Case Scenario Critical Care

Background: EMS arrives with a 83 year old female from a SNF and c/o increasing confusion and a fall
after slipping out of bed. The patient was found immediately after the incident by a CAN. The patient is
disoriented but has is able verbalize and follow simple commands, she has no focal deficits, denies
syncope, and GCS is 13-14. The patient has a Hx of Alzheimers, DMII, CAD, HTN, and a past MI. Her
medications listed from records are: Aspirin 81mg, Metoprolol 25mg, Percocet 5/325mg, Aricept 23mg,
and Keflex 500mg. She is noted to have a left frontal hematoma but no other notable injuries or
trauma. She denies n/v/d, CP or abdominal pain, but endorses some SOB and tactile fever. She is
flushed, warm and dry. The nursing staff at the SNF report that she has been more confused for 2 days
and has been incontinent more frequently. EMS VS were BP 101/40, pulse 112bpm (Sinus Tach no
ectopy or ST changes), RR 24, 90% on 2LNC, and a BGL of 156 was obtained. EMS was able to initiate 1
PIV LH #20 with NS at TKO, no blood drawn or medications administered. The pt arrives fully
immobilized with spinal precautions. The family is reported as en route. At this point the ER team
begins assessment and care of the patient.
Current Dx/DDx: ????
ER VS: BP 98/44, HR 115bpm, RR 24, 92% 4LNC, Temp 36.2C TA, BGL 180mg/dl
Your orders from the MD are (Please order and document):
CBC CT Brain NC CT C-spine Insert Foley
POCT CHEM Rectal Temp ABG/VBG POCT Trop
PT/PTT NS bolus 2 Large IVs POCT BGL
UA/Cx NS bolus Fentanyl 25mcg CXR
Lactate EKG Blood Cx x2

After orders have been placed, go through entire head-to-toe assessment.
Your initial labs have been sent and you patient is returning from CT. Your recheck VS and note that she
remains hypotensive after 2L NS. Notify the MD. Another NS bolus is ordered.
The family arrives and wishes to talk to a Chaplain.
Labs result and show abnormal of WBC 17.8, Lactate 6.4, and signs of UTI. Vanco and Zoysn are
ordered.
The patient begins to decompensate with increased RR and decreased LOC. A decision is made to
intubate for airway protection. A 8.0 tube is placed without incident at 24cm at the lips, confirmed by
auscultation, color change EtCO2, and XRAY. After intubation the patients BP drops to 70/35. A
Levophed drip is ordered to keep MAP>65 and SBP >90.
The patients BP responds well to Levophed and she is admitted to the ICU for urosepsis. You give report
to the ICU nurse and the patient is transported with family. Take time to review your charting.