or if their condition changes (and predicting what some critically ill patients will do can be a crapshoot) and, while not always the case, in general an ER will be better suited to deal with that versus a single person in an ambulance.  So with the patient who might not "need" X done right then while sitting in an ER  it may be better to do X anyway, even with the associated risks, instead of putting them in a different environment with different levels of stimulation, movement, less medical resources, maybe less experienced providers, and no extra help and hoping that they'll maintain until they reach their destination.

There is no single right answer for all situations; it will be dependant on the patient and what is wrong with them.  It just needs to be remembered for people who are doing this type of work that, if you see something that you think should be done prior to leaving, you need to be asking why it wasn't done.

The answer may or may not change things, but you still better be asking, because what you're seeing may not be what the doc is seeing, and what you're capable of may be different than what they think you can do.


----------



## SeeNoMore (Dec 14, 2014)

It's one thing to hold off intubating a patient that it is being sent with  a CCT able to RSI if the patient requires it en route. It's another to send that patient with a single Paramedic who has less options.


----------



## MonkeyArrow (Dec 14, 2014)

SeeNoMore said:


> It's one thing to hold off intubating a patient that it is being sent with  a CCT able to RSI if the patient requires it en route. It's another to send that patient with a single Paramedic who has less options.


I think that this is a very one-dimensional mindset looking only at the EMS transport aspect. As stated above, the problem here is intubating this patient could cause him to further de-compensate. Therefore, the docs may want to hold off on managing the airway until they are quite literally left with no other option. Yes, they are playing the odds and counting on their lucky stars that the patient will be able to maintain their own airway through the transport. 

Option 1: Intubate him now

 more problems arise, potentially further delaying transport of the critically ill patient to the tertiary care center
Option 2: Holding off on the intubation 

the patient maintains his own airway and does not face any of the problems
the patient crashes during transport, probably leaving him dead


----------



## EMT11KDL (Dec 14, 2014)

SeeNoMore said:


> It's one thing to hold off intubating a patient that it is being sent with  a CCT able to RSI if the patient requires it en route. It's another to send that patient with a single Paramedic who has less options.



I also disagree with this type of thinking.  and like Monkey Said, we have two options.  

We have to think of this patients care long term, treatment of the patient as a whole not just focus on the airway, and not just the short amount of time that we are in charge of the patient.  There are complications that go along with intubating a patient and putting a patient on a vent, especially with how her Gasses are already, along with everything else that is going on with the patient.  Like I said before, the patient was maintaining his own airway, and from what was presented to us, I do not believe this patient would crash during the transport, so I would feel comfortable taking him the way he is.  But in our protocols we can RSI so I might be a little bias on that.


----------



## SeeNoMore (Dec 15, 2014)

How does advocating a team with the OPTION of RSI = one dimensional thinking? I am aware of the potential complications of intubation and mechanical ventilation. What makes you believe this patient would not decompensate during transport? I don't really have an opinion on it either way, given the presentation I consider further decompensation a distinct possibility. In any event, I am not trying to say that intubating this patient somehow fixes all problems. If the ED Doctor wants to avoid intubation until they have "no other option" it might be wise to employ the use of a critical care team that could intervene with RSI or other therapies for this very ill patient. I understand these teams are not always available in a timely manner.


----------



## systemet (Feb 14, 2015)

I see that there's  a lot of folk with ICU / CCT experience on here, so I'd just like to throw a few ideas out for feedback.

* The patient meets criteria for severe sepsis (SIRS + lactemia)
* The, _"Audible congestion was noted w/ cough. Patient had course crackles throughout. Chest x-ray only showed atelectasis"_ coupled with PaO2 / FiO2 ( 54 / 0.33) = 163, sounds a lot like moderate ARDS.
* The eleveated CK / CK-MB sounds a lot like rhabdomyolysis from being, _"found at home alone on the floor after several days with no heat"_.
* The renal failure is probably a consequence of the rhabdo'.

This seems like someone who has a large potential to decompensate following intubation. We have a range of B/P readings reported, some of which are definitely soft (108/50 = ~70), they're lactemia, and have this, _"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."._ With a HR of 80, and some tachypnea. This sounds like she's likely volume-deleted (it would be nice to know how much fluid the ED has given her), and has relatively little sympathetic drive left. It may be a disaster if we take this away. Likewise, paralysing with "pH = 7.06", satting in the 70's-80's, with a PaCO2 of 54 (Winter's predicts PaCo2 of 30-34 for a HCO3= of 16), sounds like a cardiac arrest waiting to happen.

It seems to me like it might be worth bolusing a couple of liters, prepping some norepinephrine, trialling some BiPAP, ensuring the sending facility has proper ABx coverage, and then reassessing? It might be nice to know where her hemoglobin is sitting, and having a bit of a guess at why she ended up stuck on the floor for several days?

If we're not looking better after some initial resuscitation, we could consider intubating with a low dose of ketamine (0.5 mg/kg, perhaps?), with the levo' ready to go (or even bump her MAP a little first, in anticipation of it dumping). Any opinions on a dose of bicarb immediately before the intubation attempt? Ventilate per ARDSnet. Does this seem reasonable?

It seems like she could benefit from some stabilisation / optimisation prior to transport. I agree that an overeagerness to RSI could be dangerous.


----------

