I thought I should post a reply to the scenario I posted earlier on the Obese, shocky, semiconscious patient. Top five differential Diagnosis: 1- Sepsis/Septic shock 2- Pneumonia- Untreated and contributing to sepsis 3- UTI- Untreated and contributing to sepsis 4- Decubitus Ulcers - Untreated and contributing to sepsis 5- Consider electrolyte abnormality secondary to possible early DKA as well as unrecognized renal failure. See comments below. (Thanks BAYA) Top Five /Keystone treatments 1- Fluids (preferably warm) 500 cc repeated PRN after reassessments. Several liters likely required 2- Vasopressors, preferably epi or nor-epi 3- ETT, via RSI/MAI or Nasal and ETI suction. NOTE: Difficult intubation is likely, so be prepared via bougi, etc. 4- Nebulized Broncheodilators 5- Consider transport to a sepsis center if one is in your area. Discussion Points - CPAP is contra- indicated due to B/P, though if the B/P is increased s/p vasopressors it is a viable option. - Sepsis specialty centers are the next big thing, after stroke/trauma/STEMI centers. Unlike the other specialty center designations there isnt a lot of EMS involvement ...YET...so many providers arnt aware they exist. - Does this patient qualify as a bariatric patient and require special unit response on your local agency protocol? At my agency, technically not, though depending on SIZE (how big around) we still may request their assistance. Unfortunately this patient is too unstable to wait too long. - ETI is indicated due to likely respiratory failure more so than airway failure. This patient will likely develop ARDS secondary to MODS/SIRS secondary to sepsis. he is already in respiratory failure and is not a candidate for less invasive interventions. - The electrolyte imbalance is dubious. The elevated BG may be early DKA (DKA has been reported a slow as 250 mg/dl though typically higher). With no history of IDM, HHNC is more likely and that is typically much much higher blood glucose levels (800 mg/dl or more) .The Hyperglycemia is more likely a stress response to the shock. The risk of renal failure and electrolyte imbalance more real however... due to both shock and the UTI. As another admin pointed out, if you RSI/MAI him you may avoid succs for this reason alone (fear of unrecognized hyperkalemia secondary to unrecognized renal failure) Comments? ---Admin Cole
Posted on: Sat, 02 Nov 2013 19:37:57 +0000
Trending Topics
Recently Viewed Topics
© 2015