spenac Posted March 26, 2010 Posted March 26, 2010 Sepsis. Keep in mind often in late stage sepsis patients are often hypothermic rather than hyperthermic though. Sepsis often leads to multi system failure. The body basically shuts down organ by organ to a point that it can no longer restart and they die.
VentMedic Posted March 26, 2010 Posted March 26, 2010 Sepsis. Keep in mind often in late stage sepsis patients are often hypothermic rather than hyperthermic though. It can be either hyperthermia or hypothermia and staging may depend on the orgin of the sepsis and age of the patient. Where you take the temp is also of importance and few EMS providers are going to be able to do a core temp from the esophagus or be inclined to do a rectal temp. Hyperthermia > 38.3 °C (101.0 °F) Hypothermia < 36 °C (96.8°F) Here is a link to guidelines and some good reading on the topic of sepsis. Surviving Sepsis Compaign http://www.survivingsepsis.org/GUIDELINES/Pages/default.aspx Physiological Monitoring for Critically Ill Patients: Testing a Predictive Model for the Early Detection of Sepsis Am J Crit Care. 2007;16: 122-130 Karen K. Giuliano http://ajcc.aacnjournals.org/cgi/reprint/16/2/122?ijkey=59ca6a51e57bbd491e87b501b52032817438d99c
flight-lp Posted March 27, 2010 Posted March 27, 2010 Any palpable abdominal masses? Varying BP between right and left sides? Back or chest pain?
DartmouthDave Posted March 27, 2010 Author Posted March 27, 2010 (edited) Any palpable abdominal masses? Varying BP between right and left sides? Back or chest pain? Hello, This fellow abd is large and soft. He has no c/o N+V. However, he has felt too sick to eat or drink. Even his beer. The BP is the same in both arms. No back or chest pain. The pain is localized down South. Here is a few questions to ponder: Hear Rate: 100-120 irregular The EKG shows A.Fib with a slight widen QRS. There is an odd sloping of the Q-wave (Delta). Alas, I have not had time to scan the 12-lead. Patient states that he has had a history of rapid heart beats. He thinks that is why he is on the Dig. What could it be? Ideas to manage the A.Fib if it gets worse? Tyl: Are we concerned with an APAP OD? Sepsis: Sepsis is a solid DX. What treatment should we start? What is the source? There is a particular condition (rare) that obese male patients are at an increased risk for down there? GU: He can not remember voiding for a long time. Impact on treating the sepsis? Cheers... Back to work... Edited March 27, 2010 by DartmouthDave
chbare Posted March 27, 2010 Posted March 27, 2010 With the history, we need to put Fournier's gangrene on or list of differentials. Clearly we also have additional problems such as WPW. If treating the WPW is needed, it will most likely consist of cardioversion as many medications may facilitate additional use through the accessory pathway. Pronestyl or amiodarone may be considerations; however, if this patient requires immediate intervention, cardioversion will be the best bet. Digoxin is a poor choice of agents for WPW. Our treatment will be limited. This patient will require a comprehensive workup and if possible a catheter placement. We will need to be careful with medications as there may be underlying hepatic and renal issues. I would attempt to limit pre-hospital pharmacological interventions. Take care, chbare. 1
Dustdevil Posted March 27, 2010 Posted March 27, 2010 Exactly. Excellent summation. I've seen a couple cases of this in my day, and it's not pretty. You'll never forget the smell of Gangrene once you've experienced it. The first patient I ever had with this did indeed die from sepsis. I actually had one of these patients in Iraq. Some medic missed the diagnosis on the first visit because he didn't want to do a proper exam. A week later, the guy comes in febrile and tachy and I immediately knew what was going on, before I even looked. Gangrene is bad enough on an otherwise healthy person. When you pile it on top of the multiple conditions this guy is sporting, it becomes a nightmare to manage. All of the normal supportive care you would give this guy has to be very carefully considered in light of the pre-existing conditions. And yeah, I thought about the APAP situation there. Not good for the liver, which is already in trouble.
chbare Posted March 27, 2010 Posted March 27, 2010 Yeah, one of the worst cases of my career to date involved a morbidly obese patient with multiple additional co-morbidities who fell and could not get up. He was found down after several days and had developed extensive cellulitis with large, purulent areas of necrosis and drainage. In fact, it was so bad, we initially treated it like a hazmat incident and did an initial cleaning kitted up in our decon room. This particular case was even more disturbing initially than most of what I experienced in Afghanistan. In addition, the patient did a downward spiral on us while we were waiting for Medevac. With luck, the team had a PC 12 and could fly the guy. Unfortunately, the patient did not end up doing well. As Spenac stated, once you go down the road of multiple organ dysfunction and failure, the prognosis is not typically great. Even worse, you run into all the physiological and pharmacological problems with multiple organ failure. Take care, chbare.
Kiwiology Posted March 27, 2010 Posted March 27, 2010 Yahoo finally a chance to bust out the old school reconstitute-required vial of funny yellow powder and give cerftriaxone! Wait, should I call medical control first? Not in Los Angeles are we? Did I mention Los Angeles recently?
JackMaga Posted March 27, 2010 Posted March 27, 2010 (edited) Yahoo finally a chance to bust out the old school reconstitute-required vial of funny yellow powder and give cerftriaxone! Wait, should I call medical control first? Not in Los Angeles are we? Did I mention Los Angeles recently? Great... now you have screwed my chances to take a couple of hemocultures in the ER... Seriously though... do you think this patients warrants aggressive antimicrobial therapy in the field or can he wait untill you get him in the ER and cultures are drawn? Does the transport time to the hospital play a role in deciding this? How so? Edited March 27, 2010 by JackMaga 1
DartmouthDave Posted March 27, 2010 Author Posted March 27, 2010 Great... now you have screwed my chances to take a couple of hemocultures in the ER... Seriously though... do you think this patients warrants aggressive antimicrobial therapy in the field or can he wait untill you get him in the ER and cultures are drawn? Does the transport time to the hospital play a role in deciding this? How so? Hello, Not in this case. In an urban/suburban area doing abx on scene will slow things down. Get the abx in once in the ED. Not that EMS can't do it rather it is an issue of time. In an urban setting the crew will have enough to do (assessment, history, lines, packaging the patient and transport). Really, the initial stages of any good evidence based Sepsis protocol. Now, in an isolated setting with long transport time abx based on the suspected source of sepsis is a good idea. Early abx equates to better outcomes. Here is a nice reference from London Health Sciences Critical Care Site: CCTC Cheers...
Recommended Posts