# options...pt with a temp of 103.7



## b2dragun (Dec 4, 2010)

So here is my question.  
44yom
You have a pt with a temp of 103.7(tempanic), pt is found at care facility recovering from CVA.  Safe to assume no care prior has been given.  Pt is non-responsive, AOx0, gcs 3.  Rate is 140-165 sinus tach on the monitor.  Bp is 140/100.  Pt is hot, sweating profusely.  Pt is on a trach with a t-piece (5lpm).  Facilty called due to elevated temp and heart rate, everything else is "normal."

You want to cool the pt enroute, you do the whole ice pack thing.  Where I am lost is my medic had a choice between using NS that has been on a iv warmer x8hrs(obviously warm but not hot) or NS that is in a fridge/cooler (hypothermia therapy/environmental emergency saline).  I suggested we use the cold saline to bring his temp down.  He goes with using the warm saline, his reasoning being that it is still cooler than the pt.

What would you do in this situation?  Transport time is 15min

I am just trying to learn...i would like to know if my thinking was correct and if it isn't,  why.

Thanks for the replies


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## abckidsmom (Dec 4, 2010)

What do you think his root problem is?  

What do you think a dangerous temperature is?

What actions/inactions that you take now are going to have a lasting impact on this patient's outcome?

This is less about what *I* would do in a situation, and more about what are you going to learn from it.


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## Aidey (Dec 4, 2010)

How cold is the cooler saline?


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## zmedic (Dec 4, 2010)

You can cool using room temperature water and fanning. Also turning up the ambulances AC. You want to stay away from ice cold usually because you don't want to start the patient shivering and increase their temperature. Also keep in mind that your goal is really to maintain the pt's temp or lower it a bit, you aren't trying to bring them down to normal. Also things to consider:

1: Before you start running around about the temp, you need  a rectal. Not worth delaying care but worth thinking about.

2: 103/104 is high but it's not 105/106 with the patient having a seizure. So prob don't need to be super aggressive with the cooling.

3. The patient is still sweating, indicating it is not likely heat stroke. Sweating, tachycardic, probably dehydrated. IV fluid might be a bigger priority than cooling (just watch their lungs to not put them into PE)

4. What is this patient's problem? I think this is a patient most likely with an infection, maybe septic. It doesn't sound like the problem is mainly a temperature problem. Ie the fever is a symptom of something rather than what needs to be treated. So this patient needs IV fluid, rectal temp, blood culture, antibiotics.


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## b2dragun (Dec 4, 2010)

I believe the temp of the cold saline is 40, i may be a little off.

I think he is septic, he is on two antibiotics (foget which two).  I would like to bring his temp down, from what I remember the facility did nothing but sit around and wait to call 911.  It was one of those nights where we had three units at the same time there.  I think that cooling him would be the key, it would bring his rate down too.  Give the hospital a head start since they are already behind do to shotty facility care.  I personally would have given the cold saline.  As far as whats dangerous, it depends on the pt.  This guy not being able to tell ke how he feels, i would have started treatment earlier and if it was unsuccessful i prob would have called around 102.

What i am wondering is if there would be a reason not to.  I have only been doing this for 7 months so I'm not sure if there is possible "contraindication."  I know so much of what we do is depends on how we interpret and what we have in our experience.  I am trying to pull from everyones knowledge and experience.


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## b2dragun (Dec 4, 2010)

The problem with what this guy really needs is we aren't a hospital.  Don't do rectal, blood, or antibiotics...and you know this.  But my thinking is to try to work. On what i can affect enroute.  Cooling him and giving fluids, we did give him a liter.  With my thinking i would have given him cool saline.  A liter of cold saline isn't going to make him hypothermic, but i think it might drop the temp a bit...but we just got the cold saline so i honestly don't know.  I was using the train of thought that if we can use it for environmental emergencies, ie heat exposure, then it would work under the same principle.


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## Shishkabob (Dec 4, 2010)

Let me ask you something:

With a bp of 140/100, why do you want to give him so much fluid when he could be cooled in a different manner?


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## MrBrown (Dec 4, 2010)

sounds like he is septic ... quick get the ceftriaxone


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## b2dragun (Dec 4, 2010)

It wasn't my call to do the fluid, if i was to justify it...i would go with possible sepsis, lower the temp, sweating profusely.  Monitor and if the bp changed drastically tko it.  He did have a hx of htn, so 140/100 may not be too far off from his baseline.


