85yo F with severe hypotension and altered mental status

[HMartinho]

We were called for nursing home to a severe hypotensive patient. Upon arrival, we found a 85 yo female severe pale, conscient but disorientated in space and time.
The nurse state that the patient had a vomit episode 2 hours before, and had a severe diarrhea since yestarday. In the last 30 minutes, the patient becames more disorientated, confuse, pale, with a blood pressure of 70/50 mmhg, so the nurse put the patient in trendlenbourg position and starts a bag of normal saline wide open,with little BP improvment.

GCS 14 (4-4-6). Pupils equal and reactive to light.

Vital signs: 81/54 mmHg, HR: 60 bpm with barely palpable radial pulse. Carotid pulse weak and regular. IV normal saline running wide open. Capilary refill time 2 seconds.
RR: 21 cpm with some dyspnea. Pulse ox: 92% on room air.
Tympanic temperature: 35,5 ºC
BGL: 98 mg/dL
chest auscultations reveals some crackles in both lungs bases.
Abdomen is soft, with no pain to palpation in all quadrants.
Severe right leg edema with cellulittis. Godet +++/++++

12-lead ecg: sinus rythm.

Regular meds: Omeprazole20mg, beta-histine 24 mg 2id, alprazolam 0,25 mg 3id, vitamin b12 1g, tramadol 37,5 mg + 375 mg 3id, and recently, amoxicilin/clavulanic acid for leg cellulittis.

So, we put some O2 via simple facial mask at 5 liters, and switch the normal saline for ringers lactate.

Durint transport to hospital, pulse ox goes for 98% and BP 87/54 with ringer's lactate running wide open.

Any thoughts?

 

[GMCmedic]

Initial thoughts are sepsis

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[DrParasite]

sepsis secondary to UTI

 

[VFlutter]

Lots of possibilities. Sepsis from cellulitis, C. Diff from recent antibiotic therapy, GI bleeding, etc. Volume resuscitate then pressors if needed. No compensatory tachycardia, with no beta blocker listed, likely isn't helping.

 

[Medic27]

Like everyone said my initial thought was sepsis as well, does the patient have any further history? If not, was there any abnormal discharge? The cellulitis possibly spreading?

 

[iExposeDeformities]

What gives it away that it’s sepsis?

 

[Akulahawk]

What gives it away that it’s sepsis?

Altered mental status in the elderly always has infection/sepsis as a potential. Whenever I get a patient in the ER with a complaint of altered mental status I always look for it. It's that common of a cause of altered mental status in the elderly. (Notice a theme here?)

Also this patient has a known, documented infection and is on antibiotics already. This patient has had diarrhea during the course of antibiotic therapy. That makes me suspicious about Clostridium Difficile (C.Diff) infection. The patient has a slightly elevated respiratory rate (not enough to trigger a SIRS/Sepsis alert on its own), a decreased blood pressure, a decreased SpO2 at 92% that requires supplemental oxygen to achieve >94%, crackles in the lungs.

While I'm also alert to the potential for other issues playing a role in this patient's presentation, I'm going to go with sepsis (and probably severe sepsis at that) as my starting point. While I don't want to flood the patient and do some pressors, etc, I also don't want to be on the bleeding-edge of sepsis resus without solid medical director backup.

 

[Summit]

Top of my diff is Sepsis d/t CA-MRSA of right leg. Pt could have aspiration Pna too.

Augmentin doesn't cover MRSA. The Ancef or Keflex you carry are not much broader and are ineffective against MRSA (and CDiff).

Diarrhea is best explained as a common adverse effect of the clavulanic acid in the Augmentin, although it could be Cdiff if she was colonized already or there is an active outbreak in the facility.

Either way, aggressive NS boluses, monitor BP and etco2 for improvement... pressors if fluids don't do it.

O2 via NC.

IV Vanco and Pip/Tazo ASAP - I might choose a less definitive ED if it meant a large time difference in admin of these meds.

 

[Carlos Danger]

What gives it away that it’s sepsis?

It is always sepsis.

 

[DrParasite]

 

[iExposeDeformities]

It is always sepsis.

Nurse: “I’ll take the report”
EMT: “Pt was A/Ox4 transported code 1 with bilateral open femur fractures after falling from the 5th floor of an apartment and had muffled heart sounds. Started compressions and shocked twice after noticing tracheal deviation and JVD. We suspect it’s sepsis”
Nurse:.....

 

[VentMonkey]

Nurse: “I’ll take the report”
EMT: “Pt was A/Ox4 transported code 1 with bilateral open femur fractures after falling from the 5th floor of an apartment and had muffled heart sounds. Started compressions and shocked twice after noticing tracheal deviation and JVD. We suspect it’s sepsis”
Nurse:.....

Seriously, people like you make it nearly impossible for people like me to turn this into a life-long career.

 

[iExposeDeformities]

Seriously, people like you make it nearly impossible for people like me to turn this into a life-long career.

 

[VentMonkey]

Believe me, I got your (attempt at) humor.

 

[CALEMT]

My first initial thought is sepsis. Cellulitis with prescribed antibiotics there already is an infection, given the pt is elderly and living in what sounds like a SNF just further increases my suspicion of sepsis.

 

[Colt45]

Lol I just came here to read VentMonkey's reply .