Possible Sepsis

[NomadicMedic]

I think for a basic, it should be this:

1) put the patient in the ambulance.
2) start an ALS intercept.
3) if the hospitals closer than ALS, go there.

Am I looking at this from a skewed perspective? ALS can start to manage hypotension with fluid and pressors, but the patient needs to be in a hospital. That should be the number one priority of the basic that's on scene without a paramedic.

 

[DesertMedic66]

I think for a basic, it should be this:

1) put the patient in the ambulance.
2) start an ALS intercept.
3) if the hospitals closer than ALS, go there.

Am I looking at this from a skewed perspective? ALS can start to manage hypotension with fluid and pressors, but the patient needs to be in a hospital. That should be the number one priority of the basic that's on scene without a paramedic.

That's how I would run the call. Even if ALS is 10 minutes out and the hospital is 10 minutes out, I'm still going to the hospital.

 

[JPINFV]

Arrive on scene for a c/c of high temp. You find the patient semi-Fowler with a N/C set at 6 LPM. B/P is 58/38, HR is 130, RR is 58, and temp 103.5. After being placed on NRB at 15 LPM, no change in RR. How do you treat taking into consideration the low BP with high RR?

Well, considering that you have 3 of the 4 criteria (you need a WBC with manual differential (note: easiest way to clear up a bandemia at my hospital is to order an automatic diff) to get the 4th), and you only need 2 of the 4, your patient is in systemic inflammatory response syndrome, especially with the elevated temp. Give a source (UTI, PNA, etc) and you have sepsis.

So, yep, sounds like sepsis, which prehospitally is fluids, fluids, fluids, and more fluids.

 

[JPINFV]

That's how I would run the call. Even if ALS is 10 minutes out and the hospital is 10 minutes out, I'm still going to the hospital.

If I was BLS and I saw this upon entering (presumably altered, drastically tachypneic), I'd make the decision there to either call paramedics or transport to the closest hospital depending on ETA including time to package the patient. If I decided that package+move+transport time < paramedic ETA, I wouldn't even bother with an on scene assessment because it wouldn't change anything. NRB, move to gurney, move to ambulance, lights, sirens, camera, action. With a patient in respiratory failure (or really any sick medical patient), EMTs are going to max out their potential interventions pretty quickly, and any additional action, including a "proper assessment" just delays desperately needed medical care. I can get lung sounds in the ambulance. I can get a blood pressure in the ambulance. I can dig through the chart in the ambulance. However none of those are going to change the decision to transport to the closest available emergency department or change the decision to call paramedics.

 

[NomadicMedic]

It's another one of those "ridiculous EMT class scenarios". How would you manage this patient blah blah blah…

You can blather on and on about Trendelenburg and high flow oxygen, but this patient needs a paramedic armed with a couple of thousand bags and then a hospital.

This isn't a slam on the OP, it's just another reason why I dislike EMT classes trying to cram a bunch of knowledge into people that really should learn, "the patient is sick, I lack the resources to manage this. I either need a paramedic or the hospital, whichever is closer"

 

[Anonymous]

What's apparently not being taught are assessment skills and critical thinking.

Are we not here to learn?

Apparently you were not taught how not to be condescending. Attitudes like yours are what hinder learning.

God forbid you ever have a green basic for a partner.

 

[NomadicMedic]

I think we've all had green basics as partners, and we all do our best to teach them to think and assess patients.

Unfortunately, it's not taught in most EMT basic programs.

 

[Anonymous]

I think we've all had green basics as partners, and we all do our best to teach them to think and assess patients.

Unfortunately, it's not taught in most EMT basic programs.

Teaching someone to think seems futile. Now teaching someone is a little different.

Why would one not "think" shock position works? It makes sense that it would if you "think about it" Ask anyone outside of healthcare if they think that would work and i guarantee the majority would say yes.

It is through acquiring knowledge that one realizes it does not work, that has nothing to do with critical thinking skills. Not to mention the Do's and Dont's almost always seem to come full circle in EMS.

 

[Wes]

For the record, I love teaching and mentoring providers. I volunteer as both a medic and an EMS educator. I think we do a horrible job of teaching people at the basic level much beyond follow the cookbook. I think we can all master a good assessment, critical thinking, and research.

 

[Handsome Robb]

VOMIT with an extra line, fluids, dope, diesel and RSI if you've got it otherwise consider NTI depending on distance from te hospital. POC Lactate if you've got it *cough* chaz and DEmedic *cough*. Early notification to the hospital. Consider HEMS for RSI if you've got an extended transport considering after the NTI unless you've got something other than versed you're going to have a rough time sedating him and keeping his pressure from taking a dump even further.