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## abckidsmom (Dec 4, 2010)

b2dragun said:


> The problem with what this guy really needs is we aren't a hospital.  Don't do rectal, blood, or antibiotics...and you know this.  But my thinking is to try to work. On what i can affect enroute.  Cooling him and giving fluids, we did give him a liter.  With my thinking i would have given him cool saline.  A liter of cold saline isn't going to make him hypothermic, but i think it might drop the temp a bit...but we just got the cold saline so i honestly don't know.  I was using the train of thought that if we can use it for environmental emergencies, ie heat exposure, then it would work under the same principle.



It can be shocking to administer a liter of 40 degree saline to a guy with a 103 degree fever.  Try this:  drink a liter of ice water.  Fast, in less than 15 minutes.  Check your temp before and after.  Now imagine that you are shivery and feverish and hypertensive and tachycardic.  You think that a liter of cold saline won't make a big deal?  I could see it inducing vfib if you administer it fast enough.   I wouldn't infuse large quantities of non-warm saline to anyone who doesn't qualify for therapeutic hypothermia.

A fever is the body's defense against infection.  Fever is not necessarily dangerous.  With this heart rate and his pressure, it's clear that he's feeling the stress of his illness, but he's not going to die of that heart rate in the next 15 minutes.

I agree that he needs some fluid, he needs some IV antibiotics, and he needs some time.  He also might need some time on the ventilator.  

The disease process of pneumosepsis goes much deeper than just stressing about the numbers of his temperature.  I would address any dehydration issues he might have, and any oxygenation issues if there are any, and drive him to the hospital.

Was his mental status normal for him?  What was his respiratory rate/SpO2?


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## Shishkabob (Dec 4, 2010)

b2dragun said:


> It wasn't my call to do the fluid, if i was to justify it...i would go with possible sepsis, lower the temp, sweating profusely.  Monitor and if the bp changed drastically tko it.  He did have a hx of htn, so 140/100 may not be too far off from his baseline.



Sepsis =/= septic shock.

His MAP is 113.



What was his RR?  SpO2?  Glucose?


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## usalsfyre (Dec 4, 2010)

Excelent info on the treatment of sepsis here.


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## b2dragun (Dec 4, 2010)

I appreciate all the replies.  That's what I like about the forum is I can get opinions and learn from them.  I understand what's being said about giving fluid to somebody that hypertensive.  I don't think comparing drinking cold fluid and having an iv with cold fluids is comparable.  When it is iv it goes through the entire body when you drink it it goes into the stomach takes time to go throughout.  I understand that the fever is beneficial but I don't think a liter of fluid over 15 minutes would drop the fever drastically enough to affect its purpose.  Like I said I'm tryna get the ball rolling for the ED.

 I think I'm going to have to try giving myself a bag of cold fluid to see how I feel.  I guess I'm thinking that I would not even feel the difference in temperature going in me.


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## b2dragun (Dec 4, 2010)

RR was 18-20
93% on RA, 100% on 5L
Pt had a trach with a tpiece, no vent
Glucose was around 100 if I remember right, wasn't anything to think twice about.

I understand that septic does not mean shock.  

Let me ask this, if the pt was C/O a fever of 103.7 with no other conditions, perfect vitals except being "sick with a fever" would cold saline be appropriate?  What if the pt was hypotensive?  Lets get a baseline for the use of cold saline in a fever situation...never, sometimes, always?


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## Shishkabob (Dec 4, 2010)

If their only complaint was fever and they wanted to be seen for it, I'd consider giving Tylenol  depending on the circumstances, and take them to the hospital.  


If they are hypotensive, I'd consider fluids, but again it totally depends on the scenario, and never cold fluids just because they have an elevated temperature from an infection.


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## usalsfyre (Dec 4, 2010)

The fever is a symptom, not the root cause of anything. The patient needs fluid, but it's to treat the underlying relative hypovemia somewhat from dehydration, but more due to the vascular changes associated with imflamatory response. Treating the fever wil do nothing but inhibit the metabolic processes that are ramped up to deal with the infectious process.

Forgot to mention, back in my firemonkey days I had two liters of room temp NS pressure infused for some heat exhaustion. My arm was cold to touch, numb and tingled for two hours. I hate to think what 40 degree fluid would be like.


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## b2dragun (Dec 4, 2010)

If only the facility had thought of tylenol or not waited till that point, i checked...they gave nothing.  Like I said not a stellar care center, three 911 calls at the same time.  I have done many transports out of there abd it is always something that could have been taken care of sooner.

I agree that for a "normal" pt with a fever i would do nothing but vitals, and go from there.  I get too many calls for sick with no car and don't want to call a cab.


