This is From Novice to Night Shift, an original production from the Emergency Nurses Association. This Audible series takes you into the world of emergency nursing, where experienced professionals share real-life scenarios, discuss critical cases, and reflect on the challenges and triumphs of working in this dynamic field. Whether you're just starting your journey or a seasoned pro, this series is your go-to for expert insights and relatable stories from the front lines of healthcare. Now, here's From Novice to Night Shift. Hi, welcome to ENA's From Novice to Night Shift, an Audible learning series where experienced emergency nurses talk and explore real-life nursing scenarios, discuss critical cases, and share our experience as healthcare professionals. I'm your host, Monica Escalante-Kolbuck, the Director of Novice Nurse Education Programs at ENA. I'm joined today by two incredible nurses with extensive experience in emergency nursing, Greta Pemsil and Amy Tubbs. Hi, I'm Greta Pemsil, Program Development Specialist here with the ENA. Hi, I'm Amy Tubbs, a Program Development Specialist at the ENA. Before we jump into it, I think it's important for us to have a timeout and pause to recognize the patients that we're about to talk about. The topic we're about to dive into feels like we're always talking about it. There's a month dedicated to it. Everybody does a capstone project on it. I don't know if I've walked into an ED that doesn't have a bulletin board about this. Today, we're going to be talking about sepsis. It's one of my favorite topics. Did you know that 97 percent of nurses and 100 percent of physicians state that they're familiar with the word sepsis, but only about 30 percent of the physicians and six percent of the nurses can correctly identify sepsis criteria. It's pretty low numbers. It's pretty low. Just a quick reminder, if you're interested in the article Amy's talking about, all of the references we use can be found in the episode reference list. Amy's going to take the lead in the case study today and walk us through, because she's our sepsis guru, on understanding sepsis and septic shock. So Amy, what are we talking about today? All right. Are you ready? Yeah. Let's dig in. So we have a 64-year-old female who was brought into the ED with her two daughters for weakness and just not acting like herself. I mean, that in itself is a red flag when family or close friends say that somebody isn't acting themselves. So keep that in mind. Yeah. Especially when they're older, so many things to think about. Stroke could be infection, could be a behavioral health issue. Could be drugs. Could be alcohol intoxication. Right. So there's all these things we're thinking of when they come into triage and those are the two complaints that you initially have. So in triage, the daughters both stated that their mom is usually very active, lives on her own, lives actually down the street from one of the daughters. And the older daughter said that her mom goes on walks every single day and that they typically see her on those daily walks. She usually stops in and says hi and continues on with her walk, but they hadn't really seen her walking in two days. And while that's not super unusual, they started to get concerned. So they went over to check on her and they found her laying on the couch, napping in the middle of the day, which is not like her at all. And when they got there, she was alert, but pretty lethargic. And she told her daughters that she just hasn't really been feeling well. And she said that she has been extremely tired over the past couple of days, complaining of nausea, some abdominal pain and back pain. She wasn't really able to speak in full sentences in triage because she was so lethargic and short of breath. All right, let's pick apart the information that we currently have here. So we have an older female adult feeling lethargic. She's not acting herself. She's also having abdominal pain, back pain, and nausea. But even more important is that she's not able to provide her own history, since she's so short of breath and lethargic. What are some differential diagnoses that we're thinking about in this just immediate presentation? I mean, there could be quite a few, influenza, pneumonia. Right, depending on the time of year as well, we can't forget infectious diseases. So those are both super logical differentials to consider. She's complaining of abdominal pain, right, and nausea. Could it be gastroenteritis? What about kidney stone is another one because of the back pain. These are all possibilities. Yeah, she also, I mean, shortness of breath as well as PE, heart failure. So many things that could be going on. And as emergency nurses, we always have to think of the worst case scenario and go from there. So to your point, what are the bigger, more critical red flags that we should be considering? The PE, the congestive heart failure, maybe stroke. If in her presentation, I would agree those are things to rule out. For stroke, Amy, I'm sure the triage nurse performed a quick stroke assessment. Do they use like BFAST or FAST-ED? For those who aren't familiar with this, it's a