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
CHF, Pneumonia, Septic?
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JPINFV
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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...
medicRob
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Haven't heard it called a Chem-7 since ER. We call it a BMP 'round these here parts.
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.
JPINFV
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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.
medicRob
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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).
abckidsmom
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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.
usafmedic45
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*facepalm*
Voodoo1
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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
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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.
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.
usafmedic45
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....if sepsis from a poorly maintained urinary catheter or unnoticed/untreated bedsores doesn't get him first.
Aidey
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Beat me to it.
socalmedic
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and what if the patient has a central line?
Smash
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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)
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.
Smash covered my thoughts on this pretty well.
Smash
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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!
And I should also apologize for the terrible grammar in this post!
usafmedic45
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All the better?
usafmedic45
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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?