ICU hold in ED, baffeled

  1. 0
    ER RN here,
    I had an ICU pt who became a HOLD-over in the ED this AM. His only history was throat cancer with tumor removal surgery and hx of pneumonia. He came in to ED presenting like a pt who was septic, CXR revealed b/l lower lobe pneumonia. The pt was 90/60, when asked said his BP was always low and he didn't seem surprised by the numbers we gave him. The pt was febrile 103 R, lactate was 1.9. The pt had a spo2 of <70 on RA and 82 on 4lnc, initially we were under the impression he was a COPD'r but found out later he was not. The pt did not appear in respiratory distress and denied sob, he was not cyanotic. We threw a NRB on him and spo2 came up to 95%.The pt had dull CP, relieved with dilaudid and EKG was normal. ABG revealed co2-46, ph 7.36, hco3 24, and pao2- 46!.... All said and done after he was admitted and I was assuming his care, carrying out orders along with the 3 other ED pts I had, his BPs stayed consistent high 80s to low 90s systolic. Since I had received the pt 4 hours earlier, he was on his 4th liter bolus and had a great urine output. Still no increase in BP. His lungs clear, other then decreased lower lobe where pneumonia was. The order stated give 3.5L, so I called the hospitalist who wrote orders and he made me call the on call attending because he did not want to make any IV-pressor decisions without the true attending knowing, since pt would need a central line. THe on call Dr gave an order for ns @ 75cc/hr for 1-2 hours and if no improvement to call back and for re-eval...its harder for the MD behind the phone to make calls like this, that's what the house officer is there for and he shrugged me off. Meanwhile, pt asymptomatic. Typically this BP would not scare me too much, considering the pt had good color and was asymptomatic and was holding his pressure consistently, and he mentioned he ran low BPs to begin with. his MAP stayed above 60 consistently.
    My shift ended...I gave report...recieving RN seemed frustrated that I had not done more, other then contact the Dr. and give IVF now at such slow rate. She was worried the pt had poor perfusion and was septic, although his lactate and wbc were fine...does anyone have insight to this case and what the ICU RN would have done, should I have been more aggressive and demanded IV pressors sooner? Thanks!.
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  3. 5 Comments so far...

  4. 1
    The lack of pressors is not what I would have questioned considering his pressure was still stable...I would have question why not intubated with pO2 of 46--the same as his pCO2, on a non-rebreather...however, you can't intubate by yourself and it sounds as though the MD's were kept updated.
    resumecpr likes this.
  5. 0
    Quote from registeredin06
    The lack of pressors is not what I would have questioned considering his pressure was still stable...I would have question why not intubated with pO2 of 46--the same as his pCO2, on a non-rebreather...however, you can't intubate by yourself and it sounds as though the MD's were kept updated.

    highly doubt his pao2 was 46 on a NRB with a o2 sat of 95%..I have seen it however usually it is inaccurate....they proabably obtained the ABG while on RA and NOT on the NRB....besides....intubation does not appear to be clinically warranted....pt does not have SOB, not in distress, only a very low PaO2 which may have been because the gas was drawn prior to any intervention...and at the very least i would try bipap first.

    Also with his temp being extremely high his PaO2 will be lower due to his DO2....the temp is burning it up....Fluids were correct and 4 liters may not have been enough. CVP would have been pretty helpful in this situation....it was said that UO was great...how great and over how long? I think the main reason why I would have been upset is that you obtained an order for minimal fluids when obviously the patient required more fluids or even a pressor and you didn't mention anything about questioning that order...that is where we needed to be a bit more agressive.

    Would have questioned his ability to provide adequate answers especially given his low PaO2, bp and the confusion about his COPD status vs NON COPD... would not have assumed his normal bp to be low...

    Only other thing i can think of is abx...hope you hung some!!!
  6. 1
    I wonder if that ABG was actually a venous stick and not arterial.
    resumecpr likes this.
  7. 0
    Quote from dhammo01
    I wonder if that ABG was actually a venous stick and not arterial.

    Not a bad thought however I honestly would doubt his SvO2 was 46...that is pretty low...I guess it could be as his temp was high and if he wasn't oxygenating very well....maybe...however I would expect him to be a lot more ill if was an actual svo2...more acidotic as cells not getting o2....we just started using the new SvO2 TLC's for septic patient's.....they work ok, still trying to work out the kinks..
  8. 0
    Quote from roses1130j
    ER RN here,
    I had an ICU pt who became a HOLD-over in the ED this AM. His only history was throat cancer with tumor removal surgery and hx of pneumonia. He came in to ED presenting like a pt who was septic, CXR revealed b/l lower lobe pneumonia. The pt was 90/60, when asked said his BP was always low and he didn't seem surprised by the numbers we gave him. The pt was febrile 103 R, lactate was 1.9. The pt had a spo2 of <70 on RA and 82 on 4lnc, initially we were under the impression he was a COPD'r but found out later he was not. The pt did not appear in respiratory distress and denied sob, he was not cyanotic. We threw a NRB on him and spo2 came up to 95%.The pt had dull CP, relieved with dilaudid and EKG was normal. ABG revealed co2-46, ph 7.36, hco3 24, and pao2- 46!.... All said and done after he was admitted and I was assuming his care, carrying out orders along with the 3 other ED pts I had, his BPs stayed consistent high 80s to low 90s systolic. Since I had received the pt 4 hours earlier, he was on his 4th liter bolus and had a great urine output. Still no increase in BP. His lungs clear, other then decreased lower lobe where pneumonia was. The order stated give 3.5L, so I called the hospitalist who wrote orders and he made me call the on call attending because he did not want to make any IV-pressor decisions without the true attending knowing, since pt would need a central line. THe on call Dr gave an order for ns @ 75cc/hr for 1-2 hours and if no improvement to call back and for re-eval...its harder for the MD behind the phone to make calls like this, that's what the house officer is there for and he shrugged me off. Meanwhile, pt asymptomatic. Typically this BP would not scare me too much, considering the pt had good color and was asymptomatic and was holding his pressure consistently, and he mentioned he ran low BPs to begin with. his MAP stayed above 60 consistently.
    My shift ended...I gave report...recieving RN seemed frustrated that I had not done more, other then contact the Dr. and give IVF now at such slow rate. She was worried the pt had poor perfusion and was septic, although his lactate and wbc were fine...does anyone have insight to this case and what the ICU RN would have done, should I have been more aggressive and demanded IV pressors sooner? Thanks!.
    we, unfortunately, hold some of our SCU/CCU patients in the ED for HOURS as well. Sounds as though you did what you needed to do for that patient - of course they're a ICU patient, so you wouldn't expect them to turn around and have a vast improvement in the ED. Bp staying low, sats low on RA and low levels of oxygen.... sounds like it was an appropriate admission location and wanting to see an improvement isn't a realistic expectation in the ED. That's why they're admitted.

    I had a CCU admission for over EIGHT HOURS held in the ED on a patient with a multitude of problems, but #1 being a K of 1.4 with ectopic beats and lots of irritability. The CCU doc wanted to decide whether or not to take that patient once the K was above 3!!! ARE you KIDDING me?! That's why they're admitted! Meanwhile, I have to take care of a hypoglycemic patient with BS in the 20's and 2 CP patients.... seriously. I nearly burst a forehead vein over the stupidity of it all. ED's get the arse end of everything with no one considering what we deal with....


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