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?