CHF, Pneumonia, Septic?

Ignorant question now the likely culprit is named

1. What's the optimal IV fluid for impending septic shock? Oddly, the word "albumin" leapt to mind, but so did "French Toast"...


2. Second the Albuteral facepalm. Nice try nurse, now how about some medicine? Was it even ordered?
3. Central line in a nursing home: the tip probably looks like the bottom of a shower curtain in a frat house.
4. Common OTC med...dunno, with both raised pulse and lowered BP. "Mah-wong"?B)
5. Agree with drawing labs (red top, tiger top, purple top) before dumping meds onboard, other than volume expanders and O2. If you have a ridealong, have her get a urine spec too.

A good case to make sure they send lots of documentation along. If possible, call the ER and tell them you have the specimens after giving the pt heads-up, they can have the lab slips waiting.

PS: YAY for "rales", I hate "crackles" as I've heard rhoncii called crackles too.
 
mycrofft said:
1. What's the optimal IV fluid for impending septic shock? Oddly, the word "albumin" leapt to mind, but so did "French Toast"...
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Of the commonly available pre-hospital fluids Ringers is a better choice than NS.
 
CaCO3 OD can cause drop in BP due to arrythmia, and IV fluid

Don't know if that consitutes a rapid pulse, though.


Yeah, SNS is a placesaver for other stuff.
 
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Don't know if that consitutes a rapid pulse, though.
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Nope. It also doesn't induce fever either.
 
Your avatar is appropriate.

By the way, interestig article I googled about IV resuscitation of septic patients:
http://www.ivteam.com/fluid-resuscitation-in-septic-shock/
I loved the Gatorade ad banner on the top.

ADDIT: "To answer your question more explicitly, there is no clear evidence on which to base the choice of intravenous fluid resuscitation agent in patients with septic shock. Colloids have physiologic advantages in maintaining colloid osmotic pressure, but suffer from higher acquisition cost and a variety of adverse effects. Gelatin solutions have been associated with anaphylactoid reactions, as have dextran solutions. Hydroxyethyl starches and dextrans may increase bleeding by induced coagulopathy and altered blood viscosity. Without clear evidence to guide the choice of intravenous solution, they should be chosen based upon solution-specific and patient-specific factors." Gregory S. Martin, MD, MSc http://www.medscape.com/viewarticle/448198
 
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usafmedic45 said:
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"?
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Iron poisoning?

It is the only differential that comes to mind at the moment involving an OTC.
 
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medicRob said:
Iron poisoning?

It is the only differential that comes to mind at the moment involving an OTC.
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Nope. It's even more common than iron poisoning.
 
Salicylates

Back off the Pepto.
 
I was running out of candidates.

Sen-sen, Proctosil, TigerBalm, Dr Scholl's Gel from the shoe inserts...
 
Thanks for that note usafmedic. I wasn't aware of that. Did some research on salicylate poisoning, interesting reading.
 
It never ceases to amaze me that I don't see more salicylate toxicity, given how ubiquitous it is and how tasty the chewable aspirin is.

Any update on this patient? How did he do? Was he septic?
 
Jciota said:
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
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Any pitting edema? If not does the patient appear dehydrated (is mucosa dry, skin turgor? etc.). CHF is something that happens over a couple days, if its acute onset, it is not CHF. 15L NRB to improve sats, if no improvement albuterol x 1, keep in mind pneumonia can also cause crackles, not every crackle is a CHF case. 250cc fluid bolus and re-asses the need for further fluids. Just because the cause seems obvious, I would infuse fluids cautiously since patient cannot reliably report symptoms.

Many possibilities here but I would say pneumonia.

If at any point during treatment I become unsure about the cause of respiratory distress or the patient deteriorates further despite my best abilities, I will contact med control for further assistance.

It is not like we are out here cooking breakfast.
 
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Look up and read about the "Surviving Sepsis" early goal directed guidelines. Will give you specifics on initial fluid resuscitation, and goals to meet before moving on to things such as pressors, steroids, etc...

In the hospital setting we're doing SCVO2 monitoring which combined with other labs can point us to which intervention we want to do.... such as giving blood, inotropic support, oxygen, etc...

And if they come in with a central line then in all likelihood that line is getting pulled (and cultured) when they hit the hospital and another one put in.
 
Im all for intubating these people for decreasing demand and work load, but dont they have a propensity to die after being being tubed? Doesnt it have to do with setting a "normal" resp rate and them not being able to compensate for Acidosis anymore? SO, just be careful of your vent settings! USAF maybe you can correct me if thats not correct.
 
Im all for intubating these people for decreasing demand and work load, but dont they have a propensity to die after being being tubed?
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Some studies have shown increased mortality associated with intubation, but it most likely has to do with the increased severity of the underlying condition rather than a direct complication of being intubated or mechanically ventilated. If you're already far enough up :censored::censored::censored::censored: Creek to need tubed, chances are decent that the currents going to continue to carry you to that final destination you were headed for to begin with.

Doesnt it have to do with setting a "normal" resp rate and them not being able to compensate for Acidosis anymore?
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You do know that we adjust ventilator settings to compensate for the patient right? There is no "normal" (see the other thread) but rather it's guided by blood gas findings. Unless the RT and doc are total morons, inadequate compensation (within reason) should not be a major factor. The lack of ABGs in the field is the main reason why I don't like to see people put on vents by medics.

SO, just be careful of your vent settings!
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Exactly.
 
Absolutely agree with ya about being FUBARed...
ya, i know that you can and do adjust vent settings... I vaguely remember an EMRAP discussion about patients dying post intubation due to sepsis and inability to continue to compensate after being tubed. I think they were talking about it during the very short time between ED intubation and first ABG...
 
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