Air Care Orientation Case #4

The Case

You are dispatched for an interfacility transfer from a rural ED (flight time 45 min), returning to the MICU, for a 65yo male who presented to the outside hospital with altered mental status from his nursing home.  He was found to have a temperature of 101.5 F and pneumonia on CXR.  He is responsive to verbal stimuli but confused.  Paperwork with patient has no DNR order and he is listed as full code.

VS:     HR 75     BP 95/40     RR 20     O2 95% on 4L NC     Glucose 75

PE:

General: male, can answer some orientation questions

CV: normal sinus rhythm, no m/r/g

Pulm: able to speak in full sentences, right basilar rales

Abdomen: soft, non-tender, non-distended

MSK: moves all four extremities

Neuro: able to answer questions, but is somewhat confused as to place and time, knows name, does not understand why he is in the emergency department, symmetric strength

PMH:     Hypertension (BB, ACE), Hyperlipidemia (statin), Diabetes (metformin), BPH (prazosin)

Interventions prior to arrival:    

20G PIV with NS 1L bolus x 4

Labs:

WBC 18, Cr 2.1 from 1.3 baseline, BUN 38


Discussion

Another great discussion ensued with orientation flight case #4 for a septic patient with pneumonia being transferred from a rural ED.  It was astutely pointed out that this case is different from the previous orientation cases, as this patient requires attentive critical care at bedside, as opposed to a time dependent specialist intervention and rapid transport.

Question 1: What are your initial assessment and treatment priorities upon arrival?

The patient has been diagnosed with pneumonia-related sepsis with evidence of multi-organ failure at the OSH.  He is protecting is airway; however, he has a new oxygen requirement with radiographic evidence of pneumonia and has undergone aggressive fluid administration.  Priorities include starting antibiotics ASAP, stopping fluids, obtaining additional IV access (large bore IV vs central access if unable to obtain additional IV), and initiating pressor support.  Logistically, the team discussed using the OSH resources such as pharmacy to obtain antibiotics and norepinephrine drip, however, we also carry cefepime and pressors on the aircraft.  Meanwhile, push dose epinephrine could be used to temporize blood pressure until a drip was mixed. 

The patient has an oxygen requirement with a process that is not easily reversible.  While these are not hard indicators for immediate intubation, there was an appropriate concern for clinical worsening during the flight.  It was discussed trialing the patient on NIPPV versus intubating if the condition were to decline.

Question 2:  After discontinuing the fluids, initiating antibiotics and pressors, you notice the patient has become progressively hypoxic.  It's apparent the patient requires intubation; however, he refuses.  What is your next step?

Using NIPPV as a temporizing measure, the team would assess if the patient has the capacity to make medical decisions given he has several reasons to be altered.  The four factors a patient must meet to have capacity include:

  1. Maintain and communicate a choice
  2. Understand the pertinent information present
  3. Appreciate the situation/choice and its consequences
  4. Process the information presented in a rational fashion

We discussed the importance of having the patient articulate the risks of their choice and rephrasing them in their own words to ensure understanding.  Additionally, a patient's capacity can change from moment to moment, so this must be assessed dynamically.

Question 3:  After an in-depth discussion with the patient, he agrees to get intubated.  What is your plan to successfully and safely do this?

This part of the case highlighted the importance of patient optimization before intubation in addition to the 7 P's for RSI.  Prior to pushing drugs, the patient requires push dose pressors or a pressor drip.  To oxygenate him if the standard NRB on flush rate and NC is not successful, the patient can be trialed on NIPPV.  A RSI or delayed sequence intubation approach can be used.  The induction options include the hemodynamically favorable choice of ketamine, particularly at a reduced dose to mitigate against sympatholysis.  Etomidate was also an option but adequate sedation might not be assured at reduced doses.  Paralytics include either succinylcholine or rocuronium depending on labs.  There are many options for post-intubation analgosedation, but ketamine was the popular choice given the patient's hemodynamics. 

Question 4:  After a successful intubation you load the patient into the helicopter.  You then notice that the patient has become hypotensive.  What do you do now?

The differential for hypotension in this patient is broad, but immediate considerations included tension pneumothorax, autoPEEP, worsening sepsis and acidosis, and medication effect.  Immediate actions would be to decrease or stop sedation, check ETT position for migration, evaluate for pneumothorax, consider increasing or adding pressor/inotropic support, and removing the patient from the ventilator if there was a concern for stacked breaths.

After these interventions you are able to improve the patient's hypotension and safely transport him to the receiving facility. 

This month yielded some great points related to sepsis care and the complicated decisions that must be made often with minimal information.  The rising flight docs acknowledged that while quick transport is important, what is more important is to get the patients the interventions they need as fast as possible.  In this case, they correctly identified the need for antibiotics and pressors which can be given prior to transport, bringing the capabilities of an ICU to the patient. 


Authored by Maika Dang, MD

Posted by Tim Murphy, MD