83 y/o N/V + Fever

[rhan101277]

I wanted to get some feedback and see how other might treat this patient I had. You are dispatched to a local nursing home for above complaint.

Pt in a DNR

You arrive and obtain the following vitals:

Staff report temp 102.2 axillary, 88% SPo2 room air
pt baseline gcs 9, non verbal
monitor shows sinus tach 130
SPo2 77% on room air, 38RR
skin hot to touch
146/86 b/p
120cbg
L/S rhonchi b/l
red rash noted in a few spots on the legs and chest, staff report this has been there for two days.

In route patient has PSVT with rates as high as 180 and back down to 100 and runs of vtach.

How would you treat this patient?

 

[Handsome Robb]

Fluids, treat dysrhythmias PRN but I'd try and stay away from it if I could. Titrate O2 to >92% SpO2. Sounds like sepsis. Tachypnea, tachycardia, febrile, low Spo2. You said baseline GCS 9. We're they at their baseline or more altered than usual? There's at least 4 SIRS criteria points right there, depending on their mentation might have 5.

 

[EMT B]

12 lead, IV, Med Control for 4mg Zofran ODT, Fluid Bolus, if the patient is able to swallow then 1g Tylenol PO for fever, and get the O's flowing via nasal prong capnography at 4LPM.

Robb, why would you try to stay away from treating the PSVT?

 

[rhan101277]

the patient started on Levaquin on 11/28 the rash the patient had that was there for "2 days" spread like wildfire and looked like hives all over. I think pt was allergic to levaquin, but this was the least of his worries and I didn't notice it spread until we were at the hospital.

18g Left FA established with fluids wide open in route.
ETCO2 done
12 lead on back burner, you had to worry about suctioning

 

[chaz90]

Robb, why would you try to stay away from treating the PSVT?

I'll bite on this if Robb doesn't mind. For me, I'm not overly concerned with short runs of tachyarrythmias as they seem to be self-terminating. The patient also has a (perhaps suspiciously) good BP per the OP. Baseline GCS of 9 and no mention of change in mental status makes it more difficult to assess possible AMS related to the fever or runs of tachycardia. Also, how were these runs of PSVT and V-Tach differentiated during transport?

As far as my treatment, I'd go with PIV access, O2 titrated to SpO2 (while also evaluating validity of SpO2 values by evaluating peripheral perfusion and the waveform), re-evaluating that possibly suspicious BP, IV fluids, lactate reading, 12 lead. I wouldn't touch the arrhythmias with meds unless they became sustained or hemodynamically compromising.

On a side note to EMTB, why would you want to administer ODT Zofran? Did I miss something in the presentation? Furthermore, I don't see the reason for ODT if you already have an IV established with fluids flowing.

 

[teedubbyaw]

I wouldn't be inclined to treat these arrhythmias, either. Underlying cause is what's setting them off, IMO.

 

[EMT B]

nausea and vomitting im going to give zofran. i can only give ODT...i cant draw it up because med director is stupid


sounds like ODT is contraindicated anyways because need for suctioning. sounds like i wouldn't be giving the tylenol either.

only drugs i can "push" are d50 narcan and epi 1:1k. oral i can give normal stuff plus tylenol and zofran

 

[Handsome Robb]

You know what Chaz? I do mind!!!

12 lead, IV, Med Control for 4mg Zofran ODT, Fluid Bolus, if the patient is able to swallow then 1g Tylenol PO for fever, and get the O's flowing via nasal prong capnography at 4LPM.

Robb, why would you try to stay away from treating the PSVT?

Because like Chaz said they're self terminating. Also the "P" in PSVT stands for "paroxysmal" which means the dysrhythmia is abruptly starting and stopping. My first guess is that it would be a hypovolemic induced PSVT. Now knowing it was an allergic reaction relative hypovolemia can certainly cause tachydysrhythmias.

The squiggles will just keep doing what you don't want them to do unless you fix the underlying problem.

I was way off...figured the rash might be important.

Crackles must've been from aspiration, eh? Considering you mentioned suction.

 

[rhan101277]

When I first saw the rash, I am calling it that, I thought it would be an allergic reaction because they were hives. I dismissed that when she said they were there for 2 days, but when we got to the ER they had gotten worse. I did some reading online and several medications can cause rashes that can mimic an allergic reaction and still need to be treated as such. Even if I had treated that rash it definitely wasn't my top priority. I sure wasn't going to administer an albuterol treatment or solumedrol, if anything benadryl.