simple field scale to help identify large vessel occlusion strokes. And that's based on the NIH, the National Institutes of Health Stroke Schedules. We'll add a link in the reference list so you can go learn more about it if you're interested. So what are the other information was provided at triage for her? Well, the daughter said that she had a history of hypertension and AFib and type 2 diabetes. Did the triage nurse get a glucose by chance? Not in triage itself. We did in the back and I think it was around 288 or so. Her vitals in triage were a blood pressure of 90 over 40 with a MAP of 56, heart rate of 104, an O2 set of 78%, a respiratory rate of 32, and her temperature was 102 degrees Fahrenheit. The triage nurse put her as an ESI-2 and placed her on oxygen via non-rebreather and brought her straight back to a room. She also called... Say it, don't say it. I want to break this down a little bit more so we can get into what she called. For our novice nurses, I want to point out something. Based on the initial patient presentation, the priority for this patient is to start oxygen and get her back to her room, right? Right. Okay. Yeah. Pardon the... Airway breathing? Airway breathing. Yes. So when a family starts pulling out the grocery bag of medications or they start talking about the primary doctor, all that stuff, defer all of that information for when the patient is in a treatment room and is more stable. That's like a, you know what? We'll get that later. Yeah. We need to bring her back right now. That's kind of how I deal with that. Okay. So Amy, she's brought back to the room. Now go ahead and tell us what the triage nurse called. Dun dun dun. A sepsis alert. Nice. Bingo. Every ED has policies and protocols. So make sure you understand what yours are and what your hospital considers a sepsis alert and what warrants actually calling that code sepsis or whatever you call it in your facility. Generally, most EDs follow the national guidelines, but there may be some slight variations in your ED. So make sure you know what yours is. We'll provide links in the episode references so you can see examples of some sepsis screening tools. Okay, Amy, now break it down for us on how this patient meets sepsis criteria. So like Monica just stated, sepsis criteria and sepsis alert criteria does vary from facility to facility. Some facilities require organ dysfunction to be present to call the sepsis alert and triage while others do not. So this patient had a temperature greater than 100.4 and a heart rate greater than 90, which automatically gave her two SIRS criteria. You need two SIRS criteria and a suspected infection in order to call a sepsis alert. Some facilities may require organ dysfunction. And in this case, the patient was hypotensive with a MAP of under 65 as well. So Monica, do you remember when we were out teaching and there was so much confusion with the new grads about SIRS versus sepsis? Yes, they were so hung up on whether or not it was SIRS or sepsis and whether or not, like, should I call a code? Should I not call a code? And I remember us thinking sepsis is just all about time. You like that? I do like that. Yeah. And so does the Sepsis Alliance. That's why they came up with it. Because they're so smart, the Sepsis Alliance. So they created an acronym that is called TIME and that stands for temperature, infection, mental decline, and extremely ill. I also like to teach new grads though that SIRS is a part of sepsis. For our novice nurses and maybe other nurses too, because apparently only 6% of us know the difference. Can you explain the difference between SIRS versus sepsis? All right. So SIRS, this is how I teach all my nurses. SIRS is the systemic inflammatory response syndrome. It's what our body does when we respond to any sort of infection or fungus or bacteria or virus. We might develop a fever, our heart rate might go up and we might have tachypnea. So those three things are part of SIRS criteria which also includes an elevated white blood cell count. Sepsis is then when the patient has two SIRS criteria and a source of infection or a suspected source of infection. So those are your definitions. So why don't they call it SIRS alert versus sepsis? From triage, like I'm calling a SIRS because they meet SIRS criteria, but not sepsis. But wait, when does it, sorry, say that again. The definition of sepsis is I suspect or have a confirmed infection plus two SIRS criteria. So SIRS is just criteria. SIRS is just criteria. And sepsis is the actual, okay, now we have the source of the infection. All right, let's get back to the case then. So at this point, she was triaged and code sepsis is called overhead and now the patient's being wheeled from triage. Right, I saw her getting wheeled from triage to the room and she did not look great. Who, the triage nurse or the patient? In this case, it was the patient. She was mottled, pale, looked absolutely exhausted. And you could tell she was having a really hard time breathing. And her daughters were obviously visibly upset. I mean, diapers, I'd be upset too. She doesn't sound very well. So basically you got her into the bed, started getting her into a gown. Yep, all that standard stuff we do with patients when they come to the room. We got her into the bed, put her in a gown, put her on the cardiac monitor, grabbed an EKG, and we're already starting to do vitals again while we were grabbing stuff to start an IV. The tech took her glucose because of her history of diabetes and the fact that she was altered. Okay, all that. We got her into the bed, put on her gown, put her on the cardiac monitor, grabbed an EKG, and we're revitalizing her all at the same time while grabbing stuff to start an IV. Usually at this point you would get the glucose. You guys did that already though, right? We mentioned it earlier. Yep, mentioned it earlier. Okay. Around 288. 