Elizabeth Blair Archibald

Gold Beach General Hospital 11/21/17

Emergency Department

62-year-old female (83.5 KG) present to emergency department via ambulance. Patient was on
vacation with her family from Medford, and was having coffee with her family this morning
when she fell over and onto her face. She was unconscious. Family member started CPR, and
called 911. Later, family reported that patient is a heavy drinking (at least a fifth of hard ETOH
per day), smokes 1/2 a pack a day, and uses THC. They stated that patient seemed sluggish
for about 3 days, but they thought it was because of her drinking. Patient has no known
allergies.

Patient has co-morbidities of HTN, a right hip replacement, and metabolic syndrome. Patient is
on Lisinopril 5 MG, and Vitamin D3 at home.

The code crew was ready for the patient before she arrived. On arrival, the patient had a GCS
of 5 and a CBG of 197. Patient had pale, dry MM, with a large abdomen. The respiratory
therapist intubated the patient (7.5 Fr, 23 CM at gum line), the pharmacist got medications
prepared, the nurse instilled a second 18 G catheter to the left AC and pushed sedation per
doctors orders, and the nursing student applied the EKG leads. NS was initiated wide open.
Patient was not breathing well on her own, and so the nursing student bagged the patient with
BVM per doctors orders. Pink color of perfusion returned with manual breaths. BP on arrival =
211/99 mmHg.

After administering Fentanyl for sedation, the patient was taken to radiology to have a head CT
performed without contrast. Patient was bagged for entire imaging process.

After returning from CT, patient was put on a SIMV, 400 tidal volume, mechanical ventilator
with an FiO2 of 60% (titrated down from 100%).

Copious amounts of serosanguinous liquid deep suctioned from patients lungs by RT. RT
infused sterile saline to break up secretions and re-suction.

Labs showed: elevated- MCV, MCH, RDW, PT/INR, GLU, ALK PHOS, AST, LACTATE, PCO2, PO2,
HCO3, SAO2, and decreased- CREA, PH, TCO2, and BASE EXCESS.

Increased MCV, MCH, and RDW are all related to alcoholism and a folate deficiency.
Increased ALK PHOS, AST, and PT/INR is related to liver disease.
Results of PH, PCO2, and PO2 reflect respiratory acidosis.
Elevation in HC03 is the kidney trying to compensate for acidosis.
Elevated Lactate is related to respiratory acidosis.

Pending blood cultures.

Patient had a blood alcohol level of 0%.
EKG showed a sinus tachycardia with prolonged QT interval.

Chest radiographs showed patchy lung opacities in the left lower and right upper lobes
consistent with pneumonia. ET tube seen in imaging.

Head CT showed a large area of cystic and gliotic encephalomalacia to left posterior temporal
lobe, consistent with an old infarct. No bleeds or masses visualized.
Nursing student initiated insertion of OG tube and Foley catheter.

DAR #1
1030; 11/21/2017
Diagnosis: Risk for aspiration R/T abdomen ascites, AEB instillation of 16 french OG tube, and
removal of copious amounts of serosanguinous fluid with intermittent low wall suction.
Action: Nursing student passed an OG tube in a clean fashion.
Response: Placement verified by injecting a bolus of air into abdomen while auscultating
concurrently. Air heard through bubbling of abdominal fluid.
Student Nurse, Liz

Dar#2
1130; 11/21/2017
Diagnosis: Risk for electrolyte imbalance R/T low urine output AEB no urine being produced
one hour after Foley catheter was inserted.
Action: Student placed a Foley catheter into patients urethra and bladder in a sterile manner.
Response: U/S of bladder with doctor showed an empty bladder. Foley balloon could be seen
in bladder with ultrasound.

Meds given: Total 500 MG of Fentanyl, 100 MG of Versed, 10 MG of Rocuronium, 20 MG of

etomidate, and 150 MG of Succinocoline. An infusion of IV Levoquin was given post blood
culture draw.

Generic and Trade Name: Fentanyl, Sublimaze

Class: Therapeutic: opioid analgesics /// Pharmacologic: opioid agonists
Dose/Route/Rate: 500 MG given total IV push
Onset and Peak: 12 min (O) 35 min (P)
Intended Action/Therapeutic Use: Sedation
1 Adverse Reaction: Apnea
Nursing Implication: Continuous monitoring of RR.

Generic and Trade Name: Midazolam, Versed

Class: Therapeutic: antianxiety agents, sedative/hypnotics /// Pharmacologic: benzodiazepines
Dose/Route/Rate: 100 MG total given IV push
Onset and Peak: 1.55min (O) rapid (P)
Intended Action/Therapeutic Use: Sedation
1 Adverse Reaction: Phlebitis at IV site
Nursing Implication: Monitor IV site for erythema and infiltration.

Generic and Trade Name: Rocuronium, Zemuron

Class: Therapeutic: neuromuscular blocking agents-non depolarizing
Dose/Route/Rate: 10 MG total given IV push
Onset and Peak: 1 min 0.51 min
Intended Action/Therapeutic Use: Sedation
1 Adverse Reaction: Bronchospasm
Nursing Implication: Continuous monitoring of oxygenation.

Generic and Trade Name: succinylcholine, Anectine, Quelicin

Class: Therapeutic: neuromuscular blocking agents-depolarizing
Dose/Route/Rate: 150 MG total given IV push
Onset and Peak: 0.51 min (O) 12 min (P)
Intended Action/Therapeutic Use: Sedation
1 Adverse Reaction: Hyperkalemia
Nursing Implication: Monitor electrolytes for rises in potassium.

Generic and Trade Name: Levofloxacin, Levoquin

Class: Therapeutic: anti-infectives /// Pharmacologic: fluoroquinolones
Dose/Route/Rate: 150 ML bag IV infusion
Onset and Peak: Rapid (O), end of infusion (P)
Intended Action/Therapeutic Use: Treat possible sepsis.
1 Adverse Reaction: Elevated ICP
Nursing Implication: Check GCS every 15 minutes

Many sedative agents were used because patient had a high tolerance to depressants, and was
coming out of sedation quickly.

Currently, physician is unsure what is going on with this patient. The plan is to stabilize, and
transport. Ideas of what is going on: Probable Ischemic Stroke, possible PE, possible sepsis.

Doctor did not initiate TPA, because patient has an area in the brain that he suspects will cause a
bleed if TPA is given.

Patient did not produce any urine after one hour with Foley instilled into bladder. Doctor
confirmed that he wanted to continue infusion NS wide open, and mentioned that the lack of
urine could be due to the paralytic agents given.

Patient transported by life flight to Providence in Medford, Oregon.

When patient left for transport her BP was 110/60
The EMTs were given orders to keep systolic blood pressure up around 180 mmHg, and to bolus
the patient with NS because she was not producing urine.