thinking of emergencies

Your 72 y/o female patient arrives to your level 1 facility after receiving pre-hospital treatment from a BLS crew. She was found down in her home for an unknown length of time. Neighbors called 911 because they haven’t seen her “in a while.”

En route, the patient is GCS 14, BP is 74/55, HR 140, RR 35, shallow. IV access 18g left ankle running 1L NS. The crew is unable to obtain a pulse ox. You have a few minutes to look through the chart and discover an admission 4 months ago for cardiogenic shock/LVEF 8-10%.

The patient arrives and you are the primary RN.

What are your first steps?

The patient’s core temp is 89.2 F (31.7 C). How do you manage this?

What diagnostics can you anticipate?

How do you manage hypotension with a patient history of cardiogenic shock?

Reblog with your ideas!! I will post updates to the case.

2. Use your facility’s warming devices, such as a Bair Hugger and warm blankets. Ask the provider if a Foley temp probe or esophageal temp probe is appropriate. As you are assessing your patient, keep other parts of her body covered and warm.

3. Septic work up labs - CBC, CMP, Lactic Acid, Coags, Blood Cultures, POC glucose. Consider a stat chest x-ray, VBG/ABG. A bedside echo may be indicated.

4. Small amounts of warmed fluids may support the hypotension, but a plan should be made to start pressors (or at least have them ready).

—

After getting the patient undressed, under a warming device, placed on BiPAP, a chest x-ray is obtained and shows bilateral diffuse infiltrates in upper and lower lobes. COVID should be considered. The patient’s HR is down to 110’s, but the blood pressure is not improving. MAP is 53 and dropping. The patient is becoming increasingly agitated. The ABG shows a pH of 7.07, CO2 65, HCO3 28, SpO2 99%. The patient is started on Dobutamine.

5. What is the mechanism of action of dobutamine?

6. Why is dobutamine indicated in this scenario? What is your starting dose? Is there a better option?

7. Should the patient continue on BiPAP? Why or why not?

8. The ICU in your facility is full and you are making plans to keep this patient for several hours. What should you anticipate as an ER RN?

6. In patients with cardiogenic shock due to decompensated heart failure, dobutamine decreases left ventricular end-diastolic pressure and raises blood pressure by increasing cardiac output. The recommended starting dose is 5-7.5 mcg/kg/min. In this case study, norepinephrine was added after the patient went into cardiac arrest while placing a central line.

7. This patient is highly unstable and is in severe respiratory acidosis. She is most likely reaching end of life care. While BiPAP would be the best non-invasive option to blow off CO2, the patient experienced cardiac arrest and was intubated.

8. A common problem nowadays is boarders in the emergency department. ROSC was achieved after one round of Epi per ACLS guidelines. The patient continued to be hypotensive, so an epinephrine drip was added. Managing 3 vasoactive infusions, sedation, and 3 other patients can be challenging. Work with your teammates, charge nurse, provider, and pharmacist to maintain continuity of care. Although it is the emergency department, the patient and family deserves comfort. The patient was showing no signs of discomfort or pain, but a decision was made to add 25-50mcg/hr of Fentanyl. The family made the decision to make the patient DNAR/COT, and after 6 hours boarding in the ED, the patient was transferred to the ICU.

What are your thoughts??

References

Your 72 y/o female patient arrives to your level 1 facility after receiving pre-hospital treatment from a BLS crew. She was found down in her home for an unknown length of time. Neighbors called 911 because they haven’t seen her “in a while.”

En route, the patient is GCS 14, BP is 74/55, HR 140, RR 35, shallow. IV access 18g left ankle running 1L NS. The crew is unable to obtain a pulse ox. You have a few minutes to look through the chart and discover an admission 4 months ago for cardiogenic shock/LVEF 8-10%.

The patient arrives and you are the primary RN.

What are your first steps?

The patient’s core temp is 89.2 F (31.7 C). How do you manage this?

What diagnostics can you anticipate?

How do you manage hypotension with a patient history of cardiogenic shock?

Reblog with your ideas!! I will post updates to the case.

2. Use your facility’s warming devices, such as a Bair Hugger and warm blankets. Ask the provider if a Foley temp probe or esophageal temp probe is appropriate. As you are assessing your patient, keep other parts of her body covered and warm.

3. Septic work up labs - CBC, CMP, Lactic Acid, Coags, Blood Cultures, POC glucose. Consider a stat chest x-ray, VBG/ABG. A bedside echo may be indicated.

4. Small amounts of warmed fluids may support the hypotension, but a plan should be made to start pressors (or at least have them ready).

—

After getting the patient undressed, under a warming device, placed on BiPAP, a chest x-ray is obtained and shows bilateral diffuse infiltrates in upper and lower lobes. COVID should be considered. The patient’s HR is down to 110’s, but the blood pressure is not improving. MAP is 53 and dropping. The patient is becoming increasingly agitated. The ABG shows a pH of 7.07, CO2 65, HCO3 28, SpO2 99%. The patient is started on Dobutamine.

5. What is the mechanism of action of dobutamine?

6. Why is dobutamine indicated in this scenario? What is your starting dose? Is there a better option?

7. Should the patient continue on BiPAP? Why or why not?

8. The ICU in your facility is full and you are making plans to keep this patient for several hours. What should you anticipate as an ER RN?

1. Forgoe the bookstore entirely. Sometimes you can get a good deal on something, usually a rental, but it’s usually going to be considerably more expensive to go through official channels. Outsmart them, babies.

2. Does your syllabus call for edition eight? Get edition seven. Old editions are considered worthless in the buyback trades, so they sell for dirt cheap, no matter how new they are. It’s a gamble, sure; there might be something in edition eight you desperately need, but that never happened to me. However, I’ve only ever pulled this stunt for literature/mass comm/religious studies books, so I don’t know it would work in the sciences.

3. Thriftbooks.com, especially for nonfiction and fiction. Books are usually four or five dollars unless they’re really new, and shipping is 99 cents unless you buy over 10$ in books, in which case shipping is free. 

4. Bigwords.com. It will scan every textbook seller on the internet for the lowest price available, and will do the same to find the highest price when you try to sell your books back at the end of term. Timesaver, lifesaver.

5. In all probability, your library offers a service called interlibrary loan which is included in your tuition. This means if your library doesn’t carry a book you can order it for free from any library nationwide in your library’s network and it will be shipped to you in a number of days. Ask a librarian to show you how to search for materials at your library as well as though interlibrary loan; you’ll need to master this skill soon anyway.  If you get lucky you can just have your required reading shipped to you a week before you need to start reading, then renew vigorously until you no longer need to item. I’m saving over 100$ on a History of Islam class this way.

3. You can find PDF’s of a lot literally by just searching “Book Title” PDF in Google. Also check with people who have previously taken the course to see if they have a PDF version or are willing to sell/lend the book to you.

4. DON’T BUY YOUR BOOKS BEFORE SCHOOL ACTUALLY STARTS. I wait until the 2nd week, after i have been to all of my classes, seen the syllabus, etc. If that syllabus only uses the textbook twice, you bet I’m not buying it. You will find out what you really need by attending the first day of class. 

- That an oral themometer has to go all the way under the tongue in order to be accurate. You wouldn't believe how many people can't deal with a themometer. Or follow basic instructions.

- The difference between the urethra and a vagina in a female and all the functions of each. Grown ass women get their mind blown around me.

- That you physically CANNOT get the flu from the flu shot.

- That their 5 year battle with toe pain is NOT an emergency at 3am on a Tuesday.

- That if you are being seen for nausea/vomiting/abdominal pain, you shouldn't be eating a whole bag of Cheetos in triage. We can see you....?