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“Hi, I’m Calling about the Patient in Room…”

TNP’s 30th Annual Conference, Dallas, TX9/8/18

Elizabeth Gigliotti, MS, APRN, ACNP-BC

Blair Witch Project Unicorns and Rainbows

Background

Objectives

• Describe an effective tool for facilitating communication

• Outline an approach for taking on-call notifications• List early signs and symptoms of critical illness• Describe management principles of frequently

encountered problems such as fever, chest pain, & shortness of breath

An Effective Tool

An Effective Tool An Approach

• Can’t always spend 60 minutes doing/reviewing an H&P L– The phone call: questions & orders– Elevator thoughts– Bedside

• Quick look: well, sick, about to die

• Airway & VS • Select history, exam, chart review

and management

Patients seldom deteriorate abruptly, even though clinicians may recognize the deterioration suddenly

Marshall S, Ruedy J. On Call: Principles and Protocols. 5th ed. Philadelphia: Saunders (Elsevier), 2011.

Recognition and assessment of the seriously ill patient. (2012). Fundamental critical care support (5th ed., p. 1-1). Mount Prospect,

IL: Society of Critical Care Medicine

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Recognizing Critical Illness

• How sick is the patient?– Fever, delirium, shaking chills, tachypnea– Confusion, irritability, impaired consciousness, or a

sense of impending doom

• The goal is to recognize that a problem exists and to maintain physiological stability while pursuing the cause and initiating treatment

Risk for critical illness is increased with:

emergency admission, advanced age,

severe coexisting illness, need for

emergent procedures, deterioration or

lack of improvement

Recognizing Critical Illness

• Making a diagnosis• What needs to be corrected now to prevent further

deterioration?• Good clinical skills and a disciplined approach– Primary survey: initial contact- first minutes– Secondary survey: subsequent reviews (what’s the

underlying cause?)The presence of metabolic acidosis is one of the most important indicators of critical illness

Ongoing deterioration or

development of new symptoms

warrants repetition of primary survey

Recognizing Critical Illness

Airway Breathing Circulation

Causes of obstruction, inadequate breathing/oxygenation, and inadequate circulation

Trauma, blood, FB, vomitus,central nervous system depression, infection, inflammation

Depressed respiratory drive (CNS depression), effort (muscle weakness, chest wall abnormalities, pain), pulmonary disorders (PTX, aspiration, COPD, asthma, PE, ARDS, pulmonary edema)

Directly involving the heart(ischemia, arrhythmias, valvular disease, CMP, tamponade) vs pathology elsewhere (drugs, hypoxia, electrolyte disturbances, dehydration, sepsis, acute blood loss, anemia)

Look Cyanosis, altered respiratory pattern and rate, use of accessory muscles, tracheal tug, altered LOC

Cyanosis, altered LOC, altered respiratory pattern and rate, use of accessory muscles, tracheal tug, equality and depth of breaths, oxygen saturation

Reduced peripheral perfusion (pallor), hemorrhage (obvious or concealed), altered LOC, dyspnea, decreased urine op, JVD

Listen Noisy breathing (grunting, stridor, wheezing, gurgling); silence indicates complete obstruction

Dyspnea, inability to talk, noisy breathing, dullness to percussion, auscultation of breath sounds

Additional or altered heart sounds, carotid bruits

Feel Decreased or absent airflow Symmetry of chest movements, position of trachea, crepitus, abdominal distention

Central and peripheral pulses (assessing rate, quality, regularity, symmetry), cool extremities

Recognizing Critical Illness

• Early recognition is essential for preventing or minimizing critical illness

• Clinical manifestations of impending critical illness are often nonspecific

• Tachypnea is on the most important predictors of risk and needs more detailed monitoring and investigation

• Resuscitation and stabilization often precedes a definitive diagnosis

• Detailed history: diagnosis, determining reserve & treatment preference

• Clinical and lab monitoring of pt’s response to treatment in essential

Recognition and assessment of the seriously ill patient. (2012). Fundamental critical care support (5th ed., p. 1-1). Mount Prospect, IL: Society of Critical Care Medicine

Pt scenario: fever

• JL 89 YOF admitted through the emergency room with cough, myalgia, and fever, no N/V/D.