I'd be going emergent with this gentleman, not a huge fan of code 3 transports but is say its appropriate in this guy's case.

I'd also say this is past "possible sepsis".

 

[NomadicMedic]

I always take any indication of sepsis seriously. My first legitimately septic patient was a 19-year-old female, and she died.

Granted, she was a drug user and her immune system was compromised… But for a 19-year-old to die from sepsis is just a shame.

 

[Clipper1]

Why would one not "think" shock position works? It makes sense that it would if you "think about it" Ask anyone outside of healthcare if they think that would work and i guarantee the majority would say yes.

It is through acquiring knowledge that one realizes it does not work, that has nothing to do with critical thinking skills. Not to mention the Do's and Dont's almost always seem to come full circle in EMS.

Why would you ask someone outside of healthcare if something medical works?

In this situation critical thinking should tell you it not only would not work but also be harmful to the patient.

The airway is also already compromised and not secure. Placing a person's head down will make those rapid respirations even more ineffective.

Placing the head down can also lead to aspiration. This type of PNA along with the cause of the sepsis would probably be a death sentence for the patient.

Trendelenberg is only a very, very temporary fix. If you have seen it done in the hospital it is only for a minute or two until fluids and pressors are adjusted. During that time a physician will take advantage of the position for a central line. There is also the appropriate suction equipment and probably an NG placed which may be also to suction. There is intubation equipment and there is the appropriate "high flow" oxygen to give adequate oxygen. A NRBM is not effective at providing the adequate high FiO2 and flow to meet the patient's demand.

If you do not have fluids or pressors, what happens to the patient when you move them from the trendelenberg position to get them onto another stretcher?

This is not something you have to trial on a patient so you can see them crash for yourself before you believe it. Others have already done that for you.

 

[VFlutter]

I love Trendelenburg....when pulling heavy patients up in bed. But that is about all I use it for.

 

[NomadicMedic]

I love Trendelenburg....when pulling heavy patients up in bed. But that is about all I use it for.

Trendelenburg. The King County fluid bolus.

 

[Aprz]

Why would you ask someone outside of healthcare if something medical works?

That's the point he was making.

 

[Anonymous]

That's the point he was making.

Thank you

The point was a lack of knowledge and lack of critical thinking skills are not the same thing.

 

[Clipper1]

Thank you

The point was a lack of knowledge and lack of critical thinking skills are not the same thing.

Critical thinking comes from knowledge for medical situations. They go hand in hand.

This was your earlier post.

O2 saturation?

also might lay the patient supine and elevate the feet

When a patient's RR is this tachypneic, SpO2 is not going to mean to much except if the person is hypoxic but in this situation the oxyhemoglobin curve will be shifted due to acidosis. That means the SpO2 probably will not be accurate. As a Basic all you have is a NRB mask and a BVM which means you are very limited. The patient will probably over breathe the NRB mask since it is not a high flow device and it is doubtful you will be able to over ride the acidosis and rapid respiratory rate without causing the patient more stress if still conscious.

 

[Carlos Danger]

Early sepsis management is pretty straightforward and non-controversial: improve perfusion with lots of IVF and vasopressors. If you are an EMT, you just need to get the pt to the hospital ASAP, and get an ALS intercept or possibly use HEMS if you have a long transport time.

The only disagreement I have with others in this thread is on early intubation. I would do everything in my power to avoid intubating this patient in the field, at least until the BP has improved substantially. These are the types of patients (especially if he is elderly) who can easily arrest on induction or shortly after.

Also, as an aside, if I did have to intubate a patient like this, ketamine would not be my first choice. It has direct myocardial depressant effects and can exacerbate hypotension in highly SNS-dependent patients, which could be fatal in a patient like this.

 

[Summit]

I don't have anything to add...

Also, as an aside, if I did have to intubate a patient like this, ketamine would not be my first choice. It has direct myocardial depressant effects and can exacerbate hypotension in highly SNS-dependent patients, which could be fatal in a patient like this.

What would you choose?

 

[Carlos Danger]

What would you choose?

A small dose of etomidate.

Ketamine has a tendency to directly depress the myocardium (via a Ca+ blocking mechanism, I believe), but this is normally more than offset by its positive SNS effects (which are due to inhibition of catecholamine reuptake). So the idea is that a patient who is "on the edge" and already maximally SNS stimulated will not have the SNS reserve needed to offset the myocardial depression and may see a further reduction in CO with an induction dose of ketamine. Which of course could be catastrophic in a patient who is already severely hypotensive.

To be fair, I think this is mostly theoretical. I don't think there is a lot of research backing it up, but it is mentioned in the anesthesia texts and lots of anesthesia folks will tell you they avoid ketamine in severe shock.