options...pt with a temp of 103.7

[b2dragun]

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

 

[abckidsmom]

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.

 

[Aidey]

How cold is the cooler saline?

 

[zmedic]

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.

 

[b2dragun]

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.

 

[b2dragun]

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.

 

[Shishkabob]

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?

 

[MrBrown]

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

 

[b2dragun]

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.

 

[abckidsmom]

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?

 

[Shishkabob]

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?

 

[usalsfyre]

Excelent info on the treatment of sepsis here.

 

[b2dragun]

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.

 

[b2dragun]

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?

 

[Shishkabob]

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.

 

[usalsfyre]

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.

 

[b2dragun]

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.

 

[abckidsmom]

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?

Never.

 

[b2dragun]

So we have one for never and one for sometimes.

 

[abckidsmom]

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.