options...pt with a temp of 103.7

[ebass30920]

What were the breath sounds? I would remove as much clothing as I could just a sheet. IV TKO and O2. I cant see a reason to dump fluid into the patient. I think you are on a fine line with this patient of making them unstable esp. if you start putting cold fluid in them. There are alternate methods of cooling a previously mentioned and yes the fever way high but he still wasnt in immediate danger. All in all given pt. condition there is not a lot that will be done in an ambulance to make them better. I am agreeing with the need for antibiotics, and no on the fluid.

 

[usalsfyre]

I'm curious what makes you hesitant to give fluid.

Large amounts of IV fluid (albeit not cold) are absoloutely indicated to compensate for imflamatory response. The patient not hypotensive because, for the moment, he's able to compensate with a large increase in cardiac output (hence the hr of 140).. He won't be able to do this forever (or even long) and will get hypotensive. Much better to get ahead, fill up the tank and give his myocardium a rest.

 

[ebass30920]

You are right USA. I just looked back at the initial vitals. I think a bolus is in order. I didnt realize the patient was that tachy. I remembered increase hr when I posted but forgot it was that high.

 

[Aidey]

Never.

x2

It is possible to reduce a fever too quickly. 40 degree saline would definitely do that.

I also agree that fluids are indicated. I bet when they were giving the bolus his BP went down.

 

[Bieber]

All right, this is my first post, and I'm still just a paramedic student till the 18th when I take boards, but I'll give my humble opinion, such as it is.

Personally, I would just passively cool this patient. Remove or loosen his clothes and turn up the AC in the back of the ambulance. I don't want to drop his temperature too suddenly, and I don't think fluids are indicated in this instance because we've got a good blood pressure and I think active cooling is a little too much for this guy.

What I WOULD like to know more about is this patient's history. I hate to sound like the guy looking for zebras, but honestly there are a LOT of reasons for a fever and not all of them are infection. And though his temperature is pretty high, it doesn't seem like it would be high enough to put this guy completely unresponsive like this.

You said this guy was on two antibiotics? What for? How long had he been taking them? Had he been compliant? Was the CVA an ischemic or a hemorrhagic stroke? How long ago was it and what kind of treatment did he receive for it? What other medications is he on? Blood thinners, perhaps? What do his pupils look like?

As long as this guy's vital signs are good, I'm going to stay conservative in my treatment. I don't know what's causing this guy's fever, and there's a lot of possibilities. Does he have an infection? Is this a drug-induced fever from the antibiotics he's on? Did he have a hemorrhagic stroke that's causing this fever? All of those are possible, and personally I am VERY suspicious about a patient who is completely unresponsive despite good (as in, perfusing) vital signs who has a recent history of CVA and infection and current antibiotic use. That just seems off to me, but like I said, I'm just a humble student so if I'm way off let me know.

 

[zmedic]

If you have cold saline on your truck I bet it is specifically for post cardiac arrest hypothermia. You can't just use it for other reasons. I highly doubt that you have a protocol that allows you to give it for hyperthermia, and I think your on line medical control would say heck no if you called and asked about it.

Prehospital, sepsis give normal temp saline. Consider cooling the patient by wetting them and fanning if they are hyperthermic. No cold saline IV.

 

[18G]

To the OP.... think of the IV fluid temperatures this way. The reason we have IV fluid warmers is because room temperature fluids are too cool for certain patients (ie trauma). A room temperature fluid of say 70F is well below the body's temp and to someone who is febrile ambient temp fluids would be suitable. There is no need to give chilled saline to someone who your suspecting of having SIRS.

The fever was compensatory to what sounds like an underlying infection. This patient is rehabbing for a CVA I believe you said so more than likely this patient has been immobile for some length of time, was recently in the hospital, and has a trach. And I'm sure the patient also had a foley catheter as well. All this to me points to an infectious process and conditions that increase risk of infection especially nosocomial infections.

Definitely no chilled fluids.

 

[usalsfyre]

All right, this is my first post, and I'm still just a paramedic student till the 18th when I take boards, but I'll give my humble opinion, such as it is.

Personally, I would just passively cool this patient. Remove or loosen his clothes and turn up the AC in the back of the ambulance. I don't want to drop his temperature too suddenly, and I don't think fluids are indicated in this instance because we've got a good blood pressure and I think active cooling is a little too much for this guy.

What I WOULD like to know more about is this patient's history. I hate to sound like the guy looking for zebras, but honestly there are a LOT of reasons for a fever and not all of them are infection. And though his temperature is pretty high, it doesn't seem like it would be high enough to put this guy completely unresponsive like this.

