Severely Acidotic / Sepsis

Akulahawk said:
Indeed we do...
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So I was originally right anyways with Hypoxia on that side, I just just way over looked it when I replied. Do you have anything else you would like to add to this case?
 
EMT11KDL said:
So I was originally right anyways with Hypoxia on that side, I just just way over looked it when I replied. Do you have anything else you would like to add to this case?
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Nope. Here's what I see: A hypoxic, hypothermic, septic patient that's in renal failure, liver failure and has an amazing case of rhabdo going on. I'm amazed the patient lived that long.
 
Remi said:
While I agree that this patient should probably have been intubated for transport, I also understand the ED doc's reluctance. This is not a routine patient and thus routine decision making and risk/benefit analyses do not necessarily apply. "GCS <8 = intubate" is not always true. This is the kind of patient who arrests on induction if. Attempting to improve things without intubation may have been the wiser choice. Discretion is sometimes the better part of valor.
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They don't, but when moving a patient out of the hospital, a whole new set of considerations comes up that make it even more convoluted.

This one had a shortish transport time (<35 drive time apparently), but when faced with something longer, or shorter sometimes, it often may be better to perform the procedure (higher risk though it may be) than to put the patient into a lower level of care with an unsupported/underperforming whatever and hope that the same thing won't have to be done on the road.

It probably would have been beneficial for the OP to ask the sending doc what his thoughts on intubation were, and why it wasn't performed.
 
triemal04 said:
They don't, but when moving a patient out of the hospital, a whole new set of considerations comes up that make it even more convoluted.

This one had a shortish transport time (<35 drive time apparently), but when faced with something longer, or shorter sometimes, it often may be better to perform the procedure (higher risk though it may be) than to put the patient into a lower level of care with an unsupported/underperforming whatever and hope that the same thing won't have to be done on the road.

It probably would have been beneficial for the OP to ask the sending doc what his thoughts on intubation were, and why it wasn't performed.
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All truth.

It also comes down to clinical perspective, though.

As transport folks, we tend to look at every patient care situation from the angle of the transport. "I'm alone in the back of ambulance. The patient will be safer if their airway is secured before we go" is (nearly) always a true statement. But as with every rule, there are exceptions.

We are taught to be hyper-aggressive with airway management, and in most really sick patients, that is the right approach. What we aren't taught however, is the downsides of invasive airway management in certain populations, or the nuance of analyzing the risk:benefit of intubating certain people who, if you only look at one side of the clinical picture, clearly should be tubed. We are great at identifying people who should be RSI'd, but not so experienced with choosing who maybe should not.

In reality, a 30 or 60 or even 90 minute transport is a very small window in the course of a patient who is going to require perhaps weeks of intensive care. So when non-EMS folks look at these situations, they don't always rank priorities the same way that we do. EM docs and others tend to be better are looking at the bigger picture and viewing the transport is simply a brief phase in the overall course of the patient.

So as a sending physician, you might look at the OP's scenario something along the lines of this:
  • If the ambulance crew has to tube her during transport, it likely won't go well.
  • But if I tube her, it likely won't go well, either.
  • She's best off not having to be intubated at all, and that's the goal here. But if the DOES have to be tubed, the best place for that is probably in a tertiary ICU by intensivists and/or anesthesia.
  • She's been holding her own since she's been here, and while that could change in the next 30 minutes or so, I really have no reason to believe that it will.
When you look at it that way, you can maybe see why an EM doc in that situation would try to send the patient without intubating first.
 
Rescue7RN said:
5. What's everyones thoughts on anticoagulation and going direct to a cath lab? What was the 12 lead like? She's definitely having an NSTEMI and seeing what an echo is like would also be a benefit?

Tim
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There's a half a dozen different things that's going on with this patient that can cause elevated cardiac enzymes, especially the renal failure and the sepsis. Furthermore, even if it was an NSTEMI, then a cath would do nothing in this case except cause even more renal failure from contrast induced nephropathy.

http://circ.ahajournals.org/content/124/21/2350.full.pdf+html
 
Remi said:
In reality, a 30 or 60 or even 90 minute transport is a very small window in the course of a patient who is going to require perhaps weeks of intensive care. So when non-EMS folks look at these situations, they don't always rank priorities the same way that we do. EM docs and others tend to be better are looking at the bigger picture and viewing the transport is simply a brief phase in the overall course of the patient.

So as a sending physician, you might look at the OP's scenario something along the lines of this:
  • If the ambulance crew has to tube her during transport, it likely won't go well.
  • But if I tube her, it likely won't go well, either.
  • She's best off not having to be intubated at all, and that's the goal here. But if the DOES have to be tubed, the best place for that is probably in a tertiary ICU by intensivists and/or anesthesia.
  • She's been holding her own since she's been here, and while that could change in the next 30 minutes or so, I really have no reason to believe that it will.
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This is where it get's more problematic though, and where both the sending doctor, and the transporting team need to both be involved and aware of what the other is thinking and capable of.