Sometimes you get calls that go beyond the textbooks. Sepsis, fever and rash don't read the textbooks and sometimes they don't react as suspected. This patient had a bounding pulse and moving air "ok" except for the rhonchi. It becomes more complex when patients present with multiple issues.


Here is the thing about tachycardia, if you have a patient with a sustained rate of 160 who presents in this fashion w/ stable vitals try fluid first. Figure out what is causing the rate problem. Patients with fever often present with tachycardia and combined with dehydration, rates can be this high. Pushing adenosine on this would probably cause a transient rate slowing and then it will immediately rise back up. You could also cause the patient more harm and you might just be buying him/her a back-hoe for the grave.

Just because you can do something, doesn't mean it is the correct treatment. I considered calling med control for assistance, but realized there is nothing they can have me do that I haven't already done.

 

[VFlutter]

Sepsis/SIRS + ARDS. Fluids, lots of fluids. Bipap

 

[Akulahawk]

Personally, I'd treat this patient with fluids. This patient is well down the sepsis pathway. I'd also titrate the oxygen to SpO2 >92%. What do I also notice... the patient is DNR. While I'm providing some fluid resus, the arrythmia may terminate due to better fluid status. If for some reason the patient isn't ventilating well, I would certainly consider CPAP as it's not "invasive" and isn't considered "assisting ventilation" in a way that violates a DNR order. I wouldn't give Zofran as there's no indication of N/V in this patient. Tylenol PO is likely "out" due to level of consciousness. If this actually is baseline for this patient, I would seriously wonder about whether or not this patient has a PEG or NGT for feeding. I wouldn't expect that a patient with a baseline GCS of 9 to be able to self-feed. If I have a standing order for Tylenol for fever, I would consider administering it PR...

If the rash looks like it's an allergic reaction, I may be able to provide some benadryl for it. However, this looks a LOT like SIRS/Sepsis to me at this point in patient that has a rash that may or may not be related.

 

[Handsome Robb]

I'm wondering if this guy doesn't have more going on than just the reaction.

Definitely like Chase's theory of sepsis/SIRS + ARDS.

I'm interested to hear what all they found besides the reaction.

 

[chaz90]

Also, the "rash" could instead be purpura of DIC...

 

[Anjel]

Also, the "rash" could instead be purpura of DIC...

That was my first initial thought when I read the scenario. It could be a bunch of different things, but that would fit.

I'm also going to agree with the boys. Monitor, fluid bolus, keep an eye on the dysrhythmias, but as long as the patients condition is stable, I am just going to beat feet to the ER.

 

[Handsome Robb]

Also, the "rash" could instead be purpura of DIC...

My first thought was mottling then I remembered that rhan knows what he's doing and would recognize mottling vs a rash.

 

[Mariemt]

A massive bladder infection will do all sorts of weird things to the elderly, I run into this a lot . I would suspect sepsis with infection causing the low GCS.

I agree with fluids. Monitoring, transport.

 

[Mariemt]

My first thought was mottling then I remembered that rhan knows what he's doing and would recognize mottling vs a rash.

my experience is mottling is up to several hours, but not days.
That is just personal experience, not by the book.

 

[rhan101277]

Yeah I am going to try to find the outcome. I treated with fluids, high flow oxygen and diesel gas. I did get to thinking I am glad I went to a good paramedic program, because for some it would be easy to jump on adenosine or cardioversion. I always try to remember if I have any doubt to the correctness of my action, I will call med control for consult. It is isn't asking "mother may i" its a different set of eyes with much more knowledge looking at the problem.

The nurse said it was baseline but I saw no peg tube and I even doubted he could pass a swallow test. Sometimes getting reports from nursing homes can be hit/miss.

 

[Handsome Robb]

my experience is mottling is up to several hours, but not days.
That is just personal experience, not by the book.

I was referring to the mottling that develops in hypoperfused tissues in severely septic patients. Not sure we're talking about the same thing. Mottling a late, and generally rather bad sign of hypoperfusion.

 

[Rialaigh]

First I am going to talk to family if they are there or reachable by phone and ask what their plans for treatment are or try and get a general feeling of how much they want done.

2. O2 up to a non rebreather, not putting this patient on Cpap unless the family is specifically requesting that "Everything" be done.
3. Iv and a bag of fluids.


Nothing else, certainly no medications. Average of a 25 minute ride to the hospital and the ER physician can talk to the family and see if they want antibiotics or anything or just a simple o2 mask and some morphine.

This patient is sick, based on presentation very very few of the people with those vitals survive long, especially if there is an extensive medical history (which I would suspect). Hopefully the family is at peace, time to let the body do what it is supposed to do.