Rapid response situations

1. Rapid response situations Intern Survival series 2009-10

2. What are some RR situations? • Hypotension • Hypoxia • Brady or Tachycardias

3. HYPOTENSION • One of the commonest inpatient problems • Could be an early manifestation of sepsis • Has very broad differential diagnosis • First response to a call for hypotension should be : IV Fluids unless contraindicated !

4. Hypotension = SBP < 90 Minimum MAP for brain perfusion > 60-65 If the patient is sleeping, wake them up & check the BP again (it is normal for the BP to decrease significantly during sleep) Most worried about shock (which means evidence of low perfusion) 4 main types: Cardiogenic (MI, arrhythmia, heart failure/low CO) Hypovolemic (hemorrhage, dehydration) Distributive (septic, adrenal insufficiency, anaphylaxis) Obstructive (tension ptx, tamponade)

5. HYPOTENSION Case 1 • You are team 2 intern on call. • “Doc, I just checked my pt’s BP. It is 82/56. I don’t know if you want to do anything about it.” • What do you do next?

6. HYPOTENSION Case 1 contd. • Signout: • 56 yr old M with h/o smoking, asthma a/w Fever, dyspnea, cough with greenish sputum. CXR showed RLL infiltrate. Was started on levofloxacin for pneumonia. • What do you do next?

7. HYPOTENSION • Evaluation of a patient with hypotension: • Vitals including manual measurement of BP if needed (use appropriate size cuff). • Ask for previous BP trend. • History : any symptoms of hypotension, associated symptoms • Physical exam: JVD, mucosa, conjunctivae, cardio pulm exam, look for signs of infection (Foley cath, Lines, pneumonia, decubs, UTI etc) • Review chart: medical history, medications given, previous episodes of hypotension during the day, on HD or not • EKG and Labs : CBC, C7, lactate if suspicion of sepsis • BLOOD CULTURES before broad spectrum ABX !!!! • Imaging: CXR, CT scan • Look for signs of organ perfusion: Mental status, coronary ischemia, urine output etc.

8. HYPOTENSION Common Differential diagnoses: • Sepsis: • Pneumonia • UTI • Decub infection with bacteremia • Meningitis • Hypovolemia: • Diarrhea • Vomiting • Overdiuresis • Removal of fluid during HD

9. HYPOTENSION Common Differential diagnoses (contd.): • Obstructive: • PE • Cardiac tamponade • Cardiac: • Cardiogenic shock • MI • Others: • Anaphylaxis • Severe Blood transfusion reaction • Medications: antihypertensives, benzos, opiates and etc…..

10. HYPOTENSION Case 1 contd. • Vitals: • T: 101.2 F, BP 80/58 mm Hg, P: 112/min, SaO2 93% on 4 L • Physical exam: • Pt alert and awake, diaphoretic, flushed • No JVD or icterus, no cyanosis • S1 S2 normal, tachycardic, no murmur • Basal crackles at RLL, no wheezing • Abd – soft , NT

11. HYPOTENSION • What do you do next?

12. HYPOTENSION • Pt was given NS 1 L bolus, BP improved to 96/63 mm Hg. • Labs: WBC 19.1, 40 % bands, Hgb 10.0, Na 134, K 4.1, Cl 100, HCO3 12, Creat 1.8, BUN 45, Lactate 4.2 • Imaging: CXR: persistence of pneumonia in RLL. • ABX coverage was broadened after Bl Cx were obtained, ICU was consulted and pt was txed to ICU for possible sepsis.

13. HYPOTENSION • Management: • IVF unless contraindicated • Watch for volume overload : dyspnea, increasing O2 requirements, Physical exam • Management depends on cause

14. HYPOTENSION • Pt was given NS 1 L bolus, BP improved to 96/63 mm Hg. • Labs: WBC 19.1, 40 % bands, Hgb 10.0, Na 134, K 4.1, Cl 100, HCO3 12, Creat 1.8, BUN 45, Lactate 4.2 • Imaging: CXR: persistence of pneumonia in RLL. • ABX coverage was broadened after Bl Cx were obtained, ICU was consulted and pt was txed to ICU for possible sepsis.

15. HYPOTENSION • Management: • IVF unless contraindicated • Watch for volume overload : dyspnea, increasing O2 requirements, Physical exam • Management depends on cause

16. Hypoxia or Tachypnea: • Hypoxia: low oxygen saturation • Patient with underlying lung disorder will have low o2 sats at baseline: COPD, Lung fibrosis • Why should some one with no underlying lung disorder should have low o2 sats? - Not breathing enough? Sedated patient? (excessive narcotics) - Getting IVF which are not needed? - PE?

17. Evaluation of hypoxia: • History and physical examination along with CXR will almost always help to pin point the diagnosis. • ABG can also help to make a diagnosis. • If a patient is severely dyspneic, gasping for breath, call a rapid response. • Pulmonary edema, pleural effusion, pneumothorax, PE, pneumonia are some of the common causes of respiratory distress and hypoxia. • Always find out what 02 saturation before.

18. Management • Will depend on etiology after your evaluation • Fluid overload: diuresis • Asthma/COPD: nebs, steroids • PE: anti coagulation • Opiate overdose: naloxone 0.4 mg iv • If your pateient is unable to cough out secretions, resp therapist can do suctioning, saline inhalation to thin out secretions.

19. Change of mental status: • What is the change? Arousable? Delirious? psychotic? Agitated? • Always check complete set of vitals including accucheck • Common things are common: - Always ask for any sedatives, narcotics given and all medications - What is the patient admitted for? - DM? check sugar, last insulin given - COPD? Check ABG for co2 retention (remember, o2 sats will be normal) - Infection is a very common cause of mental status change in elderly, Check UA, CXR - Consider CT head in selected cases (focal neuro def, pt on anti-coagulation, seizure) - h/o Sz or withnessed seizure? Pt could be post-ictal and unresponsive. Consider to check levels of medicines they are on (dilantin, keppra) - Does patient have a known infection? Getting septic? - Sun-downing? Always try to orient patient about time, place and person.

20. Hypoglycemia: • BSL <70 mg/dl • Symptons: • How to treat? Po intake, D10 amp, D50 amp

21. Rapid Response Team • Consists of:

22. When to call a rapid response:

23. Your role in rapid response: • Call your resident and inform about calling RR • Be with the RR team as you would still know the most about the patient • Help the RR team by giving them pertinent info abt the patient. Eg brief history, labs, imaging. Help out with putting some orders if needed. • Call the family and let them know if the patient if being transferred to the ICU.