scubanurse Posted January 12, 2013 Posted January 12, 2013 How are lung sounds now after 2L of fluid?
DartmouthDave Posted January 12, 2013 Posted January 12, 2013 Hello, Good case study. I am thinking septic pneumonia. Poor pain control, fractured ribs, and hypoventilation could be the cause. Also, it has slowly developed over three days. I would also like a repeat EKG as well. Also, I would check her skin out to see if their are any red spots. Fat embolism is a remote possibility. A PE is an other possibility. But, if a PE is big enough to cause profound hypotension I would think her SpO2 would be much lower. Cheers
Kiwiology Posted January 12, 2013 Posted January 12, 2013 If she is still hypotensive after two litres of fluid I'd start a very slow adrenaline infusion. Because our time to hospital is so great, I am considering giving her 2 g ceftriaxone IV as well.
mobey Posted January 13, 2013 Author Posted January 13, 2013 (edited) Cool guys, great interaction here. I'll move this along.... After 4lt of fluid there is 100ml urine output. BP is unchanged an Dopamine is started and rapidly titrated up to 10mcg/kg/min. MAP is brought up to 60. After about 45min of transport she begins getting confused, tired, diaphoretic, and combative pulling off NRB (she wouldn't tolerate CPAP). Current vitals Sp02 77% (Removed 02, too combative to keep it on) BP: 88/50 Pulse: 70. ECG unchanged You are 30min from closest clinic, 1.25hrs to a hospital. BLS ambulance backup 15min away. Air entry sounds unchanged - crackles throughout Edited January 13, 2013 by mobey
scubanurse Posted January 13, 2013 Posted January 13, 2013 Can we sedate her some to prevent the combative behavior? She really needs some O2 therapy. Does she have a cath in? She could have sepsis from pneumonia but also a kidney infection that is compromising her kidney function. Any possibility to fly this lady out? The agitation and confusion can be secondary to the hypoxia... probably not a possibility but RSI? Just eliminate her need to breathe on her own all together?
Arctickat Posted January 13, 2013 Posted January 13, 2013 Yeah, Kate is in the same school as I am. Snow her and intubate. CPAP if she's breathing on her own or PPV with PEEP if she's not, and monitor for pneumothorax development. I can fix a pneumo, but I can't fix her shock without proper ventilation.
HellsBells Posted January 14, 2013 Posted January 14, 2013 Dang mobey, you get all the interesting calls. What is the capacity of the clinic 30 mins away? I would certainly be setting up for an rsi, ketamine, and succs if needed. Get that BLS backup rolling buddy.
HarryM Posted January 14, 2013 Posted January 14, 2013 OK so can we recheck temp and see what that is now? Our guidelines require temp to be over 38 or under 36 along with clinical signs of shock to administer ceftriaxone. She definitely meets the clinical signs of shock along with decreased urine output and confusion (although this could possibly be due to hypoxia). Is she complaining of any aching muscles or joints and does she have any petechial spots or any other sort of skin rash?
Kiwiology Posted January 14, 2013 Posted January 14, 2013 How long ago was her bloods last done at the hospital? They were all normal i.e. no leukocytosis or other biochemical signs of infection such as increased ESR, bands, segs, monocytosis etc? Temperature? What is she like to touch; warm? hot? any cutaneous erythema? After four litres of fluid this lady should be pissing like a racehorse but the fact she is not is very concerning; she probably has some massive vascular or renal dysfunction so all her fluid is being lost into the extravascular compartment rather than being retained and pee'd out. I would sedate her a bit with 0.5 mg/kg of ketamine and see if she can tolerate passive ventilation through a tight fitting bag mask with PEEP of 10 cmH2O. If she can great, if not then I am going to RSI her. I'd give 2 g ceftriaxone IV, balance of risk is in favour of giving it.
Kaisu Posted January 14, 2013 Posted January 14, 2013 I'd have to agree with Kiwi here. This lady has bought herself a tube. RSI is the indication here. Sounds like she may be in congestive heart failure. Be that as it may, airway is the priority and management of BP with continued dopamine. I wouldn't waste time with a diversion to a clinic. If you can get a BSL intercept to get extra hands on board without too much delay then go for it. Diesel bolus in the absence of air for definitive care.
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