288, all right. So she has a history of diabetes and glucose. You're also checking to maybe rule out hyperglycemia because of the altered mental status. So explain to our new nurses, why are we doing the EKG? Well, the patient presented with tachycardia and a history of atrial fibrillation and hypertension. So all our risk factors referring to heart disease. So we know that females present differently for cardiac emergencies and especially patients who have diabetes. So grabbing an EKG is pretty essential. Got it. What did the EKG end up showing? It showed atrial fibrillation with a rate of 106. Well, at this point we can rule out a STEMI or an ST elevation myocardial infarction and a lot of other cardiac emergencies. So what's the routine treatment for this dysrhythmia? At this point, we're not gonna do anything to treat atrial fibrillation. At this point, the AFib is likely related to the fact of her disease process that we're currently talking about. So we're not gonna treat the heart rate and the AFib necessarily with any medication. And we know that AFib at rapid rates can cause a significant drop in the cardiac output, but the current rate that you're talking about was what? 106? So it's not likely the cause of the patient's hypertension that we're talking about. Right. Because remember, her BP was 90 over? 40. 40 in three hours, okay. Yep. So cardiac monitoring is necessary, but we're not gonna actually treat AFib at this time. But had it been rapid AFib that required treatment, then we would actually be debating between cardioversion or administration of an anti-dysrhythmic medication, such as diltiazem. That's right. So no treatment for the AFib. Moving on, what's next? All right, so since the code sepsis was called or the sepsis alert, whichever verbiage your facility uses, another nurse came in to help and I was already starting an IV and we needed to draw labs for our sepsis panel. What is included in your sepsis panel. In my sepsis panel at my hospital, it's a CBC with differential, a CMP, coagulation studies, a lactic acid, blood cultures, times two, a UA with a reflex culture. And for this patient, since her chief complaint is abdominal pain and shortness of breath, we're gonna be getting a chest X-ray and a CT abdomen and pelvis. Oh, and we also drew ABGs because of her respiratory status. Well, that makes sense. Can you just take a second to walk us through why getting those blood cultures are so important and how you actually go about doing that? It's hugely important. Do you know why? Part of the reason why it's hugely important? I feel like you're gonna tell us. I am. Are you ready for it? Drop the knowledge bomb. 30 to 50% of blood cultures actually come back positive. So the patient has bacteremia. So it's hugely important that we draw blood cultures correctly from two sites and follow our hospital's policy when it comes to how to draw them, because we wanna make sure that we correctly identify the source of the infection. Yes. Yeah. Let's take a second here to explain the lactate. So in most EDs, it's a gray top that goes on ice, but that's not always the case for everybody. Greta, your hospital, we've talked about this before, your hospital, what color is it? A green top. And in mine, it's a mint top, not on ice, because we run point of care. Oh, interesting. Do you guys know why it goes on ice though? I actually don't. Do you know, Greta? I always count on Greta for knowing these things now. Okay. Lactate can be produced because of the ongoing metabolic processes, especially when the cells are deprived of oxygen. So when you place the sample on ice, it's actually slowing down the metabolic process and reduces the production of more lactate during transportation. So placing it on ice ensures that the measured lactic levels accurately represent the patient's physiological condition at a time that the blood's collected. That's right. So serum lactate, which we just call lactate, is a chemical compound in the blood and it plays a crucial role in our body's energy production metabolism, right? Go back to like physiology, pathophys. So lactate is produced during the breakdown of glucose in the absence of oxygen. That's anaerobic metabolism, right? So when we put it on ice, we're capturing that point in time what that lactic measurement is. Well, I would slow down if I was put on ice too. But anyway, lactate is actually an important marker of tissue