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]

More random thoughts:

8 hours ago, Susie2310 said:

You haven't mentioned what the lab values for WBC/differential and lactate were, but I assumed they supported the diagnosis of sepsis.

An elevated lactate would support the sepsis dx, but could also go along with another cause of hypoperfusion, including another cause of shock. I realize more information has been added by the OP now which does sound a bit more like sepsis, but just thought I would mention that anyway.

3 hours ago, Binz said:

This website is super helpful! Thank you.

I think, initially, the MD thought it was a GI infection. The pt had just got back from an international trip

The plot thickens.

In addition to the other possibilities (PE), it raises even more questions. Did this patient really travel internationally (presumably via air travel) with a known EF of 20?? (Not asking you to answer, OP, just thinking out loud).

Quote

The MD came to look at her, ordered zofran, and left. We gave the zofran and then shortly after, she went into cardiac arrest.

....also interesting.

26 minutes ago, marienm, RN, CCRN said:

Right now you're training your "eyes" on patients who make you nervous.

That's right. I would say that is a good learning goal for the OP.

And... @Binz it's great that you are participating here even though we are sharing only bits of info (including anecdotes) and perhaps raising more questions than answers. I don't think anyone here will be able to say what most likely happened.

[Susie2310]

45 minutes ago, marienm, RN, CCRN said:

In my hospital (which I'm not saying is perfect so I'd welcome any input!) this patient would have gotten an ICU consult and probably a cardiology consult while still in the ED. As you've unfortunately seen, this is not the kind of pt you want to keep in the ED...they need a primary team to start managing their case. As the nurse, you can push for this when you know your ED providers. Would it have changed the outcome? Maybe, maybe not; it sounds like she went south fast. Right now you're training your "eyes" on patients who make you nervous. These are the patients you want to be transferring out...get their labs, their stat ABC interventions and antibiotics, their tests, and get them admitted!

I agree completely. I thought about this also.

[Wuzzie]

8 hours ago, JKL33 said:

And... @Binz it's great that you are participating here even though we are sharing only bits of info (including anecdotes) and perhaps raising more questions than answers. I don't think anyone here will be able to say what most likely happened.

Agreed but wanted to add even though most of what we say about this situation is mere speculation these are the kind of discussions that grow our critical thinking ability. Long, long gone are the days when we blindly carried out orders. As nurses we have a responsibility to really understand the why's of the things we are doing. Hopefully we can continue this for while longer so we all have the opportunity to learn from it.

That being said. Are there any nursing students out there who would like to tell us about Norepinephrine and it's use in this situation? Please don't copy and paste, tell us what you know! ?

[Cowboyardee]

Good discussion. Here are a few thoughts to add:

Without more info, labs, etc these things can be impossible to sort out. I'd love to look at an ABG, cxr, bmp, full echo report (not just the EF), etc. That said, sometimes even then you can't effectively determine what really happened. That said, I can brainstorm a few plausible scenarios, given the information we have.

- You were clearly treating the patient for shock. It's less clear whether that shock was cardiogenic, septic, or a mixture of both. If it was both, treatment options present something of a catch 22. If you add enough fluid to treat the distributive shock in sepsis, you run the risk of overloading the heart, worsening the heart failure, and either worsening the cardiogenic element of the shock in this way or else risking flash pulmonary edema, which is very plausible here. On the other hand, if you remove enough fluid to help treat overloaded cardiogenic, the lack of fluid volume can exacerbate the septic/distributive shock. The venous blood return to the heart can tank, the effect of which may be exacerbated by afib, which makes blood flow into the ventricles less efficient. It's a difficult balance to maintain, and a patient who looks stable can easily and quickly tip in the wrong direction. Thisight be even more likely if the patient does things that suddenly redistribute blood volume, like eating (which routes blood flow to the gi tract), standing, walking, etc.

- The lactate wasn't through the roof, but sounds like it was only a one-time check, and more importantly we don't know the patient's abg. Knowing their pH and bicarb would be useful. Pressors/catecholemines don't work well in the presence of a severe acidosis. Was the patient tachypneic? Sometimes, I see a patient on pressors who mostly looks ok except for tachypnea tank very suddenly. Why? Because they were compensating for a very low bicarb by blowing off CO2, maintaining a reasonable pH... until they tire out or build up just a little too much fluid in their lungs. At that point, their CO2 quickly rises, their pH drops like a rock as the metabolic acidosis they've had all along takes over, and their pressors suddenly seem to stop working altogether. The BP tanks and the patient tanks with it.

- The above scenarios don't even consider the real possibility of the patient having any one of a number of sudden complications you might see in this kind of scenario. Is a massive PE possible? Sure. A massive MI? Can't rule it out from the info provided. How was the patient's right heart function? Sudden exacerbation of right heart failure complete with a septal shift that worsens the already-insufficient left ventricular function can look something like what the OP described.

Knowing a little more about exactly what the heart rhythm looked like, the breathing pattern, the labs, etc would all help to make a more informed guess. But these things often wind up being a bit of a mystery, even with all the information fully available.

