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This would fall under EMTALA in the US. If the patient is being evaluated in the ER because of a change during transport that's one thing. Otherwise, the patient has to be accepted into the receiving hospital with a bed available for this specific patient. With that, as ERDoc mentioned, the patient has to go to an equal or higher level of care. If there's no ICU bed available, or if they can't tell me exactly where this patient is going in the receiving hospital aside from "going to the ER", then I wouldn't accept the transport.

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<<Vignette clipped >>

This fellow seems a little sick. He has septic shock. By definition:

SIRS : [2 or more of (i) HR > 90, (ii) RR>20 or pCO2 < 32 mmHg, (iii) T > 38 or < 26, (iv) leukocytosis or leukopenia or bandemia]

Sepsis: SIRS + identified source of infection [pneumonia complicated by secondary ? nosocomial influenza, possibly H1N1].

Septic shock: sepsis + lactemia (lactate > 4mM) or hypotension.


He also may not have the best baseline cardiovascular status [prior MI x 2, ? new-onset a.fib], or respiratory status (COPD). So there's a bit of a question as how other comorbidities may be affecting his presentation / clinical course.

A couple of things jumping out:

* SpO2 85% may not be that terrible for a COPDer. Is he on home O2 at baseline? Can we get a gas? A CO2 and a bicarb will let us see how effective his respiratory compensation is? On the same token: how is work of breathing, subjectively, is he tiring?

* His temperature is concerning. Has he been febrile previously? Is he transitioning towards "cold shock/sepsis"?

* I'd love to see a CXR -- does it look ARDSy?

* Would be nice to have an ECG, BNP and trop, to see if there's any evidence of STEMI / NSTEMI / heart failure. Granted his trop may be high if his ARF has been prolonged? When was his last period of reasonable U/O? Do we know his baseline NYHA? His med list doesn't suggest a CHF hx.

* Why is he hypomagnesemic? Is he a drinker? Is this from the lasix? How much was given?

* Goals of care? He's younger, one would assume R1/ full code? Are patient and family amenable to ICU admission / ventilator management?

* What's our transport time / mode? Are we going ground am for 20 mins? 3 hours? RW/FW? Helipad to rooftop -- or are we shuttling to the airport on both ends for ground transfer? Presumably our receiving center is tertiary care with full ICU capabilities? Looking forward, with influenza dx and rapid decompensation -- ECMO on site?

* Level of consciousness? He sounds sick, but at points in the vignette, it seems like he's talking and alert -- could you clarify this?


Moving on to intervention:

(1) He needs a lot of fluid. This seems to be a clear septic shock presentation. WBC of 22 doesn't sound like a stress response to an MI. He has two sources of infection. He's tachycardic and hypotensive. We should start with 20 ml / kg, consider whether we can / should get better access --- CVC if skilled personel exist, or a larger IV.

(2) We can leave the a.fib alone for now. At 120/min it's unlikely to be the cause of his hemodynamic compromise. Cardioversion while hypoxic, and a high demand state, is likely going to cause more problems than it resolves. Medical therapy with ARF / significant hypotension would be a brave (read: foolish) decision.

(3) If we can bring his pressure up, we could reconsider CPAP/BiPAP, and have another go. If he just "failed" because he's anxious, then we may have time to take another stab at it.

(4) If his mentation is poor, and fluids haven't brought up his MAP (55 mmHg), then we have to decide between more fluids and initiating levo, or both concurrently.

(5) If we're going to intubate this patient, we need to improve baseline hemodynamics first. The decision to intubate is going to be based heavily on anticipated clinical course -- is the patient tiring, are dealing with respiratory failure? Given the length of transport, is there a high risk of airway compromise, probably better pre-empted in the sending facility? Given his CVP is probably very low, putting positive pressure in his chest without addressing volume status / PVR is going to be a bad idea.

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In my location it is acceptable transfer a patient to the ED for reassessment. Typically, this is done by the receiving service but not always. For example, if their are concerns weather the patient will be going to the ward, step-down, or ICU. It is interesting to see how different systems work. For the sake of discussion lets say it is acceptable to take this patient to the ED at the receiving hospital.

Lots of excellent post. I would love to quote from them but for some reason I can not get it to work at the moment.

Here is some more information:

LOC: He is tired but able to follow command. He is cooperative but anxious.

Bi-Pap: It failed because the patient got anxious and kept trying to pull the mask off.

A-Fib: New. He had it in the ED and it was converted with a CCB. But, the A.Fib started again last night. They haven't give anything because of his low pressure.

Urine Output: Very low. Yesterday, his output was only 200cc. So far today his output has been zero.

CXR: Ground glass like, flat diaphragm, consolidation in the lower lobes

BNP: Not available at this hospital.

ABG: None have been done due to bleeding concerns (see below)

Lungs: A wheezing mess

Fluid Status: Very dry. The patient mouth looks like leather. His IV is running at NS 125 cc/hr

EKG: They have done a few. One shows A.Fib while the other shows an unremarkable Sinus Tachycardia.

Labs: You look through the chart. Here are some additional labs: INR 7.0 PTT 80 Tn-I 1.2 mcg/L (elevated) Na is 150 or so.

VS: His BP has been trending down and his HR trending upwards during his admission.

