Category Archives: Clinical Updates

Clinical updates for now and later

Upset, Angry, Agitated, Confused– Pulling Every Tube and Line: Calming the Storm


It happens in the ICU and in the ED.  The upset, angry, agitated, confused patient who manages to pull on every tube and line in an effort to gain freedom or control over their situation. It’s a terrible thing to witness.  An elderly patient fighting so hard to free themselves from our hard work and interventions.

While restraints are one way to combat part of the physical issues it also complicates care and can essentially cause the patient more trauma,  increased confusion and increased chances of developing PTSD.

Treating these patients, especially the geriatric population, is a bit like baking a cake, you need the right recipe.

A elderly woman in her 90’s was admitted to a tele floor for chest pain, ARF and UTI.  While on the floor she had a witnessed cardiac arrest. ROSC was achieved  within 15 minutes after 1 epi and CPR .  The patient became alert before transfer to the ICU.  She was agitated to say the least.  She following some commands.  She attempted to pull out her ETT several times, even when family attempted to redirect her.  The patient turned out to be ureoseptic was put on a pressor, pain meds were given, but the agitation didn’t  improve. Prior to admission to the hospital the patient had told her family she did not want to be on life support, but the patient’s medical proxy at the time of the incident could not make that decision.  The patient was not on a sedation drip because the plan was to extubate in the morning.  Push doses of fentanyl were given with little decrease in agitation.

As the night went on the daughter in law of the patient continued to try to calm the patient.  She reviled that the patient was very hard of hearing and didn’t have her hearing aids in.  The patient was able to write.  She wrote clearly that she wanted the tube out of her mouth, “I want this out now”.

The patient was more calm when her care was explained to her via writing.  She still required push doses of fentanyl for the rib pain she had as a result of the chest compressions as well as the pain from the ETT itself.  She also received push doses of versed which reduced her anxiety and allowed her to rest.

What’s Causing the Behavior?  PAD Check

Assess the patient, identify the cause of the behavior is essential. Look for simple fixes  and causes, such as not having hearing aids in or not understanding the language spoken, and let us not forget about the intubated patient who is alert and did not want to be intubated because it was against this health care wishes!

Pain– Is the patient having pain? Are they intubated and sedated- what sedative is being utilized?  Do they have adequate analgesia?

Agitation– How agitated are they?  What’s their RASS score?  What illness/injury are you treating? Was a medication started or removed around the time the agitation began? What is the environment like- noise and lighting levels?

Delirium– Assess level of delirium  CAM-ICU score.  Are they able to sleep, do they have hearing aids in or their glasses?  Reorientate- Reorientate- Reorientate! Assess for early mobility. Are there family or loved ones visiting?– Educate them.

(CAM-ICU Assessment Link) 

Adopting the ABCDEF Bundle Approach in ICU PatientsThe goal of this bundle is to improve patient outcomes through an approach that includes early mobilization and a decrease in ventilator days.

Assess Treat & Manage Pain

Breathing Trial SAT (spontaneous awake trial) & SBT             (spontaneous breathing trial)

Choice of Sedatives

Delirium Reduction

Early Mobility & Exercise

Family Involvement & Communication

For more information and valuable resources on ICU delirium as well and ED and non ICU settings check out


Bring On the Meds! 

Traditionally Haloperidol (Haldol) was the go to drug, but it’s not always effective and it can have negative effects on the heart.  An alternative therapy that might beneficial is Olanzapine (Zyprexa).  Head over to PulmCrit for an great read on the topic.










Sepsis Incentive Pay Is Coming to Town


Just in time for the holidays a new crowd favorite, sepsis incentive payments.  That’s right, brought to you by the folks at the Centers for Medicare & Medicaid Services (CMS).  So here’s the list, be sure to check it twice, because not recognizing sepsis and meeting the bundles set by CMS can certainly lead to a poor patient outcome as well as an unpaid bill and lost revenue for your department and facility. CODES

Sepsis identification can be a bit of a minefield, the symptoms could be sepsis and then again it might not be sepsis.  This very discussion is something that I know all to well.  As one of two nurses who helped develop a SIRS and Code Sepsis protocol in my shop, this was something that the physicians and nurses agonized over, but this is the criteria that CMS is utilizing, and yes this will make flu season interesting.

So here is the SIRS criteria— if you have two or more of the following with a known or suspected infection call Sepsis!

