Code Blue: Just Trying Figure Out What Happened?

[Binz]

I recently started in the ED. I had a patient who came in with Pnuemonia and sepsis. Was on a norepinephrine drip to maintain a MAP>65. Her BP went up, MAP was 80ish. We had to get a stool sample, so me and my preceptor sat her up at the bedside. She started feeling nauseous, felt like she was going to vomit, was very sweaty, and then it's like the life left her eyes. She passed out, became unresponsive. We activated a code and she had to be intubated. I'm just trying to understand how we went from MAP>80, pt talking, eating to intubating. What should I have done/not done? Thank you.

[JKL33]

54 minutes ago, ruby_jane said:

OP - she was septic.

It isn't so clear-cut in this case. It sounds like there was other stuff, and maybe other stuff more likely as the primary problem. I have no doubt she triggered the sepsis protocol though.

[Wuzzie]

So for giggles and learning let's start a list of differential diagnoses/reason for code. Copy and paste previous responses if you reply. I'll start:

1. HF-incompatible with life EF when upright.

[JKL33]

Basically agree. HF; I would guess a delicate fluid volume status, i.e. intravascular volume depletion and related effects, or not an actual volume overload. Pulmonary edema 2* pneumonia superimposed on CHF, or d/t AF + CHF. ?? Possible recommend NIPPV...?

I think she was imminently pre-arrest when 1) diaphoretic (attributed to BS) 2) felt like vomiting (hence the reason for only eating one bite) 3) urge to defecate

Curious about V/S and labs. Everything triggers the preliminary sepsis warning, including a deconditioned young adult with a sore throat walking from waiting room to treatment room. That's one thing every nurse should understand.

[Susie2310]

12 hours ago, Binz said:

I believe it was cardiac. She had a history of Afib, and HF with an EF 20%, and was in afib during the code. I think based on the CXR, the MD determined it was pnuemonia and we had given her lasix 20mg and antibiotics about 30 minutes before. Not on any IV fluids, just the drip. She was AOx4, on 4 L NC 95% SpO2, breathing with retractions, but super pleasant. She started getting sweaty, so we checked her blood sugar and it was 60 so the MD said give D50 and then we sat her up because she said she needed to use the restroom, and then she went to into cardiac (?) arrest. She was at 0.05 on the drip. At the start of our shift, her BP was like 70s/50s, so we increased it to 0.07 I think and I guess she responded pretty quickly. But that's been my frustration with starting drips in ED. There are usually no parameters. Nurses seem like they're just winging it. Also, are pt's not allowed to eat while on levo (sincerely asking...there is so much I don't know!!)? She only was able to eat one bite of a sandwich and couldn't really tolerate it. Please help. Thank you.

From the information you've given so far I'm not seeing a reason to discount the MD's diagnosis of pneumonia and sepsis as I recall has been previously suggested (you said the MD had reviewed the CXR and was able to make a determination of pneumonia) and sepsis. You haven't mentioned what the lab values for WBC/differential and lactate were, but I assumed they supported the diagnosis of sepsis. You said the patient had heart problems with a reduced ejection fraction and a history of atrial fibrillation (which can lead to cardiac arrest) and then became hypoglycemic, which can contribute to cardiac arrest. You also mentioned the pressor wasn't being titrated to a specific MAP. As I see it, this entire combination of medical problems on top of pneumonia/sepsis would have been enough to lead to the patient experiencing a lethal arrhythmia and going into cardiac arrest.

[JKL33]

17 minutes ago, Susie2310 said:

From the information you've given so far I'm not seeing a reason to discount the MD's diagnosis of pneumonia and sepsis as I recall has been previously suggested (you said the MD had reviewed the CXR and was able to make a determination of pneumonia) and sepsis. You haven't mentioned what the lab values for WBC/differential and lactate were, but I assumed they supported the diagnosis of sepsis. You said the patient had heart problems with a reduced ejection fraction and a history of atrial fibrillation (which can lead to cardiac arrest) and then became hypoglycemic, which can contribute to cardiac arrest. You also mentioned the pressor wasn't being titrated to a specific MAP. As I see it, this entire combination of medical problems on top of pneumonia/sepsis would have been enough to lead to the patient experiencing a lethal arrhythmia and going into cardiac arrest.

Except that for some reason they gave some lasix and not fluid resuscitation. No this is not straight-forward sepsis.

[Susie2310]

1 minute ago, JKL33 said:

Except that for some reason they gave some lasix and not fluid resuscitation. No this is not straight-forward sepsis.

I was thinking that this may have been because of the patient's ejection fraction. It appears to me they used pressors to restore the MAP initially instead of fluid resuscitation.

[Wuzzie]

4 minutes ago, Susie2310 said:

I was thinking that this may have been because of the patient's ejection fraction. It appears to me they used pressors to restore the MAP initially instead of fluid resuscitation.

What are your thoughts on the Lasix then?

[JKL33]

2 minutes ago, Susie2310 said:

It appears to me they used pressors to restore the MAP initially instead of fluid resuscitation.

Which is not how that is supposed to be done if one's premise is sepsis.

I'm not saying lasix doesn't ever fit anywhere into this actual patient scenario at some point along the way because I do think the fluid balance is probably complicated for this patient, but it isn't a first line of treatment for septic shock; that's what I meant.

[Susie2310]

6 minutes ago, Wuzzie said:

What are your thoughts on the Lasix then?

I was thinking that the patient had presented as fluid overloaded and/or in heart failure.

[Wuzzie]

1 minute ago, Susie2310 said:

I was thinking that the patient had presented as fluid overloaded.

Well, it would be interesting to know what the presenting complaint and assessment was as Lasix is not first line in treating pneumonia or sepsis.

[Susie2310]

14 minutes ago, Wuzzie said:

Well, it would be interesting to know what the presenting complaint and assessment was as Lasix is not first line in treating pneumonia or sepsis.

I agree. The patient's cardiac history led me to suspect that cardiac problems (maybe possibly renal problems also) were being taken into account in the treatment for pneumonia/sepsis. We need to know more about their medical history also.

[Lunah, MSN, RN]

6 hours ago, JKL33 said:

Anecdotally confirmed. My theory/observation is a little different, though, I think the need to defecate in the first place can be ominous in these scenarios, not just that an ill person experiences basic orthostatic hypotension or vasovagals when getting up or while voiding.

We referred to it as "the deathpoop."