Is E-coli this rapid???

racing-mom4, BSN, RN · Mar 1, 2008

all I can say is WOW, and I hope someone who can explain more will post. Very scary, and very sad. No one should die from a rare hamburger.

CraigB-RN, MSN, RN · Mar 1, 2008

50 year old man presents to the ER with less than 24 hour history of blood in stools, fever, chills. Ate some raw hamburger 2 days prior. Upon bringing the gentlman back to ER, he becomes blue.. head, ears, neck, however his extremities are mottled. Sats in the eighties. Put the gentlman on a non-rebreather, sats increased to low 90's. met. acidosis white count 0.5, platelets 15 thousand. BUN 145, creatinine 4.5, Dyspnea, rates upper 40's. hypotensive with systolic in the 80's to 90's. hr 120's at rest. He died in the helicopter. Doctor thought e-colli with hemolytic uremic syndrome. He had two large bore iv's with fluids infusing, protective isolation, iv antibiotics, he got bicarb and d5w for the acidosis.
And about the Sat...We are a small facility, with the patient being cyanotic, with mottled extremities increased RR, should he have been intubated sooner? He was able to speak to us throughout his stay, however he never did pink up. and how accurate is the sat, what other way could I have got accurate sat without intubating, I can't think of one. can you think of something I should have done differently that would have made a difference? helicoptor crew called the receiving MD who also did not want to intubate at that point.

Your Sat is fine, don't worry about it. In this case your clinical presentation showed a critical patient. Hyptensive and definitly hypoperfusing. Intubating won't give you more accurate sats, it may help oxygenate the patient better hence better sats. Intubation isn't going to help his hypopervision any, just make sure that there is as much O2 onboard as possible. Sounds like the appropriate care was done, though you didn't mention any pressors (after you fill the tank with fluids). If transport wasn't an issue and you had ICU right there, CVP might have been helpfull in evaluation of your treatment.

http://www.about-hus.com/

b eyes · Mar 1, 2008

Your Sat is fine, don't worry about it. In this case your clinical presentation showed a critical patient. Hyptensive and definitly hypoperfusing. Intubating won't give you more accurate sats, it may help oxygenate the patient better hence better sats. Intubation isn't going to help his hypopervision any, just make sure that there is as much O2 onboard as possible. Sounds like the appropriate care was done, though you didn't mention any pressors (after you fill the tank with fluids). If transport wasn't an issue and you had ICU right there, CVP might have been helpfull in evaluation of your treatment.
http://www.about-hus.com/

Gosh, that was a great article to read and explained the patient to a T. makes me wonder if he could have been saved. With HUS, what is the treatment, I mean how could we have stopped that deadly cascade of events going on inside his body??? Have you ever seen this? What did you do. sorry for bombarding you with questions, i just have so many! The article stated the E-colli toxin with HUS is a concern for bioterrorism. Scary thought....

We are a very small facility(critical access 25 med surg, 4 bed ICU 4 bed OB 6 bed ER) and althugh we do have CVP in our ICU, he definitely needed to be transported to a higher level of care where they have a profound infectious medicine department, which is where he was going.

B eyes

CraigB-RN, MSN, RN · Mar 2, 2008

Maybe and that is a BIG maybe, he might have done better if he showed up at the other hospital, but I doubt it. Sepsis is a process that is best caught early. To me from the information you gave, he was already past that point when he showed up on your doorstep.

Sometimes people die, and there is nothing you can do about it. It happens in small facilities and in large ones. In each there is a process to go through, both personally and collectivly.

1. Review the case

2. Did I reconize how sick the patient was

3. Did I start treatment appropriatly and quickly enough

4. What could I have done better

You recognized the hypoperfusion and the hypoxia and treated them both. Made the transport arrangements, filled out the EMTALA paperwork, made a nurse to nurse report and verified that that hospital could accept the patient, your looking here to see if you could do anything better. Looks to me like your getting the job done.

