Arctickat Posted January 11, 2013 Share Posted January 11, 2013 I'm jumping on the Kiwi bandwagon. I'd almost...not quite, but almost consider CPAP. Monitor lung sounds closely, but with the increased temp and dercreased BP, I'd consider a norepi and vancomycin infusion. Any chance you can call ahead to the receiving hospital and ask for the labs from them? That info would really help right now. 1 Link to comment Share on other sites More sharing options...
Kiwiology Posted January 11, 2013 Share Posted January 11, 2013 I'm jumping on the Kiwi bandwagon Welcome onboard, keep your hands and feet inside the vehicle at all times, tray table folded upright, no flash photography and please, listen to your tour guide, even if he is destroyed on valiumz No CPAP here in New Zed (sigh!) so best we can do is a tight fitting face mask from a BVM and PEEP of 10 or 15 cmH2O Link to comment Share on other sites More sharing options...
Arctickat Posted January 11, 2013 Share Posted January 11, 2013 But would we want any positive airway pressure if we can't rule out a pneumo? I'm not really comfortable providing any treatments based on what someone else told me the X-ray or Labs said. Problem is, I suspect sepsis and a likely pulmonary effusion as a result, but I can't confirm it. Her temp is just below our threshold, her heart rate isn't high enough to qualify, but with beta blockers it wouldn't go up now would it....Otherwise she fits the criteria. Bilateral IVs, titrated to maintain her systolic between 90 -100. If I can't get the BP up I'll consult with my doc to start the norEpi, if the temp goes up any higher I'll also start the antibiotics provided she has no allergies. Acetaminophen 325 PO if the temp exceeds 40C. Continue monitoring lung sounds closely in case a pneumo develops. Oh, forgot my new portable ultrasound. I'll check her over with that. Link to comment Share on other sites More sharing options...
mobey Posted January 12, 2013 Author Share Posted January 12, 2013 Ahhh, as usual Arctic is on the right train! Safe bet to be weary of pneumo... However if you look at how this has progressed over 3 days, with a crackly chest, CPAP might be safe after all! Hell if we can't oxygenate her, pneumo or not her outcome is dismal. Prior to CPAP that BP should be stabilized. CPAP will result in the loss of the bellows pump of the chest and therefore decrease preload. I know I am preaching to the quire, but others may be reading this thread. No Norepi, but you got Dopamine onboard. 2lt of fluid in, and no change in Bp, and no urine output. 1 Link to comment Share on other sites More sharing options...
Arctickat Posted January 12, 2013 Share Posted January 12, 2013 (edited) Dopamine will have to do then. Starting at 2mcg I'm curious as to why you think it could be pericarditis? Does the patient have a c/o CP or just the low sat (which isn't all that low to be honest). It's a running joke, I guess pericarditis for everything....one day I'll be right. Edited January 12, 2013 by Arctickat 1 Link to comment Share on other sites More sharing options...
island emt Posted January 12, 2013 Share Posted January 12, 2013 Trevor : i had a Pt this week that ended up being diagnosed with :::: Wait for it:::::::: Pericarditus !!!! chest pain worsening over the course of several days. Link to comment Share on other sites More sharing options...
Arctickat Posted January 12, 2013 Share Posted January 12, 2013 oooooooo, got a 12 lead? Link to comment Share on other sites More sharing options...
ChaseZ Posted January 12, 2013 Share Posted January 12, 2013 I definitely agree with Harry that her symps are suggestive (but not specific for) PE however I am unsure if a PE would "suddenly develop" out of thin air without some significant underlying pathology such as a DVT. 3 days of bed rest and no DVT prophylaxis is plenty of time to develop a new clot. Link to comment Share on other sites More sharing options...
paramedicmike Posted January 12, 2013 Share Posted January 12, 2013 It's called Virchow's Triad. Venous stasis, hypercoagulable state and endothelial injury are three things that are commonly thought to contribute to thrombus formation. She's had a few days in bed. There's the venous stasis. She's had, conceivably, some sort of vascular damage with her fall. There's the endothelial injury. Hypercoagulable state? This depends on other factors not entirely clear. Is a PE what's going on here? It's certainly on the list of differentials. Link to comment Share on other sites More sharing options...
fakingpatience Posted January 12, 2013 Share Posted January 12, 2013 Sorry if I missed it, but hows her mental status? Is she getting "tired of breathing"? I agree, after all the fluid challenges, along with no urine output, she needs a pressure agent now. 1 Link to comment Share on other sites More sharing options...
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