• PMH: DM, HTN, early dementia, hypothyroidism. • In ED 14:24 VS 109/55 HR 119 RR 17 SpO2 98%

T96.8; 18:55 VS 161/74 HR 93 RR 17 SpO2 100%• Wt based fluid bolus, cltx, abx– RPP + Rhinovirus/Enterovirus– U/A positive– WBC 8.9, Na 130, K 3.9, Cl 90, Co2 22, AG 18, BUN/Ct

59/1.5, Glu 265, LA 1.5 > 6.7

Pt scenario: fever

• 21:00 Phone call: Tachycardia & fever– Questions and orders

• 158/86, 126, 20, SpO2 98%, T 101.6

– Elevator thoughts– At the bedside

• 146/82, 148, 28, 98%, 102.6• CBC, BMP: CO2 15, BUN/CT 51/1.2, ABG 7.42/23/65/14.6/-9• Does she have sepsis or septic shock?• What level of care is needed for her?

• What interventions should be done immediately?

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EBP: sepsis

• ABCs, IV access• Fluids, abx• Initial investigations• Source control• Vasopressors/additional therapies

Schmidt, G.& Mandel, J. (2018), Evaluation and management of suspected sepsis and septic shock in adults. In G. Finlay (Ed.), UptoDate. Retrieved July 28, 2018, from https://www.uptodate.com/contents/evaluation-and-management-of-suspected-sepsis-and-septic-shock-in-adults

Pt scenario: fever

• JM 70 YOF admitted through the emergency room with lethargy/cough/HA.

• PMH: HTN, HLD, GERD, nephrolithiasis • In ED 14:00 VS 105/53 HR 75 RR 18 SpO2 93%

T99.2; fever at home, not captured• URI/bronchitis, rx levofloxacin – Bld & urine cltx, cxr– No focal neuro deficits– U/A -, CT chest no pna, rpp -– WBC 15, Na 136, K 3.8, Cl 101, Co2 21, AG 14, BUN/Ct

14/0.5, Glu 176, LA 0.8

Pt scenario: fever

• 21:00 Phone call: Fever & AMS– Questions and orders

• 156/76, 81, 24, SpO2 98%, T 97.5

– Elevator thoughts– At the bedside

• As above, FSBG 158• Ill appearing, lethargic, c/o severe HA, neck pain, + nausea• What level of care is needed for her?• What interventions should be done immediately?

EBP: meningitis

• Medical emergency• CT, LP• Abx, adjunctive dexamethasone

• 15-20 min before/during abx administration• 0.15 mg/kg every six hours for four days Tunkel, A. (2017). Initial therapy and prognosis of bacterial meningitis in adults. In J. Mitty (Ed.), UptoDate. Retrieved July 28, 2018, from https://www.uptodate.com/contents/initial-therapy-and-prognosis-of-bacterial-meningitis-in-adults

EBP: meningitis Pt scenario: CP

• About 72 hours later JL 89 YOF…05:46 Phone call: Chest pain– Questions and orders

• 165/85, 89, 18, SpO2 100%, T 96.7

– Elevator thoughts– At the bedside

• 155/82, 115, 20, 98%, 98.6• What info is needed to determine the type of ACS she may have?• What immediate interventions should be performed?

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Pt scenario: CP Pt scenario: CP

EBP: ACS

• Anti-ischemic, analgesic – O2, ntg, MsO4, bb, statin

• Anti-thrombotics– Anti-platelet and a/c

• Potassium and magnesium• NSAIDs• Risk stratification • Early reperfusion and revascularization

Aroesty, J., Simons, M., Breall, J. (2018). Overview of the acute management of non-ST elevation acute coronary syndromes. In G. M. Saperia (Ed.), UpToDate. Retrieved July 24, 2018, from https://www.uptodate.com/contents/overview-of-the-acute-management-of-non-st-elevation-acute-coronary-syndromes

Reeder, G., & Kennedy, H. (2018). Overview of the acute management of ST-elevation myocardial infarction. In G. M. Saperia (Ed.), UpToDate. Retrieved July 24, 2018 from https://www.uptodate.com/contents/overview-of-the-acute-management-of-st-elevation-myocardial-infarction

Pt scenario: CP

• TB 58 YOM admitted through the emergency room with chest pain, malaise.