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## abckidsmom (Dec 4, 2010)

b2dragun said:


> RR was 18-20
> 93% on RA, 100% on 5L
> Pt had a trach with a tpiece, no vent
> Glucose was around 100 if I remember right, wasn't anything to think twice about.
> ...



Never.


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## b2dragun (Dec 4, 2010)

So we have one for never and one for sometimes.


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## abckidsmom (Dec 4, 2010)

b2dragun said:


> So we have one for never and one for sometimes.



Changing that to never in EMS.  There are plenty of reasons to do it in the right environment for the right reasons, with the right monitoring and treatment underway.

Until you know whether the patient's heart rate is a result of endocarditis, hypovolemia, or is just extremely hypermetabolic, you can't know what you're dealing with.

Plus there's the 2nd Law of the Universe:  People coming out of nursing homes with fever and altered mental status definitely have more than one thing going on.


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## ebass30920 (Dec 4, 2010)

What were the breath sounds?  I would remove as much clothing as I could just a sheet.  IV TKO and O2.  I cant see a reason to dump fluid into the patient.  I think you are on a fine line with this patient of making them unstable esp. if you start putting cold fluid in them.  There are alternate methods of cooling a previously mentioned and yes the fever way high but he still wasnt in immediate danger.  All in all given pt. condition there is not a lot that will be done in an ambulance to make them better.  I am agreeing with the need for antibiotics, and no on the fluid.


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## usalsfyre (Dec 4, 2010)

I'm curious what makes you hesitant to give fluid.

Large amounts of IV fluid (albeit not cold) are absoloutely indicated to compensate for imflamatory response. The patient not hypotensive because, for the moment, he's able to compensate with a large increase in cardiac output (hence the hr of 140).. He won't be able to do this forever (or even long) and will get hypotensive. Much better to get ahead, fill up the tank and give his myocardium a rest.


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## ebass30920 (Dec 4, 2010)

You are right USA.  I just looked back at the initial vitals.  I think a bolus is in order.  I didnt realize the patient was that tachy.  I remembered increase hr when I posted but forgot it was that high.


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## Aidey (Dec 4, 2010)

abckidsmom said:


> Never.



x2

It is possible to reduce a fever too quickly. 40 degree saline would definitely do that. 

I also agree that fluids are indicated. I bet when they were giving the bolus his BP went down.


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## Bieber (Dec 4, 2010)

All right, this is my first post, and I'm still just a paramedic student till the 18th when I take boards, but I'll give my humble opinion, such as it is.

Personally, I would just passively cool this patient.  Remove or loosen his clothes and turn up the AC in the back of the ambulance.  I don't want to drop his temperature too suddenly, and I don't think fluids are indicated in this instance because we've got a good blood pressure and I think active cooling is a little too much for this guy.

What I WOULD like to know more about is this patient's history.  I hate to sound like the guy looking for zebras, but honestly there are a LOT of reasons for a fever and not all of them are infection.  And though his temperature is pretty high, it doesn't seem like it would be high enough to put this guy completely unresponsive like this.

You said this guy was on two antibiotics?  What for?  How long had he been taking them?  Had he been compliant?  Was the CVA an ischemic or a hemorrhagic stroke?  How long ago was it and what kind of treatment did he receive for it?  What other medications is he on?  Blood thinners, perhaps?  What do his pupils look like?

As long as this guy's vital signs are good, I'm going to stay conservative in my treatment.  I don't know what's causing this guy's fever, and there's a lot of possibilities.  Does he have an infection?  Is this a drug-induced fever from the antibiotics he's on?  Did he have a hemorrhagic stroke that's causing this fever?  All of those are possible, and personally I am VERY suspicious about a patient who is completely unresponsive despite good (as in, perfusing) vital signs who has a recent history of CVA and infection and current antibiotic use.  That just seems off to me, but like I said, I'm just a humble student so if I'm way off let me know.


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## zmedic (Dec 4, 2010)

If you have cold saline on your truck I bet it is specifically for post cardiac arrest hypothermia. You can't just use it for other reasons. I highly doubt that you have a protocol that allows you to give it for hyperthermia, and I think your on line medical control would say heck no if you called and asked about it. 

Prehospital, sepsis give normal temp saline. Consider cooling the patient by wetting them and fanning if they are hyperthermic. No cold saline IV.


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## 18G (Dec 4, 2010)

To the OP.... think of the IV fluid temperatures this way. The reason we have IV fluid warmers is because room temperature fluids are too cool for certain patients (ie trauma). A room temperature fluid of say 70F is well below the body's temp and to someone who is febrile ambient temp fluids would be suitable. There is no need to give chilled saline to someone who your suspecting of having SIRS. 