If your looking for more information, I'd google "surving Sepsis" and start there. Put together a poster for what you've learned about e-coli and what it can do to the body for your co-workers to learn from your research also. Even put out a public service announcement to the community newspaper about the risks of eating raw meet.

Small and rural doesn't mean substandard care, sounds like you were getting the job done.

bluesky, BSN, RN · Mar 2, 2008

I mean you know his kidneys were gone, his platelets depleted, hypotensive and motled. This man was in an advanced stage of an aggressive septic process. It sounds like he was in MODS or at least starting to be. You did everything you could.

Here is an excellent e-medecine article on sepsis...

http://www.emedicine.com/MED/topic2101.htm

I mean OK let's say he had landed plum in the middle of a high acuity teaching hospital with CVVH and specialists galore within immediate reach. Even then he was looking at about a 50% chance at best.

But then again you could have been a nurse somewhere in a rural clinic in Nicaragua and he could have been a 6 month old baby and you might not even have basic equipment to work with. That baby would have died in your arms septic. Life is full of what ifs that are completely beyond our control.

I truly wish I could develop a full-proof therapeutically sound method of making sense of it all. There are only 2 things I can say. 1) Becoming numb and jaded is not healthy and won't work. 2) you can either run away from the pain of these experiences or use it as a reminder of both your greatness (your all-out effort, your empathy for this man and his family, your rigor with yourself and your team) AND your limitations as a human being.

Hugs :heartbeat

LiverpoolJane · Mar 2, 2008

Unfortunatley with the best medical and nursing care in the world sometimes people die of this - attached is a link to a BBC news site with some statistics.

I have nursed a number of patients with HUS and thankfully with plasma exchange & RRT they have pulled through - but we wouldn't see the ones that end up in ITU.

http://news.bbc.co.uk/1/hi/health/medical_notes/83169.stm

KatieBell · Mar 2, 2008

Yes, ecoli is that rapid, but its the septic cascade causing more problems than the actual e-coli itself. When I was a new grad, we had a patient who was very similar in our ICU. I was not taking care of her, but even with CVVHD, and all the pressors we could use,this patient also died. She was a young person, so it was very shocking to all.

Dinith88 · Mar 3, 2008

This may be long, but here goes. I am just having a hard time understanding the pathophysiology with e-coli and hemolytic uremic syndrome. And I feel like I missed the boat somewhere because this man died.
50 year old man presents to the ER with less than 24 hour history of blood in stools, fever, chills. Ate some raw hamburger 2 days prior. Upon bringing the gentlman back to ER, he becomes blue.. head, ears, neck, however his extremities are mottled. Sats in the eighties. Put the gentlman on a non-rebreather, sats increased to low 90's. met. acidosis white count 0.5, platelets 15 thousand. BUN 145, creatinine 4.5, Dyspnea, rates upper 40's. hypotensive with systolic in the 80's to 90's. hr 120's at rest. He died in the helicopter. Doctor thought e-colli with hemolytic uremic syndrome. He had two large bore iv's with fluids infusing, protective isolation, iv antibiotics, he got bicarb and d5w for the acidosis.
Such a horrible sad story, never thought he would die before he reached a larger facility. I mean he looked like he could die, just never thought it would happen ten minutes after he left the facility. And about the Sat...We are a small facility, with the patient being cyanotic, with mottled extremities increased RR, should he have been intubated sooner? He was able to speak to us throughout his stay, however he never did pink up. and how accurate is the sat, what other way could I have got accurate sat without intubating, I can't think of one. can you think of something I should have done differently that would have made a difference? helicoptor crew called the receiving MD who also did not want to intubate at that point.
Cause of death was sepsis per the coroner.
bless his family..wife and two kids. I am just so upset over this...
b eyes

Next time look at the ABG's if you're not comfortable with the pulse-oximeter saturation...

And like others have said you personally couldnt have done anything to change this persons outcome. MODS from Toxic-shock/septic shock can be rapid given the right bug (the 'hemolytic uremic syndrome' producing strain of e coli is as good a guess as any)

and the guy probably sat at home toxic for WAY longer than he should have before coming in...