From the post most people want to give some more IV fluids and consider Levophed. Second, intubation is a possibility but lets get some more support and see if he responds (fluid responsive). Third, lets try the Bi-Pap again.

Lastly, the transport time will be around 60 minutes.


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Labs: You look through the chart. Here are some additional labs: INR 7.0 PTT 80 Tn-I 1.2 mcg/L (elevated) Na is 150 or so.

Ok...didn't expect that. Is he on blood thinners at home beyond aspirin? Any chance he could have accidently ingested some? Gotten extra aspirin?

What were his initial clotting times?

Any history of liver issues or alcoholism?

Signs of bruising or bleeding on physical exam?

Given his anemia, prolonged hypotension and some degree of renal insufficiency or failure the elevated troponin isn't that unexpected, or worrisome; yes, an echo is in order in the future and if it continues to elevate post resuscitation or if other cardiac symptoms develop then it needs to be addressed more, but for now...leave it alone.

Continue with the fluids, very unlikely that 1 bolus will be enough at this point; fluid responsiveness should still be checked after the first but plan on several. Levophed still may come into play later though. What's the patient's recent history before admission; how long has he really been sick for?

With the known recent onset (and complete lack of ability to clot) technically the afib could be converted...but that can wait until (much) later; it's not the cause of his issues and there are much more pressing concerns that need to be addressed.

Any chance of getting the ETCO2 with a waveform?

Not much change in treatement at this point; lots of fluid, maybe levophed later on, albuterol and atrovent, magnesium after his BP is a bit better, and without marked improvement in his respiratory status, intubate before leaving.

This is not someone to fuck around on intubation with; he's already tired, anxious, hypoxic, and has a host of other problems. If his mentation, respiratory status and overall work of breathing don't return to normal, leaving without a secure airway in an obese man with a 60 minute transport time is plan dumb. It doesn't need to be done immedietly; take the time, get fluids on board, give what meds you can, but it does need to be done before leaving. Trying for something like Bi-PAP/CPAP with sedation is not appropriate in this guy, and leaving the most controlled setting with the most resources available for the opposite is a bad deal waiting to happen.

A transfusion is also in order, but I think that can wait until you get to the next hospital, unless the present location has blood that they can hang and send with you, in which case I'd say go for it.

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I agree with the above. Realistically he's probably going to get intubated unless we can get the NIV working well, but he's going to have to get a decent fluid bolus or two first. Even if the pressure comes up, it wouldn't be unreasonable to have the levo hung at 0 and ready to go.

It would be nice if the sending facility could run a peripheral venous sample through their ABG machine, and at least give us an idea about the bicarb and pH. They're probably both not so great.

Do we have difficult BVM/Intubation/Cricothyrotomy indicators? I like the ketamine and topical anesthesia approach for intubation. I don't think we've actually been given a respiratory rate so far, but I imagine it's not good, and sux is probably out at a K of 6.2 mM. Do we have a decent vent?

Any evidence of DIC? I'm guessing we don't have a fibrinogen? platelets?


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Plus, look at his troponin, he's also had an MI. This guys screwed and you are getting ready to transport a train wreck that is only going to get worse and probably end up as a massive chemical spill as well.

Any chance to discuss air transport on this guy unless your transport time is much shorter than the air time?

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Sorry for the slow reply.

The patient is give a couple of boluses and his pressure improves slightly and HR comes down.

With some encouragement the patient is able to tolerate Bi-Pap and his SpO2 improves some.

With some more encouragement you get a VBG done and the results are worrisome. (pH 7.0 O2 30mmHg CO2 65mmg with Lac of 8) The lytes on the gas show his K is still 7.0.

The staff feel the low Mg is due to not eatting much (he was sick at home for awhile before he came in).

They are not sure why his INR and PTT are up. They can not do fribinogen at this hospital. LFT have not been done.

GCS 15

HR 100 (fib)

BP 90/50

SpO2 90-91% on Bi-Pap

So, transport or tube? The hospital is not keen on this, of course.



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I say intubate him with Ketamine 0.5mg-1.0mg/kg and Fentanyl.

The patient has responded to fluid boluses, but I'd like to have a Levophed infusion set up and ready to go prior to transport.

I would ask the staff why they gave Lasix to an ARF patient, document how much they gave, and look in the charts to see if that's when our septic patients BP began trending downwards.

How is our patients colour, peripheral circulation, distal pulse quality, mental status and affect after the fluid boluses and initiation of BiPap?

I'd check lungsounds for crackles, if non are present, I'd be comfortable with one more 20 ml/kg bolus of Ringers Lactate to replenish some nutrients and to try to avoid making him more acidotic than with saline. Any chance we could get some whole blood infused prior to transport along with some Tranexamic Acid?

Is air ambulance transport available? If not, I'd get either an RT or RN to join me during transport incase things go south.

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When placing the patient on a transport ventilator, we should be aware that we'll be taking away his only compensatory mechanism since his renal function is impaired.

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Does this patient have any allergies?

How would everyone feel about infusing some broad spectrum antibiotics for this patient? My local sepsis protocol says we can infuse Cefotaxime 2g q 6-8hrs or Vancomycin 500mg q 6 hrs or 1g q 12 hrs would be indicated.

Taking into account his impaired renal function, we should give a modified dose of Cefotaxime1g q 8-12hrs, and stay away from Vancomycin being that it is nephrotoxic.

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