The fever was compensatory to what sounds like an underlying infection. This patient is rehabbing for a CVA I believe you said so more than likely this patient has been immobile for some length of time, was recently in the hospital, and has a trach. And I'm sure the patient also had a foley catheter as well. All this to me points to an infectious process and conditions that increase risk of infection especially nosocomial infections. 

Definitely no chilled fluids.


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## usalsfyre (Dec 4, 2010)

Bieber said:


> All right, this is my first post, and I'm still just a paramedic student till the 18th when I take boards, but I'll give my humble opinion, such as it is.
> 
> Personally, I would just passively cool this patient.  Remove or loosen his clothes and turn up the AC in the back of the ambulance.  I don't want to drop his temperature too suddenly, and I don't think fluids are indicated in this instance because we've got a good blood pressure and I think active cooling is a little too much for this guy.
> 
> ...



Your only sorta off. That said, a hot flushed (sign of inapproprite vasodilation) patient with a heart rate of 140 (screams compensated shock) and an altered LOC (end organ being affected perhaps?) is SIRS without a doubt. These are NOT good vital signs, his B/P just hasn't crapped out yet. 

While SIRS can be caused by a whole host of issues, look at the setting. A NH,in a patient with a trach (increased risk of pneumococal infection) and probably a foley (UTI) being assisted by nurses and aides who deal with other sick people all day (think nonsocomial routes). Sepsis is just the most likely posibility, although I wouldn't rule out CVA.

The treatment will be the same either way. Lots and lots of fluid (liters if you have the time, they'll need it), and consider an antipyretic to reduce metabolic demand (not something I'd routinely do). If his B/P tanks, start him on norepinephrine if you can't get it back up with fluid. Everything else will be supportive care.


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## Akulahawk (Dec 4, 2010)

b2dragun said:


> So here is my question.
> 44yom
> You have a pt with a temp of 103.7(tempanic), pt is found at care facility recovering from CVA.  Safe to assume no care prior has been given.  Pt is non-responsive, AOx0, gcs 3.  Rate is 140-165 sinus tach on the monitor.  Bp is 140/100.  Pt is hot, sweating profusely.  Pt is on a trach with a t-piece (5lpm).  Facilty called due to elevated temp and heart rate, everything else is "normal."
> 
> ...


Ok, so let's review:
44YOM
s/p CVA, A&Ox0 with GCS 3
HR: 140-165 STach
BP: 140/100
RR: unk
Temp: 103.7* tympanic.
SpO2: 100% on 5L/Min via T piece through a trach.
On 2 Abx. 

What's going on? He's going septic. And not a nice one at that. Since he's also got a history of HTN, I wonder about what his normal SBP is. I'd be willing to bet it's normally higher than than 140... He's profusely sweating, feels hot, has a probably lowering BP from a likely baseline. I also wonder about breath sounds. 

IMHO, he needs fluid at the moment. Just use the fluid in the warmer. I currently see no immediate need to try to aggressively actively cool this patient.

I'd say transport, give boluses to start filling the tank, so to speak. Get ahead of him as once his HR comes down, he's going to crash. He's relatively hypovolemic and he may be relatively hypotensive compared to his norm. Why? His "container" got bigger or it's leaking. He's sweating still because that part of his body hasn't run out of fluid yet. (credit to usalsfyre) The flushed appearance does highly suggest inappropriate vasodilation to me as well. He's got fluid going to places where it shouldn't be...

Did anyone find any documents that state what his baseline vitals are? If he's normally running, say, 180/120 (MAP 140) and he's now at 140/100 (MAP 113)... well, that's nearly a 40 point drop over a short time from what his body is likely acclimated to. Take someone whose BP is normally 120/80 and drop it fairly quickly to 86/60... what happens?

In any event, I would expect that in-hospital treatment is likely to be what usalsfyre suggested, and an attempt to treat with different ABX, by IV if indicated.

Personally, I think that this patient is going to have a rough time, if he survives.


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## Bieber (Dec 5, 2010)

usalsfyre said:


> Your only sorta off. That said, a hot flushed (sign of inapproprite vasodilation) patient with a heart rate of 140 (screams compensated shock) and an altered LOC (end organ being affected perhaps?) is SIRS without a doubt. These are NOT good vital signs, his B/P just hasn't crapped out yet.
> 
> While SIRS can be caused by a whole host of issues, look at the setting. A NH,in a patient with a trach (increased risk of pneumococal infection) and probably a foley (UTI) being assisted by nurses and aides who deal with other sick people all day (think nonsocomial routes). Sepsis is just the most likely posibility, although I wouldn't rule out CVA.
> 
> The treatment will be the same either way. Lots and lots of fluid (liters if you have the time, they'll need it), and consider an antipyretic to reduce metabolic demand (not something I'd routinely do). If his B/P tanks, start him on norepinephrine if you can't get it back up with fluid. Everything else will be supportive care.


