Altered Mental Status
76yo female presents to ED via EMS from a nursing home after being found to have altered mental status by the staff. ALS was unavailable and pt. was brought in BLS. Transport time was 5 minutes. As a result, IV access has not been established. (only given if asked for by team leader: accucheck= 80)
A. Fib - warfarin 4mg qd
HTN - HCTZ 25mg qd
CAD - ASA 81mg qd
Monitor and Vital Signs:
Monitor: atrial fibrillation. Degenerates to VT if students take too long to start fluids and manage the patient appropriately.
- initially unstable
- BP: 68/12
- HR: 132
- RR: 24
- O2%: 78%
- Temp: 102.3
- glucose: 80 (remains 80 throughout scenario)
- VS remain the same until norepi is started. If norepi isn't started after 10 minutes put the patient into VT.
- after 5 minutes of 2L NSS running wide open, and NRB at 30 lpm:
- BP: 76/20
- HR: 128
- RR: 20
- O2%: 86%
- Temp: 102.3
- after Norepi (or other appropriate pressor) drip is started and ran for a few minutes:
- BP: 96/50 (MAP ~65)
- HR: 116
- RR: 16 (pt. fatiguing, sternal retractions present)
- O2%: 82%
- Temp: 102.3
- if patient is managed INAPPROPRIATELY:
- BP drops to 40/0 and pt. enters pulseless VT until ACLS protocol followed correctly and the team manages the patient appropriately
- Mental Status: AOx0, not following commands appropriately, verbal response is to pain only, eyes open only to pain
- HEENT: NC/AT, PERRLA
- Cardiac: tachy, a. fib, otherwise normal
- Respiratory: rales present in right lung bases/posterior lobe
- Neuro: reflexes normal, patient not following commands appropriately, cannot perform FAST evaluation for stroke.
- Rectal: hemoccult negative
- assess mental status and obtain VS, expose patient, obtain 2 large bore IVs.
- start 2L NSS wide open. Place patient on NRB 30 lpm. Simultaneously perform physical exam and/or POC U/S. Obtain 12-lead.
- consider placing arterial line for continuous BP monitoring
- Once rales heard, order stat portable CXR, unless dx made on U/S
- after 5 minutes repeat VS (VS the same unless norepi started) should at least consider starting norepinephrine.
- once POC U/S or CXR is interpreted and pneumonia is Dx'd:
- Draw blood cultures
- start patient on broad spectrum ABX: cefepime 2g + Azithromycin 500mg + Vancomycin 2g (20mg/kg) because this pt. is presenting from a nursing home. (source: EMRA ABX app 16th edition)
- Once BP rises sufficiently, intubate patient. Confirm ETT placement with auscultation in 5 spots, CXR. Once CXR confirms placement, start sedation drip, place OG tube and foley catheter.
- Order: CBC, CMP, lactate, PT/INR, ABG, VBG, troponin.
- Consider CT head non-contrast to r/o stroke if pt's INR returns subtherapeutic/very supratherapeutic
Pertinent Diagnostics Results:
- POC U/S (more specific and sensitive than CXR for pneumonia, see sources below): Lung windows show air bronchograms and consolidations in Right 6-9 intercostal spaces. Left lung windows are clean. cardiac windows and FAST windows normal.
- CXR (link to image) : pneumonia in right posterior and lower lobes. ø pneumothorax, rib fractures, cardiomegaly, or pleural effusion, trachea midline (if taken post intubation, cxr would show ETT in proper position: link to a normal ETT placement CXR (ignore the rest of this cxr for this case).
- CT Head non-contrast: no acute intracranial pathology (no stroke, no bleed)
- EKG: tachy a. fib, ST depressions w/ T wave inversions in lateral leads
- Lactate: 9.2
- WBC: 30,000
- Hgb/Hct: normal
- CMP: AG of 25 (Na 140, Cl 100, HCO3 15) K is 4.0. Cr is 1.6
- PT/INR: 2.8
- ABG: 6.9/33/70/15
- Troponin: 0.06 (reference is <0.04 but this is possibly due to AKI; trend troponins before activating cath lab)
- UA: grossly wnl
- sepsis= SIRS + source
- severe sepsis= sepsis + end organ damage (elevated Cr, LFTs, Troponin)
- septic shock= severe sepsis + hypotension and/or lactate ≥4
- two most common sources of sepsis in the elderly= pneumonia and urinary tract infection (but don't forget about meningitis, esp. for peds and immunocompromised patients!)
- septic shock requires immediate IV fluids, at least 2L in first 6 hours for all septic patients. Obviously more if pt. is in septic shock but be careful not to flood the patient if they have concomitant CHF.
- Norepinephrine is the pressor of choice in septic shock (source)
- Norepinephrine should be considered early in sepsis and especially in patients presenting with profound septic shock
- lung ultrasound is more sensitive and specific than CXR for pneumonia (sources below). Two great resources for learning to Dx a pneumonia via lung U/S: The ultrasound podcast on lung ultrasound part two and this ultrasound of the week post.
- blood cultures should be drawn before ABX administered to septic patients so that abx sensitivities can be acquired
- broad spectrum abx should be given for patients with presumed or confirmed sepsis as soon as possible (but after cultures are drawn)
EMRA ABX App
Landmark articles on Sepsis care:
- ProCESS Trial [PMID 24635773]
- Arise Trial [PMID 25272316]
- ProMISE Trial [PMID 25776532]
- Note: EGDT based on the trial done by Rivers in 2001: EGDT Trial [PMID 11794169]
Tintinalli's Emergency Medicine a Comprehensive Study Guide 7th Edition