[Susie2310]

I know the OP does not know the triage information but this would be important to consider also. I am not asking the OP to provide any more information about this in view of patient privacy/confidentiality, but just for the purpose of our case study I assumed the patient arrived on foot/private vehicle at the ED and not by ambulance. In order to more fully understand what happened with the patient we would also need to consider what their chief complaint was; their presenting symptoms; their vital signs at triage; previous medical history, age, current home medications, allergies; and what their ESI classification was and how long the patient waited in the waiting room before being taken to a bed.

Other questions that come to mind are how promptly the patient was assessed and seen by the physician, and how quickly treatment started. How soon were labs drawn and diagnostic tests done? What was the patient's temperature and what were their BP, heart rate/rhythm, SpO2, and respiratory rate on the monitor at the start of care and during their time in the ED until they arrested? What was the plan for the patient in the ED? Was there a plan to admit them as an inpatient?

There are many parts to the situation and without having been present and having knowledge of the whole situation and all the events that unfolded it is not really possible in my opinion to conclude whether the patient's arresting could have been avoided.

[murseman24, MSN, CRNA]

I second the orthostatic hypotension. n/v was a major clue. I don't think there was any way you could have predicted that would happen though. The patient sounded fairly stable as you described her.

[RNDarling]

A less likely option, but just for the heck of it, perhaps the Zofran threw her into a fatal rhythm r/t her history of arrythmias/HF.

[Kooky Korky, BSN, RN]

On 12/10/2019 at 1:29 PM, Pixie.RN said:

We referred to it as "the deathpoop."

Kind of like when Carlo had to answer for Santino and he and Luca Brasi were both garrotted to death and their bowels let loose while they were in their death throes? The move doesn't say it but the book does. Not really joking here, it really does say it.

Might have happened to Pauli, too, when he was murdered.

[Cowboyardee]

On 12/10/2019 at 7:41 PM, Binz said:

I wish I had more info. I didn't get a chance to read the triage and we didn't admit her but the pt presented with fever, respiratory retractions, hypotension and tachycardia. She had gone out of the country shortly before, so the MD suspected GI infection and wanted a stool sample but based on the CXR, I think she determined it was PNA and ordered 20 mg lasix and antibiotics. A previous echo revealed an EF of 20%. Pt had a history of HF and afib and I think that was it. I remember knowing the WBC was elevated and i think the lactate was 2.5. She said she needed to "poop" so we sat her at the bedside. Her MAP had been good. But then she said he was nauseous and she was diaphoretic so we lied her back down. Checked her BG. I went to find the MD who told me to give d50, which we did. The MD came to look at her, ordered zofran, and left. We gave the zofran and then shortly after, she went into cardiac arrest. She had been super pleasant and was laughing and responsive so I'm trying to pinpoint the cause, I guess.

Laying her back down was a good call. One major thing to keep in mind for next time though: if a patient in shock or suspected shock suddenly complains of nausea and becomes sweaty, those can be signs of severe hypoperfusion. Checking the blood sugar is ok - many things can cause sweating, and hypoglycemia is one of em - but first check and stabilize the blood pressure. Cold, clammy skin would be another common finding in this scenario, as would dizziness, blurry vision, or maybe shortness of breath. The sweating was possibly the best clue you had that the patient was suddenly in very serious trouble.

Again, you're a new nurse and you did fine, so this is not meant to criticize.

[2BS Nurse, BSN]

If this were my parent, I would be thinking "I'm glad she got to have a meal before she passed". It sounds like this person was very sick.

Something that has always stuck with me said by an ACLS instructor: "You don't get to choose whether a patient lives or dies. You can run a perfect code and the patient may die. You can screw everything up and the patient may live".

[VNurse30]

Even though pt had a blood glucose of 60, I would never have given her anything to eat. The MD handled that issue with the IV dextrose.

Never feed an unstable patient in the ED. You never know who may need to go to the OR or cath lab stat. Or who may go south and need intubation.

Talk with the ICU nurses and run the scenario by them. They may have input from a different perspective. And don't beat yourself up because it sounds like she was just super sick.

[SquatsNScrubs, BSN, RN]

New(er) cardiac ICU nurse here. Some food for thought:

1) It sounds like your pt never made it to the CT scanner. Perhaps massive PE? AAA rupture? Cardiac tamponade? These conditions are difficult, if not impossible, to diagnose only with a CXR.

2) Zofran can prolong the QT interval, potentially leading to tachyarrhythmias (vtach, torsades). Perhaps this was a contributing factor?

3) I frequently get my cardiac surgery patients out of bed and into a chair on pressors, most commonly low-dose neo or levophed. This is not an uncommon practice in the ICU.

4) To reiterate what others have said, never feed an ED pt on pressors!

5) Always ask yourself, “is my patient peeing, perfusing, AND mentating?” If not 3/3, consider sepsis as a possible cause.

And finally, be kind to yourself. Seek critical incident debriefing if your facility offers it. This case has certainly been a learning opportunity for you!