tydek07
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We get called to a local nursing home for a female that is weak, increased temp, lethargic, and SOB. On scene we find a 72yo female laying supine in bed with staff in the room. Staff stated that pts condition has been deteriorating for the past couple days, but do not know when it exactly started.
Staff stated that pts mental status has deteriorated today and she started to get tremors. They had gotten a temp of 103 prior to our arrival. They mentioned that the dosage of pts digitalis has been changed recently (Do not know what the old dose was). Oh, they also through in there that pt may have had a stroke yesterday, but never got seen by a physician.
Hx of CHF, A-Fib, Hypertension, and mental retardation. Staff stated that pt does not usually talk, but is alert and able to follow commands. She is usually ambulatory without assistance.
Pt was responsive to verbal stimuli. She would open her eyes when we said her name, but would not follow simple commands. Breathing at 12/min, HR of 150ish, BP of 150/P. Move her onto our cot and load into ambulance.
Once in ambulance we did further assessment and treatment (not listed in any order here):
Start transporting to ER. My plan of attack is to give pt fluid bolus and see how that effects her HR. I know that an infection will increase HR and to try fluids first. The A-fib was staying around the 150-170 range to start with, would go up to the 200's for short periods of time.
I have given 500ml of fluid and recheck vitals. Vitals are now: HR 180-220, BP 108/49, O2 @ 98%, Resp 12.
Now I am thinking, Should I control the rate with Lopressor? Something is telling me to hold off on that and give MC a call. So I give MC a call, tell the doctor the situation and pts condition. He tells me to not give the lopressor and to continue fluid therapy... Good thing I called B)
Anywho, transport pt to ER... show up with vitals of: HR 200-220, BP 104, O2 @ 96%.
I go and talk to the doctor that had answered the phone earlier. He said in pts like this to hold of the drugs until you have given at least 1.5-2L of fluids to them, then consider treating the rate, but just consider. I told him that I know infection/sepsis will cause an increased HR and to try fluids first... but how do I know when enough is enough and try to fix the rate problem? Of course, before he can answer he gets a phone call.
So my question is: When do you stop trying fluids and switch over to rate control in pts like this? One of two things will happen 1) Lower the HR and stable things out or 2) Lower the heart rate... along with everything else.
Sorry this is so long, just had to get most of the info in there... I may/probably have forgotten to tell you guys something, so just ask me what you need. Hope you can read through my grammar errors... typing this up quick.
Thanks,
tydek
Staff stated that pts mental status has deteriorated today and she started to get tremors. They had gotten a temp of 103 prior to our arrival. They mentioned that the dosage of pts digitalis has been changed recently (Do not know what the old dose was). Oh, they also through in there that pt may have had a stroke yesterday, but never got seen by a physician.
Hx of CHF, A-Fib, Hypertension, and mental retardation. Staff stated that pt does not usually talk, but is alert and able to follow commands. She is usually ambulatory without assistance.
Pt was responsive to verbal stimuli. She would open her eyes when we said her name, but would not follow simple commands. Breathing at 12/min, HR of 150ish, BP of 150/P. Move her onto our cot and load into ambulance.
Once in ambulance we did further assessment and treatment (not listed in any order here):
- 4-Lead (A-Fib 150-200)
- 12-Lead (Unremarkable)
- BGL (186)
- IV (18 gauge w/ NS WO)
- Vitals (B/P 142/78, O2 sat 98% of 6L via NC)
- Eyes: PEARL, CMS x4, Lung sounds: Deminished in lower lobes
Start transporting to ER. My plan of attack is to give pt fluid bolus and see how that effects her HR. I know that an infection will increase HR and to try fluids first. The A-fib was staying around the 150-170 range to start with, would go up to the 200's for short periods of time.
I have given 500ml of fluid and recheck vitals. Vitals are now: HR 180-220, BP 108/49, O2 @ 98%, Resp 12.
Now I am thinking, Should I control the rate with Lopressor? Something is telling me to hold off on that and give MC a call. So I give MC a call, tell the doctor the situation and pts condition. He tells me to not give the lopressor and to continue fluid therapy... Good thing I called B)
Anywho, transport pt to ER... show up with vitals of: HR 200-220, BP 104, O2 @ 96%.
I go and talk to the doctor that had answered the phone earlier. He said in pts like this to hold of the drugs until you have given at least 1.5-2L of fluids to them, then consider treating the rate, but just consider. I told him that I know infection/sepsis will cause an increased HR and to try fluids first... but how do I know when enough is enough and try to fix the rate problem? Of course, before he can answer he gets a phone call.
So my question is: When do you stop trying fluids and switch over to rate control in pts like this? One of two things will happen 1) Lower the HR and stable things out or 2) Lower the heart rate... along with everything else.
Sorry this is so long, just had to get most of the info in there... I may/probably have forgotten to tell you guys something, so just ask me what you need. Hope you can read through my grammar errors... typing this up quick.
Thanks,
tydek
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