Possible Sepsis

[shademt]

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?

 

[Wes]

At the EMT level without ALS support, PUHA (Pick Up Haul A**) comes to mind. Get a good assessment in. What are lung sounds like? Is pneumonia with sepsis your differential? I'd think about assisting ventilations with a BVM.

Paramedic level, this guy needs to be on a monitor and definitely needs fluids. Large bore IV access. Possibly even considering pressors, especially if you're familiar with early goal directed therapy for sepsis.

 

[Anjel]

Was the patient anxious? Could you possibly coax them enough to let you try to assist ventilations? Like Wes said pick up and haul *** to the nearest ALS crew or hospital.

They need fluids, antibiotics, and if they can't get the pressure up and RR down, the pt will need an advanced airway. CPAP really isn't an option with that low of a BP. The pt is going to get tired pretty quick, when breathing once almost every second.

 

[Wes]

If allowed, I'd seriously consider RSI for this patient. As an added benefit, we use Ketamine for our induction agent. Ketamine's hypertensive and bronchodilatory effects would be ideal for this patient.

 

[TransportJockey]

Nasal tube might be a good choice in this patient... And then if they will tolerate it, sedate them to maintain bag compliance. But this patient would get 2 large bore lines running wide open, possibly pressors, and ventilator assistance. We get to do this often due to having some piss poor rural SNFs in our response area.

One other thing (lol w/ recent threads, I'm hesitant to say this) you can do as a BLS provider to help R/I sepsis is check a CBG. Most patients in septic shock will have a rather high BGL reading.
Also asking about urine output would be a good thing. With sepsis, urine output will decrease or stop all together

 

[Anonymous]

O2 saturation?

also might lay the patient supine and elevate the feet

 

[Wes]

What would O2 saturation tell you that the patient's respiratory rate wouldn't tell you? I'd be more inclined to get an EtCO2 on the patient.

And hasn't the science pretty much shown that Trendelenburg is meaningless?

 

[STXmedic]

I'll echo a few:

BLS: Get 'em and go. Assist ventilations with a BVM if they can tolerate it. If they won't tolerate it, they will shortly. If the hospital is a good ways away and you can arrange for a ALS intercept, by all means do so. Like Wes said, Tburg is for all intents and purposes worthless.

ALS: RSI if available, if not, BVM (I also like JT's thought on nasal). Two lines and a lot of fluid. Pressors if the fluid doesn't help.

Just based on the information you gave, it sounds like a pretty standard septic shock patient.

 

[STXmedic]

O2 saturation?

also might lay the patient supine and elevate the feet

Are you doubting this patient is hypoxic? I know there are a few items in the assessment missing, but with significant hypotension, significantly elevated RR, elevated HR, and 103+ temp, I think oxygen would be a fair assumption... I'd even be willing to take a stab that you'd hear rales when auscultating the lungs.

 

[Wes]

Agreed. In this case, oxygen saturation would be just another vital sign to add to the chart. It's not going to help you with a differential or in treating this patient at this point.

And, assuming the respiratory rate is in the 50s, but the sats are, say, 97%, would you withhold oxygen?

 

[Mariemt]

How far out are you? If you can't get als intercept and have a ways to go, I'd consider helo

 

[Wes]

I'm not a flight junkie, but in this case, I'd agree with Mariemt if you're a ways out from a hospital with ICU beds.

Also, another question on assessment of the patient.... How's his mental status? I've seen several septic patients who are extremely altered, as in hallucinating.

 

[Anonymous]

What would O2 saturation tell you that the patient's respiratory rate wouldn't tell you? I'd be more inclined to get an EtCO2 on the patient.

Just Curious

And hasn't the science pretty much shown that Trendelenburg is meaningless?

and yes I know Trendelenburg is but the same goes for shock position?

 

[Wes]

The only difference between Trendelenburg position and shock position is that, in Trendelenburg, the head is also lowered. So, nope, I don't think the results will be any different.

Just for the sake of discussion, may I ask where you practice and what level you're at?

 

[STXmedic]

and yes I know Trendelenburg is but the same goes for shock position?

:blink: Huh?...

The "shock position" is trendelenburg... Well, it's a modified trendelenburg. How would modified trendelenburg be useful when trendelenburg is not?

 

[Anonymous]

The only difference between Trendelenburg position and shock position is that, in Trendelenburg, the head is also lowered. So, nope, I don't think the results will be any different.

Just for the sake of discussion, may I ask where you practice and what level you're at?

Yes I am a basic

:blink: Huh?...

The "shock position" is trendelenburg... Well, it's a modified trendelenburg. How would modified trendelenburg be useful when trendelenburg is not?

I don't know. I do know one is still taught and one is not and lowering the head has more risks associated with it.

 

[Wes]

What risks are you concerned about?

And I'd look at this link regarding Trendelenburg: http://www.ems1.com/ems-products/education/articles/384771-The-Current-Slant-on-the-Trendelenburg-Position

 

[DesertMedic66]

I thought shock position was now taught as just supine

 

[STXmedic]

Yes I am a basic



I don't know. I do know one is still taught and one is not.

They also still teach spinal immobilization, mechanism of injury, the golden hour, and O2 for all. The twos' effectiveness are the same- none.

 

[Wes]

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