• PMH: nothing significant. • Current VS: 134/65, 87, 14, SpO2 98%, T 98.2• Wkup: - CE x 2, laboratory data otherwise

unremarkable

Pt scenario: CP

• 20:30 The phone call: Doesn’t look so good… here for chest pain– Questions and orders

• 134/65, 87, 14, SpO2 98%, T 98.2

– Elevator thoughts– At the bedside

• 142/82, 68, 18, 98%, 98.6• Diaphoretic and anxious• What info is needed to determine the type of ACS he may have?• What immediate interventions should be performed?

Pt scenario: CP

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Pt scenario: CP

ST elevation, consider inferolateral injury or acute infarct

EBP: Pericarditis

• Activity restriction• Colchicine & NSAID• Glucocorticoids

Imazio, M. (2018). Acute pericarditis: treatment and prognosis. In B. C. Downey (Ed.), UpToDate. Retrieved July 24, 2018 from https://www.uptodate.com/contents/acute-pericarditis-treatment-and-prognosis

Pt scenario: Respiratory failure

• About 4 days later JL 89 YOF…03:30 The phone call: SOB, hypoxia, and increased FiO2 requirements– Questions and orders

• 116/60, 112, 20, SpO2 94%, T 97.7

– Elevator thoughts– At the bedside

• Moderate distress, pale, lethargic• Should this patient be intubated?

• What is the management of respiratory failure?• Should I call for help?

Supplemental O2 should be considered a temporizing

intervention while the primary etiology of hypoxemia is diagnosed and treated

EBP: Respiratory failure

Causes Management

Cardiovascular: CHF, PE Diuretics, a/c

Pulmonary: PNA, COPD, asthma Bronchodilators, steroids, abx, CPT

Miscellaneous: Obstruction of upper airway, anxiety, ptx, massive pleural effusions, massive ascites, postop atelectasis, aspiration of gastric contents

Various

HYPOXIA = MAJOR THREAT TO LIFE!Inadequate tissue oxygenation is the most worrisome end result of ANY process

causing shortness of breath. Therefore, you initial exam must be whether hypoxia is present.

Treat the cause!

Supplemental O2 should be considered a temporizing intervention while the primary etiology of hypoxemia is

diagnosed and treated

Pt scenario: Respiratory distress

• NC 36 YOF admitted through the emergency room with swelling of her upper lip. Started few hours PTA. Similar episode 2 weeks ago. Recently developed dry cough.

• PMH: HTN, anemia, and PCOS. • In ED 15:30 VS 142/76 HR 84 RR 16 SpO2 98%

RA, T96.8; • IV Solu-MEDROL, Pepcid, and Benadryl (Benadryl

50mg at home no relief)– Labs unremarkable

Pt scenario: Respiratory distress

• 22:30 The phone call: SOB, and increased swelling of lips, restlessness– Questions and orders

• 102/83, 105, 20, 91% RA

– Elevator thoughts– At the bedside

• Moderate distress, restless• Should this patient be intubated?• What is the management for what is going on?• Should I call for help?

Supplemental O2 should be considered a temporizing

intervention while the primary etiology of hypoxemia is diagnosed and treated

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EBP: Anaphylaxis

Campbell, R. & Kelso, J. (2018). Anaphylaxis: emergency treatment. In A.M. Feldweg (ED.), UpToDate. Retrieved July 24, 2018 from https://www.uptodate.com/contents/anaphylaxis-emergency-treatment

In Summary:

• Have a high index of critical illness• SBAR• Good history and physical exam• Monitoring of VS• Frequent reevaluation after intervention• ….. always check a FSBG!

Thank You

• references