Oh no, the guy definitely has SIRS.  And I'm not saying it can't be infectious, but there's also some other possible culprits as well.  And yeah, he could still get an infection even while on the antibiotics, but the fact that he IS on the antibiotics definitely makes me wonder if there might be a non-infectious cause of the SIRS.


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## Smash (Dec 5, 2010)

*By definition: Sepsis.*

I would like to know what his normal GCS is: I'm assuming higher than 3.  If so, then this patient has not just sepsis but severe sepsis (HR >90, RR>20, Temp > 100F and evidence of end organ dysfunction in the setting of a known or strongly suspected pathogen: ie he is on antibiotics)

Usalsfyre has very succinctly covered all his history, risk factors and problems.
His temperature is not really the problem as usalsfyre has pointed out: it is merely a symptom and doesn't need managed at this stage.  His BP is not entirely what it seems either.  The early stages of sepsis are characterised by a hyperdynamic state: his HR is very high and his BP is currently "normal", although in reality it is not adequate due to the massively increased metabolic demand (and we see evidence of this in his decreased conscious state).  I'm also willing to put money on the fact that he won't be making much urine at the moment.

So, I agree with usalsfyre:  Oxygen, lots of it (one of the few times it is necessary) and consider intubation depending on a number of factors such as his baseline neurological status and his response to further management.  Aggressive fluid resuscitation, get inotropes prepared, not yet running, administer 1g of ceftriaxone IV and transport to a suitable ICU equipped hospital.


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## Smash (Dec 5, 2010)

Bieber said:


> Oh no, the guy definitely has SIRS.  And I'm not saying it can't be infectious, but there's also some other possible culprits as well.  And yeah, he could still get an infection even while on the antibiotics, but the fact that he IS on the antibiotics definitely makes me wonder if there might be a non-infectious cause of the SIRS.



There are indeed many causes of SIRS, but given the natural history of the disease and the patients risk factors, looking far beyond a nasty little bug is probably wasting time and resources.  The fact that he is on antibiotics already doens't mean that he can't get an infective process happening: it means he already has one and the antibugs aren't up to fighting it off.


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## 18G (Dec 5, 2010)

Bieber... My questions on the antibiotics would be when were they started and for what infection were they prescribed for. Perhaps the infection got well ahead of the antibiotics or the antibiotics prescribed were not strong enough  or suitable for the infection type. 

I get what your saying but knowing the patient is on antibiotics would not make me think this patient has something else going on besides infection.To me it would raise my alert to an advanced infectious process.


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## b2dragun (Dec 5, 2010)

Ok, so more info...I had to do the whole sleep thing between shifts.  I'll try to remember what I can.  Keeping in mind that this is the kind of facility where you are lucky to have someone that claims they don't know the pt, usually we don't even get that.  As for knowledge and paperwork.  He is there post CVA, they state his baseline is normal so gcs of 3 may not be too off from normal.  As for hx, cva and htn is what we got.  No baseline vitals available.  From experience he has probably been like his for at least 12 hrs, I'm surprised they didn't just put it off till day shift.  He did have a foley + for urine output, nice and normal yellow.  I also remember hearing that he had a shunt from the ventricle to the belly for csf drainage and that part of his skull was "soft."  

I didn't originally put all that in because it was more of a question of the use of cold fluids, but this is turning into a good discussion.


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## JPINFV (Dec 5, 2010)

MrBrown said:


> sounds like he is septic ... quick get the ceftriaxone



Is there anything that can't do? I'm in respiratory and it seems like the answer to every other case is ceftriaxone.


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## Smash (Dec 5, 2010)

b2dragun said:


> He did have a foley + for urine output, nice and normal yellow.



What sort of yellow and what sort of volume?  Septic shock patients late in the progression of the disease typically have oliguria/anuria. However, early on in the piece they tend to produce large volumes of poor quality, very dilute urine. This of course just adds to their woes in terms of hypovolemia.


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## Veneficus (Dec 5, 2010)

JPINFV said:


> Is there anything that can't do? I'm in respiratory and it seems like the answer to every other case is ceftriaxone.