  1. Temperature greater than 101.0 F or less than 96.8 F
  2. Respiratory Rate greater than 20
  3. Tachycardia, rate greater than 90
  4. WBC count above 12,000 or less than 4,000 (this one is kind of hard unless they come in with labs and present them to you in triage)  *If your patient from triage is on Neupogen there’s probably a reason why.. “Do you known what your last WBC count was?”

Additional signs include:

  • Altered mental status
  • Elevated lactate, greater than 2.0, at 4.0 you might be dealing with a the beast!
  • Hypotension SBP below 90
  • Hyperglycemia without history of diabetes

The sepsis time clock begins clicking the moment the patient is triaged for CMS reimbursement, but the patient’s sepsis timer started counting long before they came through your door.

The Bundles (tied to your reimbursement)

1) Measure lactate level
2) Obtain blood cultures prior to administration of antibiotics
3) Administer broad spectrum antibiotics
4) Administer 30 ml/kg crystalloid for hypotension or lactate ≥4mmol/L

“Time of presentation” is defined as the time of triage in the emergency department or, if presenting from another care venue, from the earliest chart annotation consistent with all elements of severe sepsis or septic shock ascertained through chart review.


5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65 mm Hg
6) In the event of persistent hypotension after initial fluid administration (MAP < 65 mm Hg) or if initial lactate was ≥4 mmol/L, re-assess volume status and tissue perfusion and document findings according to Table 1.
7. Re-measure lactate if initial lactate elevated.



• Repeat focused exam (after initial fluid resuscitation) including vital signs, cardiopulmonary, capillary refill, pulse, and skin findings.


• Measure CVP
• Measure ScvO2
• Bedside cardiovascular ultrasound
• Dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge

Of note, the 6-hour bundle has been updated; the 3-hour SSC bundle is not affected.

We are still woking out the kinks in our sepsis response.  We have a cancer institute attached to our facility as well as a sea of nursing homes and assisted living facilities.  Often enough the folks that roll through our doors are coming to us in less than ideal health and likely well into the sepsis spiral.  This isn’t the time to play hot potato patient and park them out of the way because nobody wants the work! Sepsis is work.  Sepsis work ups are a lot of work, especially if you are doing it by yourself.  You need a team willing to work together to get-it-done! Every minute that goes by is a minute you never get back.  Small delays add up at the patient’s expense both literally and figuratively speaking.

If you have a bias about a million dollar workup on a 90-year old aspiration pneumonia urosepsis repeat offender, then you have two choices: 1) leave the profession or 2) check your ego and bias at the ambulance bay and get to work, because it doesn’t matter what you think is a ridiculous treatment, this is someone’s loved one and if they are in your ED they deserve to be cared for according to their wishes and best practice.

While the majority of septic patients will be part of the elderly population you have to keep an eye out for the younger SIRS crowd.  The potential for these folks to go bad is absolutely a good possibility especially if there are preexisting illnesses.  Your walking SIRS patients deserve a good triage, and not the 2 minute get them in and out of your chair, because you think it’s a treat em’ and street em’ flu.  Spend that extra minute to ask a few deeper questions and take  a better look.  That extra minute might mean the difference as to where you put them in your ED and how much monitoring they get before they crash.

A 34 year old female with a history of HIV comes in complaining of 3 days of fever and a non productive cough.  Vitals on triage are T 103, P 115, BP 100/62,  RR 20 and POX on room air is 97%  She is compliant with her HIV meds and AOX3.  She meets SIRS criteria because of her temperature and heart rate, we have a suspected infection.  She’s not meeting septic criteria because she isn’t hypotensive, doesn’t show altered mental status or low pulse ox.  She gets a set of labs, a chest X-ray that shows a right lower lobe pneumonia.  She gets IV hydration 2 liters of NS.  Unfortunately she’s not being closely monitored.  Two hours later, it’s shift change and time for repeat vitals: BP 74/43, HR 110, POX 95%, T 99.1, RR 20.  An additional 1 L NS bolus is given and a repeat lactate is drawn, the first lactate was 1.6, blood cultures are drawn.  The patient’s vitals are checked every 15 minutes per policy.  The SBP after bolus is 98, but doesn’t hold.  The patient is moved to the more critical part of the ED and is admitted to ICU.  The nurse that had originally received the patient had 7 additional patients before change of shift vitals were completed. The triage nurse didn’t call the sepsis alert because she didn’t feel that there was a site of infection, the patient wasn’t coughing at the time.

There are a few issues in this case that warranted sepsis re-education.  One of the biggest obstacles though wasn’t clinical, it was peoples preconceived ideas of sick and not sick. There was a sense of false security that sepsis is a disease process of older people. News flash: Sepsis does not discriminate!