Page 99 - JSOM Summer 2024

This patient clearly needs fluid resuscitation. However, a pas- • May need morphine 2–4mg IV every 3–4h, as needed for
sive leg raise (PLR) test can be performed to assess the need for pain control. If hypotension develops after morphine, the
fluid resuscitation after initial resuscitation, as the maneuver patient is likely under-resuscitated and needs an IV fluid
provides a temporary natural fluid bolus by returning venous bolus.
blood to the central circulation. It is ideally assessed with ad- • If the patient has persistent pain and tolerates oral (give in-
vanced hemodynamic monitoring (beyond a BP cuff) but may stead of acetaminophen): acetaminophen/codeine (300mg/
be a valuable physical exam tool during PCC (Box 1). 19 30mg): 1–2 tabs orally every 4–6h, as needed. (Note: no
other oral narcotic medication is available on DDG).
Time +90min
• 3L NS given, antibiotics given, IV fluids rate: NS at 125mL/h. Chemical Venous Thromboembolism (VTE) Prophylaxis:
• HR 120bpm; BP 87/55mmHg; RR 25 breaths/min; SpO • Minimum: aspirin (oral).
2
92% on room air; temp 39.5°C. • Better: heparin 5,000 units subcutaneously three times a
• Urine output 15mL (dark in color). day. (Note: Heparin is not available on DDG. Heparin is
• Alert and oriented, answering questions appropriately. preferred in patients with renal insufficiency).
• White blood cell count (WBC): 21,000/μL; hemoglobin • Best: enoxaparin 30mg subcutaneously daily. (Note: only
(Hgb) 15g/dL; hematocrit (HCT) 45%; platelet count (Plt) 10 doses of 30mg injection are available on DDG). Use
485,000/μL. with telemedicine consultation. Use with caution if there
• Abdomen is still distended with persistent nausea and three are renal impairment concerns.
episodes of emesis. (Ileus or small bowel obstruction re-
lated to intra-abdominal abscess). Nausea/Vomiting
• Consider ondansetron: 1–2 tabs oral/sublingual every 4–6h
The recommended interventions include: as needed; or 4mg IV, may repeat once in 2h if nausea/
• Nasogastric tube placement. (Note: not available on DDG). emesis returns.
• Urinary catheter placement for urine output (UOP) moni- • Check the QT interval on the monitor/electrocardiogram
toring. Goal UOP: 0.3–0.5mL/kg/h. before considering ondansetron administration because
• Telemedicine consultation. Start vasopressors If available. blood electrolytes may be abnormal with nausea or vom-
• Initiate vasopressors. Norepinephrine is preferred. Titrate iting. (Note: No electrocardiogram or three-lead cardiac
to goal MAP >65mmHg. Vasopressors should be adminis- monitoring is available on DDG).
tered by role-based approved protocols or teleconsultation • Gastrointestinal prophylaxis medications are probably not
approval. indicated in this patient. If the patient requires intubation,
• Norepinephrine drip range: 2–20μg/min, titrate up or down he may benefit from such medications. Minimum: raniti-
by 2μg every 2–5min as needed (pro re nata or as needed). dine or famotidine oral. Better: omeprazole oral. Best: pan-
Onset: rapid, peak: 1–2min. (Note: not available on DDG). toprazole IV/oral or H receptor blockers IV/oral. (Note:
2
• Epinephrine drip range (Table 2): 1–10μg/min, titrate up not available on DDG).
or down by 1μg. Onset: rapid, peak: 1–2min. (Note: only
epinephrine 1:1000 vials on DDG). To dilute to 1:10,000, Routine Nursing Care
mix 1mg/mL ampule (1:1000) with 9mL of NS. • Plan for nursing and daily progress note documentation. 20
• Ensure unimpeded flow of vasopressor and check IV site • Document full assessment and nursing progress notes for
frequently for any signs of extravasation (blanching of skin significant events, as needed.
over vein, hardness of vein, and pallor to extremity). Check • Maintain head of bed elevation >30 degrees.
the IV site that is infusing vasopressor hourly. • After initiating vasopressors, BP readings need to be taken
• Label the bag with the type of medication, concentration, every 5min for proper titration for the first 30min and then
and the time and date initiated. every 15–30min for the next 2–3h. All other vital signs
• Other medications may be advisable based on the recom- should be recorded hourly.
mendations below. • Depending on the patient’s ability to move, consider reposi-
tioning every 2h. Given that vasopressors are currently being
Pain control: titrated, the patient is not likely a candidate for ambulation.
• Acetaminophen for pain control (it has no benefit for treating
fever unless pyrexia; temp >39.5°C). Max dose 1g every 6h. Time: +8h
• Avoid non-steroidal anti-inflammatory drugs (NSAIDs) such • HR 110 bpm; BP 98/66mmHg; RR 25 breaths/min; O sat-
2
as ibuprofen due to the risk of renal impairment. uration 96% on room air; temp 38.5°C.
TABLE 2 Epinephrine 4μg/min (1:10,000) Bag Reference Chart*
Normal saline bag size Add to bag epinephrine Starting dose, Drip set: 10 drops/mL Drip set: 15 drops/mL
(0.9% NaCl) 1:10,000 μg/min Drip rate: drops/min Drip date: drops/min
50mL 1mL (100μg) 4 20 drops/min 30 drops/min
100mL 2mL (200μg) 4 20 drops/min 30 drops/min
250mL 5mL (500μg) 4 20 drops/min 30 drops/min
500mL 10mL (1mg) 4 20 drops/min 30 drops/min
1000mL (1L) 20mL (2mg) † 4 20 drops/min 30 drops/min
*Adapted from Prolonged Casualty Care Clinical Practice Guidelines. 5,9
† Not recommended. Commits a high volume of epinephrine to a large bag of intravenous fluids; may waste intravenous fluids if epinephrine
needs to be discontinued.
NaCL = sodium chloride.

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