I am guessing it is tried often because it has a wide range of affected organisms, gram positive and negative, gets around some B-Lactamase resistance and saves the better stuff for use on MRSA etc.

Just my thinking, no evidence.


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## Akulahawk (Dec 5, 2010)

JPINFV said:


> Is there anything that can't do? I'm in respiratory and it seems like the answer to every other case is ceftriaxone.


Yes. It can't cook my nachos. 

For what it's effective against... well, it's :wacko:.  I can't count the number of times I've read orders for the stuff in patient's charts over the years... :blink:


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## SanDiegoEmt7 (Dec 5, 2010)

> While SIRS can be caused by a whole host of issues, look at the setting. A NH,in a patient with a trach (increased risk of pneumococal infection) and probably a foley (UTI) being assisted by nurses and aides who deal with other sick people all day (think nonsocomial routes). Sepsis is just the most likely posibility, although I wouldn't rule out CVA.



If you hear horse hooves...


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## Akulahawk (Dec 5, 2010)

Veneficus said:


> I am guessing it is tried often because it has a wide range of affected organisms, gram positive and negative, gets around some B-Lactamase resistance and saves the better stuff for use on MRSA etc.
> 
> Just my thinking, no evidence.


From what I've learned about it, I suspect that's the reason. It's effective on a HUGE range of organisms that it kind of fits into the "give it empirically" while we culture this and determine specific sensitivities and kill "it" with something specific.


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## Smash (Dec 5, 2010)

Akulahawk said:


> From what I've learned about it, I suspect that's the reason. It's effective on a HUGE range of organisms that it kind of fits into the "give it empirically" while we culture this and determine specific sensitivities and kill "it" with something specific.



A lot of that stuff comes down to "fashion". Some docs prefer cefataxine (spelling??) some ceftriaxone. But certainly what you and vene have mentioned is why it is given early as part if the empirical treatment for SIRS/sepsis, followed by targeted ABs once the cultures are back.


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## tah06090 (Dec 5, 2010)

No PR Acetominophen??


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## tjsnc (Dec 5, 2010)

Just want to interject here and inquire what your local protocol states regarding hyperthermia.  Regardless of what you may want to do, and think is right for a particular situation, it is most important to adhere to your protocols.


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## tah06090 (Dec 5, 2010)

well with regards to hyperthermia all depends if its pyrexia or related to enviroment. In NH protocols call for PO/PR acetominophen adult 325mg-650mg and pedi is 15mg/kg for fever in adult of pediatric.


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## tjsnc (Dec 5, 2010)

I understand, and this is pretty standard across the board/states.  I hadn't read all of the posted threads to this discussion.  When I mentioned protocols, it was my intent to have that thread posted when some were discussing about the administration of cold NS as opposed to room temperature NS, etc, as well as applying cold packs.  It seemed to be departing from what is normal treatment for a febrile patient.  Thanks.


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## MS Medic (Dec 5, 2010)

tah06090 said:


> In NH protocols call for PO/PR acetominophen adult 325mg-650mg and pedi is 15mg/kg for fever in adult of pediatric.


This might not be the case. I worked with a partner a few times who was a LPN at one of the lesser thought of NH in the service area, along with being an EMT-B, and she gave me a very good education on why NH do what they do. They aren't allowed to give meds they do not have prestanding orders for and have to call the facility doc for changes in vitals. Keep in mind that most of these docs are family pracs who supplement their income with the NH, and the same doc usually has multiple NHs that they only show up at once or twice a week. So, when they get a call from the NH the default answer is to punt to us. 

This is not to justify the crap at NH that just makes you say WTF but it is something to consider when dealing with them.


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## Shishkabob (Dec 5, 2010)

I think they meant New Hampshire and not nursing home.


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## JPINFV (Dec 5, 2010)

Linuss said:


> I think they meant New Hampshire and not nursing home.



There's a difference?


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## Shishkabob (Dec 5, 2010)

In the pronunciation.


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## MS Medic (Dec 6, 2010)

Linuss said:


> I think they meant New Hampshire and not nursing home.



Oops, don't I feel sheepish. :blush:


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## Petey0397 (Dec 6, 2010)

I agree with what some of the folks here have already said, it sounds like sepsis. You may want to investigate whether your protocols will allow you to give cooled saline in that situation, as it may not be indicated for anything other than environmental emergencies.

On a side note, a flight nurse I know recently told me that we may see a 10-20 mL/kg fluid bolus put in for patients meeting the septic criteria in the near future.


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## Sam Adams (Dec 6, 2010)

This turned out to be an interesting discussion...

