Initial Presentation
The Swarm
Drawing Blood From IVs
Blood draws from EMS iv
Draw everything
Labs keep extra tubes
Is it ok to draw from EMS Lines? Blood sampled from existing peripheral IV cannulae yields results equivalent to venepuncture: a systematic review [10.1177/2054270419894817]
Second Line
18 G
Should we be placing in the AC?
Future Show: Upping your IV Game
Fluids
Get dinged for <30 mls/kg?
Which fluid?
Bolus
Rectal Temps
J Emerg Med 2002;22(2):153-7)
and
West J Emerg Med 2011;12(4):505
Antibiotics
Simultaneous antibiotics
Broad Spectrum First, Injectable First
What Nursing Ratio?
Rechecks
What are You Looking For?
Vitals repeat bp
Repeat lactate
Getting Worse
Sepsis BP RollerCoaster
Peripheral Vasopressors
[] Peripheral Vasopressor Protocol
map<65
fluids first or vasopressors first
Start High
What nursing Ratio?
1:2
Future Episode: Vasopressors and Inotropes
Pass the Plastic
verbal orders written orders readback
resus in situ vs resus room
Future Shows: Intubation, Post-Intubation Package, Post-Intubation Sedation, ICH Management
What Nursing Ratio?
1:2
2nd Vasopressor
future episode: nurse-led code
More on EMCrit
Additional Resources
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Professor
Nassau University Medical Center
No conflicts of interest (coi).
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Great start, looking forward to more! A couple thoughts: one clinical, one feedback. Clinical – You got excited about blood samples being stored in the Lab, but be cautious. After an EMR software update, I thought it suspicious when the delta high-sensitivity troponin lab order appeared for me to “acknowledge,” but collecting it did not appear on my electronic to-do list. Then the value came back exactly the same as the first one – you can see where this is going – and sure enough, the order was to “use existing specimen,” meaning we were retesting the exact same vial… Read more »
Great show! I’ve been an RN in the ED for over 10 years and I really enjoyed hearing how other facilities are handling sepsis protocols. The ED I work at is a rural level 4 trauma center in South Mississippi with 15 beds. It sounds small but some days actually more than not we see 100-130 in a less than 24 hrs. A few years ago we went to Epic and CMS guidelines have been hammered into us which is frustrating to say the least. We have a performance improvement nurse who watches all of our active sepsis cases and… Read more »
Another great podcast. You were asking about the best ways to document emergent meds so they are not verbal orders. At least for hospitals in epic, there is a feature called the code recorder. They get used all the time on the floor for the stupidest minor RRTs, but for some reason our ED never uses it. It allows the recording nurse to put in any medications, and then at the completion the entire code gets sent to the attending physician to be signed as a separate co-signature requiring your password. That is a really handy way to get all… Read more »
Great episode really enjoyed it. Would love to see you do one with a Respiratory Therapist in the future.
Great first episode.
Why not do tympanic temps over oral and rectal?
In Aussie land we go for the TM over oral and only go to rectal/oesophageal in severe hypo or hyperthermia –Temperature measurement in the adult emergency department: oral, tympanic membrane and temporal artery temperatures versus rectal temperature | Emergency Medicine Journal
thank you so very much Scott and Candice King!! great , fun, cool and thoughtful pod. I hope its the first of a great many. I passed it onto a bunch of our team, including our nursing ER coordinator and I asked him to pass it our CNO, to consider sharing hospital-wide and perhaps systemwide. you pod today was concise , clear, and fun.
thank you both.
I work in a large busy very rural-ish (merced, calif –Central Valley) ER, and I know our team would love this and future pods in this series.
tom
Great episode! Would you guys be able to speak more to the layout of your ED/how nursing assignments are made? You mentioned that this septic patient would go to the “critical care area” or “high acuity” space of your department. How many critical care spaces do you have versus actual resus bays? how much extra training/orientation do the nurses have that work in the high acuity space versus the “main ED” or lower acuity areas of the ED? how many beds are in the rest of the department or whatever name you have for the non-sick/critical ED patients? what do… Read more »
Hey Sarah Thanks for the questions back for clarification. We do have 16 high acuity beds spaces in addition to the 3 resus bays. Yes they do get additional training and development for this space as part of my orientation pathways. It is a big commitment to do it that way but I think k anyway you can get it done is worth the time. The swam method is really an expectation of all the staff working in the zone. We dont use a floater but rather good teamwork! But if you can do it with a floater to trial… Read more »
Great love the show format and frank realistic – real world case based discussion – looking forward to more!!!
Drawing labs from EMS lines is not new – at least on the west coast we’ve been doing that for at least a decade. Not blood cultures of course, but standard labs? Absolutely! As long as you draw a waste, fair game.
This was a great article. One thing that I would like to see more is what is the next step of care. I’ve done ED nursing for 12+ years, and started sharing my time in the MICU last year. I’ve gotten a greater understanding of why we do what we do, and what are some of the downstream effects of the care that we provide.
Scott, How come it took so long? We talked about this a long time ago, both online (back in twitter days) and face to face. Always nice to see nursing on the table. Our voice isn’t always heard. We all work in different environments. I’m fortunate in having a multi channel pump at every bed. You have to be careful drawing through PIV’s. One of the problems is cavitation. Suction on the cells. You have no control using vacutainers. Using a syringe allows you to control the tension. Slow and steady is good. Decreases the chance of hemolyzing. Drawing everything… Read more »
Can you make the article links hyperlinked
EMCrit’s 1:1 Nursing 001 on sepsis offers clear, practical guidance that’s essential in critical care. I appreciate how it breaks affordable low cost medical clinic down complex assessment and intervention steps into manageable actions. This approach strengthens my confidence in recognizing early signs and delivering timely treatment, which can significantly improve patient outcomes in sepsis cases.
Thanks for keeping this topic current and check back in on relevant topics like fluid resus without a lactate>4, rectal temps on elderly, etc. Thanks for setting the standards for rounding frequently on these sick patients. One thing to toss around that ends up effecting fluid resus in our ED – I see lots of providers ordering NS because Ceftriaxone – frequently used – isn’t compatible with LR. I dont know if the motivation comes from nursing frustration that they can’t y-sight their abx with their fluids or what, but I do see it happening and I wonder if that… Read more »
We hang Abx and then LR or place 2 PIVs
Just not using NS anymore but more tasks completed on time is best
Excellent podcast. The discussion allowed one to review practical aspects of care delivery and make institutionally appropriate modifications/changes if/where applicable. More and more, medicine is a collaborative/team effort and seeing how other institutions address different clinical situations allows one to more objectively assess what is done at one’s own institution and can possibly be improved. One also picks up little practical pearls from the discussion. I look forward to your continuing with this venue.
Amazing! Candice, I really appreciate your candor on the expectation of the caliber of nurses that are working in these situations. 18’s for adults, 22’s are for peds … so good! If I can’t actually work with either of you, I’m sure this is the next best thing. Thank you for taking the time to put this out there, it’s going to help anyone who listens. Perhaps in the future you could also walk through some unstable or deteriorating patients? I’m in a peds ed now and Benadryl overdoses are too frequent for comfort but not frequent enough to have… Read more »
I have been listening to EMCrit for years now. It is great to see episodes that focus on the nursing angle in the EM. This was a very informative episode. I’m really looking forward to more episodes in the future.