Multiple choice here, and, hopefully a discussion. If you are a know it all, please let us all know (so we can try to set you straight, and you can tell us why you are right )
A pt comes into the ER C/O SOB, well known to you as a drug abusing CHF pt with very poor coping skills, on very high doses of home Lasix. States she is out of Lasix. Lower extremities with 4 plus pitting edema, crackles in lungs, sats in low to mid 90s, RR 24. You've established IV access and have obtained blood, and Dr has ordered IV lasix and labs.
What should be your first action?
1)Order a urine drug screen
2)Monitor pt while awaiting lab results
3)Give Lasix and bring BSC
4) Counsel pt on better adherence to home medication routine.
I'm kind of bummed it wasn't a trick question... I was hoping it was going to be a tropical illness, or three different things happening all at once (CHF exac, CKD, and PNA at the same time!).
In practice I do the "when you hear hoof beats, think horses not zebras" thing. Online I'm totally looking for zebras.
Still might be. We haven't gotten much info yet. Clearly there's a reason he wanted to share this case.
4+ pitting edema, crackles, RR 24, c/o SOB....and discharge ready? You must have a high readmission rate!
The national average for CHF 30-day readmissions is around 24%, ours is around 7%, which is mainly due to intensive outpatient management, but reading through this thread it might also be partly due to not admitting patients that don't need to be admitted.
4+ pitting edema does not directly represent intravascular volume overload and is often chronic and certainly does not require emergent intervention. A RR of 24 in a patient prone to anxiety (drug abuser with poor coping skills) is pretty darn good, I'd be more worried if it was 16. "SOB" is not particularly useful as an objective assessment, it's just a trigger to do an objective assessment. And requiring no supplemental O2 to boot, it's certainly not something I would see as requiring an override of our basic process due to an impending crash, and not even likely requiring admission; check the CXR, check the labs, catch 'em up with some IV lasix, give them a script or enough PO lasix to tide them over and their on their way (with an outpatient follow up in the next day or two).
Multiple choice here, and, hopefully a discussion. If you are a know it all, please let us all know (so we can try to set you straight, and you can tell us why you are right )
A pt comes into the ER C/O SOB, well known to you as a drug abusing CHF pt with very poor coping skills, on very high doses of home Lasix. States she is out of Lasix. Lower extremities with 4 plus pitting edema, crackles in lungs, sats in low to mid 90s, RR 24. You've established IV access and have obtained blood, and Dr has ordered IV lasix and labs.
What should be your first action?
1)Order a urine drug screen
2)Monitor pt while awaiting lab results
3)Give Lasix and bring BSC
4) Counsel pt on better adherence to home medication routine.
I would go with 3. If they are in the ER and have a line it means that labs have probably been drawn already. They are in distress secondary to fluid overload. Lasix will take care of that.
Large amounts of Lasix at home....how much Lasix is the person taking? Or not taking?
Hopefully, when the patient was discharged, a follow up with MD would include some sort of case management. I could see a consult with a nephrologist, I could also see respiratory seeing this patient--if she smokes (or smokes/snorts her drugs) is it adding to the exacerbation I would think as far as lung function.
Sometimes "I ran out" is a convenient excuse for "I don't feel like peeing all day".
And the pp were excellent in the areas that they covered. I also am of the thinking that if this patient takes tons of Lasix at home, that there's a kidney involvement, she's not taking it.....plus there's the K thought...if it is already at rock bottom, you would need to know this. Before she starts showing EKG changes.
But I would think that another area to think about (ie: case management) is any services that can be set up for this patient. You did not mention how old this person is. Elder services? Home health?
Joint Commission has lots to say about referrals from ER's. And although that is sometimes an unrealistic expectation in a busy ED, it is worth thinking about if you have a frequent visitor with the same story and underlying comorbidities.
Think Maslow's hierarchy of needs. This is a breathing and circulation issue that can threaten her life, so addressing it comes ahead of all else. Give the Lasix. The rest is distraction, and the issues can be sorted out later.
Slap on tele, monitor and assess patient, wait for lab results, give lasix if lab indicates and do an echo. Patient is in low 90s to mid 90s in saturation, that's not too bad, give 2 L O2 via nc if needed. See what the lab shows and check ejection fraction. And I wouldn't put in a foley just for I&O because of cauti, I mean if she's mobile, she can use the commode with a hat. Bladder scan her too if she's showing signs of retention.
If orders are in, the pt was already on the monitor, and presumably EKG was done
.
An echo in the ER for a pt with CHF, in apparent exacerbation, who states they hadn't taken lasix? Maybe somewhere, but not in my world.
As far as waiting for labs- By the time the labs get labeled, sent, resulted, etc.... Unfortunately, an hour is not unusual for me.
Somebody else mentioned a right sided infarct which is fluid dependent- Sure it's a possibility. And, assuming its a NSTEMI, could take 6 hours to rule out. Could be a whole lot of even more obscure things. Pop in a second line, have some fluid ready. The portable CXR is going to confirm the CHF before labs or anything else is done anyway.
I think there is a lot of cool critical thinking here- especially if we are in a theoretical ER with unlimited staffing, resources, docs who don't mind being ignored, etc.
But- in I am heading out for the first of 3 back to back 12s. I'll probably see this patient in my real ER with slow labs, limied resources, and smart docs. If I think we are missing something, I'll check in with the doc. Other than that, I am going to give the lasix, get a bedside commode, and hope to get the pt out the door as soon as is safe. If I have the time- and I might- I will try to get the reason for the non-compliance. Hell, maybe I can even connect the pt with a community service that could prevent another visi or admission.
I couldn't even figure out what BSC was until about 4 posts in.
I still haven't figured out what BSC stands for. Anyone want to clue me in? I am reading this for education for me not because I have anything meaningful to contribute at this point.
blondy2061h, MSN, RN
1 Article; 4,094 Posts
Still might be. We haven't gotten much info yet. Clearly there's a reason he wanted to share this case.