To the OP. I would absolutely NOT give this pt cooled saline. As others have mentioned, this appears to be a metabolic issue and not an environmental one. We are allowed to give cooled saline post ROSC only. Not sure what your protocols are...

Sepsis is indeed topping my list of differentials here. He certainly has a plethora of potential origins. I'm also wondering about autonomic dysreflexia. While typically associated w/ SCIs above T6, it can be caused by other things as well. (recent CVA perhaps?) He certainly has a few of the s/s's.... Just throwing it out there....


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## Veneficus (Dec 6, 2010)

Sam Adams said:


> This turned out to be an interesting discussion...
> 
> To the OP. I would absolutely NOT give this pt cooled saline. As others have mentioned, this appears to be a metabolic issue and not an environmental one. We are allowed to give cooled saline post ROSC only. Not sure what your protocols are...
> 
> Sepsis is indeed topping my list of differentials here. He certainly has a plethora of potential origins. I'm also wondering about autonomic dysreflexia. While typically associated w/ SCIs above T6, it can be caused by other things as well. (recent CVA perhaps?) He certainly has a few of the s/s's.... Just throwing it out there....



here's the question of the hour:

Since most bacteria multiply at physiologic temperature, would inducing hypothermia also clinically reduce reproduction of the microorganism as well as reduce metabolic demands of the patient?

That would be a good study.


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## Veneficus (Dec 6, 2010)

and while I am thinkng about it,

Hypothermia also inhibits clotting which can preempt a DIC.

It may also decrease vascular permiability.


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## Sam Adams (Dec 6, 2010)

Veneficus said:


> here's the question of the hour:
> 
> Since most bacteria multiply at physiologic temperature, would inducing hypothermia also clinically reduce reproduction of the microorganism as well as reduce metabolic demands of the patient?
> 
> That would be a good study.



I'll see your hypothermically induced reduction of of bug proliferation, and raise you a reduction in the efficacy of his current other medications?


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## Veneficus (Dec 6, 2010)

Sam Adams said:


> I'll see your hypothermically induced reduction of of bug proliferation, and raise you a reduction in the efficacy of his current other medications?



considering his condition, what do you see as his chances of survival with conventional therapy? 

You might inhibit the ab that are already insufficent?

Inhibit a new ab? just give more.


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## abckidsmom (Dec 6, 2010)

Veneficus said:


> and while I am thinkng about it,
> 
> Hypothermia also inhibits clotting which can preempt a DIC.
> 
> It may also decrease vascular permiability.



Interesting.  

Hypothermia also lowers the fibrillation threshold, right?  With this guy's rate being through the roof already, I'd not want to think about the irritability that would show up if he dropped below 35.  

Also, and I'm just thinking out loud here, with ten year old anectodal experience...could stalling the peripheral circulation by inducing hypothermia cause a compartment-syndrome like effect when he's rewarmed?  All those metabolic products just hanging out, waiting for circulation to get going again?

Can you educate me on what this looks like in the OR, I know that our patients came back cooooold, especially from long surgeries with unstable periods.  We warmed them immediately, and fought the cold because of the extra stress it put on the body, but now that I think of it, I can't remember what that stress resulted from, physiologically.


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## Veneficus (Dec 6, 2010)

abckidsmom said:


> Interesting.
> 
> Hypothermia also lowers the fibrillation threshold, right?  With this guy's rate being through the roof already, I'd not want to think about the irritability that would show up if he dropped below 35.
> 
> ...



There is a long held theory about hypothermia being part of a deadly triad in traumatic injury, like surgery, and many of the studies and observations are beyond reproach. 

However, much of that was discovered before theraputic hypothermia. We know it has a benefit in certain types of trauma. We know it helps post arrest. 

So my question then becomes can the very mechanisms that make hypothermia so deadly in bleeding with an open wound, be used to beneficial purposes to prevent the complications of sepsis?

Since I just thought of it on the spur of the moment, I really don't have a lot of answers. 

http://en.wikipedia.org/wiki/Trauma_triad_of_death


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## Smash (Dec 6, 2010)

Interesting question vene.  Excuse my rambling, this is largely stream of consciousness here:  At what point would we expect to see suppression of the biological functions of bacteria that would meaningfully inhibit their activities, as opposed in inhibition of normal cellular function that leads to worse outcome.  If cold is (hypothetically) bacteriocidal or even causes bacteriostasis, why do we not see an improvement or even plateau in the condition of patients in cold shock with temperatures of 32C and the like who are also recieving aggressive supportive care that would hopefully overcome the detrimental effects of hypothermia?