Even 30 minutes can be to long for some patients to go if they continue to decompensate or if their condition changes (and predicting what some critically ill patients will do can be a crapshoot) and, while not always the case, in general an ER will be better suited to deal with that versus a single person in an ambulance. So with the patient who might not "need" X done right then while sitting in an ER it may be better to do X anyway, even with the associated risks, instead of putting them in a different environment with different levels of stimulation, movement, less medical resources, maybe less experienced providers, and no extra help and hoping that they'll maintain until they reach their destination.

There is no single right answer for all situations; it will be dependant on the patient and what is wrong with them. It just needs to be remembered for people who are doing this type of work that, if you see something that you think should be done prior to leaving, you need to be asking why it wasn't done.

The answer may or may not change things, but you still better be asking, because what you're seeing may not be what the doc is seeing, and what you're capable of may be different than what they think you can do.
 
It's one thing to hold off intubating a patient that it is being sent with a CCT able to RSI if the patient requires it en route. It's another to send that patient with a single Paramedic who has less options.
 
SeeNoMore said:
It's one thing to hold off intubating a patient that it is being sent with a CCT able to RSI if the patient requires it en route. It's another to send that patient with a single Paramedic who has less options.
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I think that this is a very one-dimensional mindset looking only at the EMS transport aspect. As stated above, the problem here is intubating this patient could cause him to further de-compensate. Therefore, the docs may want to hold off on managing the airway until they are quite literally left with no other option. Yes, they are playing the odds and counting on their lucky stars that the patient will be able to maintain their own airway through the transport.

Option 1: Intubate him now
  • more problems arise, potentially further delaying transport of the critically ill patient to the tertiary care center
Option 2: Holding off on the intubation
  • the patient maintains his own airway and does not face any of the problems
  • the patient crashes during transport, probably leaving him dead
 
SeeNoMore said:
It's one thing to hold off intubating a patient that it is being sent with a CCT able to RSI if the patient requires it en route. It's another to send that patient with a single Paramedic who has less options.
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I also disagree with this type of thinking. and like Monkey Said, we have two options.

We have to think of this patients care long term, treatment of the patient as a whole not just focus on the airway, and not just the short amount of time that we are in charge of the patient. There are complications that go along with intubating a patient and putting a patient on a vent, especially with how her Gasses are already, along with everything else that is going on with the patient. Like I said before, the patient was maintaining his own airway, and from what was presented to us, I do not believe this patient would crash during the transport, so I would feel comfortable taking him the way he is. But in our protocols we can RSI so I might be a little bias on that.
 
How does advocating a team with the OPTION of RSI = one dimensional thinking? I am aware of the potential complications of intubation and mechanical ventilation. What makes you believe this patient would not decompensate during transport? I don't really have an opinion on it either way, given the presentation I consider further decompensation a distinct possibility. In any event, I am not trying to say that intubating this patient somehow fixes all problems. If the ED Doctor wants to avoid intubation until they have "no other option" it might be wise to employ the use of a critical care team that could intervene with RSI or other therapies for this very ill patient. I understand these teams are not always available in a timely manner.
 
I see that there's a lot of folk with ICU / CCT experience on here, so I'd just like to throw a few ideas out for feedback.

* The patient meets criteria for severe sepsis (SIRS + lactemia)
* The, "Audible congestion was noted w/ cough. Patient had course crackles throughout. Chest x-ray only showed atelectasis" coupled with PaO2 / FiO2 ( 54 / 0.33) = 163, sounds a lot like moderate ARDS.
* The eleveated CK / CK-MB sounds a lot like rhabdomyolysis from being, "found at home alone on the floor after several days with no heat".
* The renal failure is probably a consequence of the rhabdo'.

This seems like someone who has a large potential to decompensate following intubation. We have a range of B/P readings reported, some of which are definitely soft (108/50 = ~70), they're lactemia, and have this, "Poor pleth due to poor distal perfusion, unable to palpate radial pulses. Hands and forearms are cool. Patient was reported with distal cyanosis on ED arrival. Patient had some mottling starting to show in lower extremities.". With a HR of 80, and some tachypnea. This sounds like she's likely volume-deleted (it would be nice to know how much fluid the ED has given her), and has relatively little sympathetic drive left. It may be a disaster if we take this away. Likewise, paralysing with "pH = 7.06", satting in the 70's-80's, with a PaCO2 of 54 (Winter's predicts PaCo2 of 30-34 for a HCO3= of 16), sounds like a cardiac arrest waiting to happen.

It seems to me like it might be worth bolusing a couple of liters, prepping some norepinephrine, trialling some BiPAP, ensuring the sending facility has proper ABx coverage, and then reassessing? It might be nice to know where her hemoglobin is sitting, and having a bit of a guess at why she ended up stuck on the floor for several days?

If we're not looking better after some initial resuscitation, we could consider intubating with a low dose of ketamine (0.5 mg/kg, perhaps?), with the levo' ready to go (or even bump her MAP a little first, in anticipation of it dumping). Any opinions on a dose of bicarb immediately before the intubation attempt? Ventilate per ARDSnet. Does this seem reasonable?

It seems like she could benefit from some stabilisation / optimisation prior to transport. I agree that an overeagerness to RSI could be dangerous.
 
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