You said this guy was on two antibiotics? What for? How long had he been taking them? Had he been compliant? Was the CVA an ischemic or a hemorrhagic stroke? How long ago was it and what kind of treatment did he receive for it? What other medications is he on? Blood thinners, perhaps? What do his pupils look like?

As long as this guy's vital signs are good, I'm going to stay conservative in my treatment. I don't know what's causing this guy's fever, and there's a lot of possibilities. Does he have an infection? Is this a drug-induced fever from the antibiotics he's on? Did he have a hemorrhagic stroke that's causing this fever? All of those are possible, and personally I am VERY suspicious about a patient who is completely unresponsive despite good (as in, perfusing) vital signs who has a recent history of CVA and infection and current antibiotic use. That just seems off to me, but like I said, I'm just a humble student so if I'm way off let me know.

Your only sorta off. That said, a hot flushed (sign of inapproprite vasodilation) patient with a heart rate of 140 (screams compensated shock) and an altered LOC (end organ being affected perhaps?) is SIRS without a doubt. These are NOT good vital signs, his B/P just hasn't crapped out yet.

While SIRS can be caused by a whole host of issues, look at the setting. A NH,in a patient with a trach (increased risk of pneumococal infection) and probably a foley (UTI) being assisted by nurses and aides who deal with other sick people all day (think nonsocomial routes). Sepsis is just the most likely posibility, although I wouldn't rule out CVA.

The treatment will be the same either way. Lots and lots of fluid (liters if you have the time, they'll need it), and consider an antipyretic to reduce metabolic demand (not something I'd routinely do). If his B/P tanks, start him on norepinephrine if you can't get it back up with fluid. Everything else will be supportive care.

 

[Akulahawk]

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

Ok, so let's review:
44YOM
s/p CVA, A&Ox0 with GCS 3
HR: 140-165 STach
BP: 140/100
RR: unk
Temp: 103.7* tympanic.
SpO2: 100% on 5L/Min via T piece through a trach.
On 2 Abx.

What's going on? He's going septic. And not a nice one at that. Since he's also got a history of HTN, I wonder about what his normal SBP is. I'd be willing to bet it's normally higher than than 140... He's profusely sweating, feels hot, has a probably lowering BP from a likely baseline. I also wonder about breath sounds.

IMHO, he needs fluid at the moment. Just use the fluid in the warmer. I currently see no immediate need to try to aggressively actively cool this patient.

I'd say transport, give boluses to start filling the tank, so to speak. Get ahead of him as once his HR comes down, he's going to crash. He's relatively hypovolemic and he may be relatively hypotensive compared to his norm. Why? His "container" got bigger or it's leaking. He's sweating still because that part of his body hasn't run out of fluid yet. (credit to usalsfyre) The flushed appearance does highly suggest inappropriate vasodilation to me as well. He's got fluid going to places where it shouldn't be...

Did anyone find any documents that state what his baseline vitals are? If he's normally running, say, 180/120 (MAP 140) and he's now at 140/100 (MAP 113)... well, that's nearly a 40 point drop over a short time from what his body is likely acclimated to. Take someone whose BP is normally 120/80 and drop it fairly quickly to 86/60... what happens?

In any event, I would expect that in-hospital treatment is likely to be what usalsfyre suggested, and an attempt to treat with different ABX, by IV if indicated.

Personally, I think that this patient is going to have a rough time, if he survives.

 

[Bieber]

Your only sorta off. That said, a hot flushed (sign of inapproprite vasodilation) patient with a heart rate of 140 (screams compensated shock) and an altered LOC (end organ being affected perhaps?) is SIRS without a doubt. These are NOT good vital signs, his B/P just hasn't crapped out yet.

While SIRS can be caused by a whole host of issues, look at the setting. A NH,in a patient with a trach (increased risk of pneumococal infection) and probably a foley (UTI) being assisted by nurses and aides who deal with other sick people all day (think nonsocomial routes). Sepsis is just the most likely posibility, although I wouldn't rule out CVA.

The treatment will be the same either way. Lots and lots of fluid (liters if you have the time, they'll need it), and consider an antipyretic to reduce metabolic demand (not something I'd routinely do). If his B/P tanks, start him on norepinephrine if you can't get it back up with fluid. Everything else will be supportive care.

Oh no, the guy definitely has SIRS. And I'm not saying it can't be infectious, but there's also some other possible culprits as well. And yeah, he could still get an infection even while on the antibiotics, but the fact that he IS on the antibiotics definitely makes me wonder if there might be a non-infectious cause of the SIRS.

 

[Smash]

By definition: Sepsis.