Petey0397 said:


> On a side note, a flight nurse I know recently told me that we may see a 10-20 mL/kg fluid bolus put in for patients meeting the septic criteria in the near future.



Really?  Why so aggressive with the fluids?...


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## Smash (Dec 6, 2010)

Petey0397 said:


> On a side note, a flight nurse I know recently told me that we may see a 10-20 mL/kg fluid bolus put in for patients meeting the septic criteria in the near future.



Sorry, I was being facetious in my last post.  10-20mls/kg of crystalloid in a septic patient would barely even touch the sides on it's way through.  These patients (particularly septic shock patients) are often getting 40ml, 60ml, 80ml/kg and more of crystalloids as well as colloids and pressors and are still struggling to maintain a CVP of 2mmHg (although there is also debate as to how useful measurement of CVP is in septic patients)


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## abckidsmom (Dec 6, 2010)

Smash said:


> Sorry, I was being facetious in my last post.  10-20mls/kg of crystalloid in a septic patient would barely even touch the sides on it's way through.  These patients (particularly septic shock patients) are often getting 40ml, 60ml, 80ml/kg and more of crystalloids as well as colloids and pressors and are still struggling to maintain a CVP of 2mmHg (although there is also debate as to how useful measurement of CVP is in septic patients)




LOL, I was gonna say that sepsis is another word for bottomless pit of fluid.


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## Sam Adams (Dec 7, 2010)

Ok, I can get on board with the benefits of coagulopathy (DIC), decreasing vascular permeability, and creating an environment of bacterial/ septi-stasis. But, when re-warmed and without further treatment aren't we back where we started? And, aren't febrile septic pts at the beginning of the end where as cold septic pts at the end of the end?


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## Veneficus (Dec 7, 2010)

Sam Adams said:


> Ok, I can get on board with the benefits of coagulopathy (DIC), decreasing vascular permeability, and creating an environment of bacterial/ septi-stasis. But, when re-warmed and without further treatment aren't we back where we started? And, aren't febrile septic pts at the beginning of the end where as cold septic pts at the end of the end?



Yes, but I think how you get to the end matters.

If you are cold because of an external intervention or cold because your body can no longer regulate temperature they are different animals.

Like I mentioned before, I really don't have much insight into this, as I was reading responses, I thought "could there be a reason chilled fluids would help?"

So I figured I'd throw it out for discussion. 

I hope to look a little more into it as well as the mechanisms, but this week I am in my least favorite division of medicine and just too lazy and tired to look anymore stuff up than what I have to right now.

But vacation is coming and I can spend as much time as i like with medicine I enjoy then.


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## Sam Adams (Dec 8, 2010)

Veneficus said:


> Yes, but I think how you get to the end matters.
> 
> If you are cold because of an external intervention or cold because your body can no longer regulate temperature they are different animals.



For the sake of further discussion: this pt has a GCS of 3 (which if I remember correctly is baseline), what of a pt, same vitals, same presentation, however with a GCS of say ... 12 of 13 and with a patent airway (no trach)? To induce or not to induce? And how would you go about it? 

I'm not overly familiar with TH in SCIs and how it's done (RSI, meds etc.) I'd imagine it's similar. Or not. I don't know. Off to go research....


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## Veneficus (Dec 8, 2010)

Sam Adams said:


> For the sake of further discussion: this pt has a GCS of 3 (which if I remember correctly is baseline), what of a pt, same vitals, same presentation, however with a GCS of say ... 12 of 13 and with a patent airway (no trach)? To induce or not to induce? And how would you go about it?
> 
> I'm not overly familiar with TH in SCIs and how it's done (RSI, meds etc.) I'd imagine it's similar. Or not. I don't know. Off to go research....




If we assume for the sake of discussion that there actually might be benefit in doing this, which I will be looking into after next week because I am curious about it, I think my decision would be based not on mental status or GCS but whether or not he was responding to the antibiotics. (which looks like "no" to me) 

So my SWAG would be to:

Induce coma, 

hypothermia him with a slurry and the proper maintenence

pour vanc into him while supporting the rest of his functions and wait for cultures and antibiotic recommendations to come back and see where we are.

Wake him up when we find his IgG topping off and see where we are.


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## b2dragun (Dec 8, 2010)

I appreciate all the replies.  I am now going to save my cold saline for the summer and for codes, which lately will be often enough.  For the past 3 weeks I have been getting one every other shift and four in a row...looking at 9 codes in 3 weeks.  

This is why I don't question my medic on scene.  I am just going to keep saline in the cooler, on the warmer, and some just in the truck at "room temp."


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