I would like to know what his normal GCS is: I'm assuming higher than 3. If so, then this patient has not just sepsis but severe sepsis (HR >90, RR>20, Temp > 100F and evidence of end organ dysfunction in the setting of a known or strongly suspected pathogen: ie he is on antibiotics)

Usalsfyre has very succinctly covered all his history, risk factors and problems.
His temperature is not really the problem as usalsfyre has pointed out: it is merely a symptom and doesn't need managed at this stage. His BP is not entirely what it seems either. The early stages of sepsis are characterised by a hyperdynamic state: his HR is very high and his BP is currently "normal", although in reality it is not adequate due to the massively increased metabolic demand (and we see evidence of this in his decreased conscious state). I'm also willing to put money on the fact that he won't be making much urine at the moment.

So, I agree with usalsfyre: Oxygen, lots of it (one of the few times it is necessary) and consider intubation depending on a number of factors such as his baseline neurological status and his response to further management. Aggressive fluid resuscitation, get inotropes prepared, not yet running, administer 1g of ceftriaxone IV and transport to a suitable ICU equipped hospital.

 

[Smash]

Oh no, the guy definitely has SIRS. And I'm not saying it can't be infectious, but there's also some other possible culprits as well. And yeah, he could still get an infection even while on the antibiotics, but the fact that he IS on the antibiotics definitely makes me wonder if there might be a non-infectious cause of the SIRS.

There are indeed many causes of SIRS, but given the natural history of the disease and the patients risk factors, looking far beyond a nasty little bug is probably wasting time and resources. The fact that he is on antibiotics already doens't mean that he can't get an infective process happening: it means he already has one and the antibugs aren't up to fighting it off.

 

[18G]

Bieber... My questions on the antibiotics would be when were they started and for what infection were they prescribed for. Perhaps the infection got well ahead of the antibiotics or the antibiotics prescribed were not strong enough or suitable for the infection type.

I get what your saying but knowing the patient is on antibiotics would not make me think this patient has something else going on besides infection.To me it would raise my alert to an advanced infectious process.

 

[b2dragun]

Ok, so more info...I had to do the whole sleep thing between shifts. I'll try to remember what I can. Keeping in mind that this is the kind of facility where you are lucky to have someone that claims they don't know the pt, usually we don't even get that. As for knowledge and paperwork. He is there post CVA, they state his baseline is normal so gcs of 3 may not be too off from normal. As for hx, cva and htn is what we got. No baseline vitals available. From experience he has probably been like his for at least 12 hrs, I'm surprised they didn't just put it off till day shift. He did have a foley + for urine output, nice and normal yellow. I also remember hearing that he had a shunt from the ventricle to the belly for csf drainage and that part of his skull was "soft."

I didn't originally put all that in because it was more of a question of the use of cold fluids, but this is turning into a good discussion.

 

[JPINFV]

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

Is there anything that can't do? I'm in respiratory and it seems like the answer to every other case is ceftriaxone.

 

[Smash]

He did have a foley + for urine output, nice and normal yellow.

What sort of yellow and what sort of volume? Septic shock patients late in the progression of the disease typically have oliguria/anuria. However, early on in the piece they tend to produce large volumes of poor quality, very dilute urine. This of course just adds to their woes in terms of hypovolemia.

 

[Veneficus]

Is there anything that can't do? I'm in respiratory and it seems like the answer to every other case is ceftriaxone.

I am guessing it is tried often because it has a wide range of affected organisms, gram positive and negative, gets around some B-Lactamase resistance and saves the better stuff for use on MRSA etc.

Just my thinking, no evidence.

 

[Akulahawk]

Is there anything that can't do? I'm in respiratory and it seems like the answer to every other case is ceftriaxone.

Yes. It can't cook my nachos.

For what it's effective against... well, it's :wacko:. I can't count the number of times I've read orders for the stuff in patient's charts over the years... :blink:

 

[SanDiegoEmt7]

While SIRS can be caused by a whole host of issues, look at the setting. A NH,in a patient with a trach (increased risk of pneumococal infection) and probably a foley (UTI) being assisted by nurses and aides who deal with other sick people all day (think nonsocomial routes). Sepsis is just the most likely posibility, although I wouldn't rule out CVA.

If you hear horse hooves...

 

[Akulahawk]

I am guessing it is tried often because it has a wide range of affected organisms, gram positive and negative, gets around some B-Lactamase resistance and saves the better stuff for use on MRSA etc.

Just my thinking, no evidence.

From what I've learned about it, I suspect that's the reason. It's effective on a HUGE range of organisms that it kind of fits into the "give it empirically" while we culture this and determine specific sensitivities and kill "it" with something specific.