oxygenation and overall metabolic health. What's the range for lactic? Well, normal serum lactate levels are typically less than 2.0 millimoles per liter. However, values of up to 2.2 millimoles per liter can still be considered normal in some labs. It just kind of depends on where your hospital lab, how it works. So overall, let's sum up serum lactate. It's an indicator of how well the body cells and tissues are receiving oxygen and energy, right? So when there's sufficient oxygen available, the body primarily uses aerobic metabolism to produce energy. Serum lactate is indicator of how well the body cells and tissues are receiving oxygen and energy. So when there is sufficient oxygen available, the body primarily uses aerobic metabolism to produce energy. Do you know of other reasons why lactic acid can be elevated other than an infection? Sure, people working out, having seizures. Heart failure, cancer. Lactic levels are critically important when assessing sepsis because it serves as an early indicator of inadequate tissue oxygenation, which can result from conditions like sepsis. So monitoring lactic levels can help identify patients who are at risk or in the early stages of septic shock. So the lactic acid actually also tells us about sepsis severity. Higher lactic levels are associated with more severe cases. What else, Amy, can you tell us? Lactic levels can be used to monitor a patient's response to treatment and a decreasing lactic level over time can indicate that the interventions that we're doing are improving oxygen delivery. Lactic levels are often incorporated into other sepsis scoring systems. All right, so let's get back on track. We're talking about labs here. We explained the correct way to draw blood cultures. Then we talked about the importance of lactate. The primary problem in septic shock is vasodilation and capillary leak, right? Absolutely. So while I was drawing the labs, radiology was already at the bedside and the other nurse was already preparing the fluid bolus. For our novice nurses, really the purpose of the fluid bolus is to help with volume replacement. Yep, but remember that the compromised capillary system lacks the ability to sustain intravascular fluid. Ultimately, the vessels are constantly leaking fluid into the interstitial space, which is why we're putting fluids back into the vessel with the bolus. But we also start vasopressors too. Sometimes. Sometimes. Can we go back to fluids for a minute? Yes, of course. Because she was hypotensive at 90 over 40, we started with the 30 mLs per kg of 0.9 NS, which is a crystalloid. All patients are weighed in triage in kilograms, but since she wasn't able to stand weight in triage, we used the bed to weigh her. She weighed 75 kilograms, so you say 75 times 30 mLs, and that gives us 2250 mLs. A lot of times, if the patient's clearly septic and hypotensive, you're not gonna wait until the bolus is completed before starting vasopressors, right? I mean, that's what I would do. Right, but again, this varies by provider to provider and probably place by place. You can start vasopressors at the same time that you start fluids, or a lot of providers will wanna give fluids to see if the patient responds and then initiate pressors. All right, so all the blood's been drawn and sent. Radiology just took the chest X-ray, and because it was a code sepsis, a lot of people are responding, including respiratory, who drew the ABG. I was busy hanging fluids and getting meds. It's important to point out here, and I know we always do this during our case discussions, but we're picking apart this case like minute by minute. This whole time we've been talking, the reality is everything that we've been talking about has been what, maybe 10, 15 minutes? Yeah, I'd say probably around 15 minutes or so. All right, so we're pulling apart each piece to analyze the case, but in truth, all of what Amy's talking about really is happening simultaneously as a team. Right. For anyone listening out there, we are very well aware of this respiratory status of the patient. Because I'm sure when you told us the O2 stats, everyone was like, yes, she was on 78% on room air. Respiratory rate was what, 32, 30? 30? 32, 32. Okay. Yep, and we had placed her on the 15 liter non-rebreather as we pushed her back to the room. And when we retook her vitals, her stats had increased to 91% on the non-rebreather. So at this point, the provider's thinking, I would hope they're thinking about intubation at this point. Oh yeah, and the ABGs and the other labs are already starting to result by this point. Can you tell us what the ABGs were? Yeah, so her pH was 7.2, her partial pressure of carbon dioxide, or her PaCO2 was 60, and her bicarb was 22. All right, let's calculate the, now you're gonna make me do ABG calculations here, okay. So what are we looking at? Oh, respiratory, what? Eskimosis. There you go. She was hypoxemic, which is different to say she was hypoxic. Right, hypoxemic is low oxygen in the blood, whereas hypoxic is low oxygen in your tissues. The reality is both aren't good, but there is a difference, right? At this point, the patient is experiencing severe uncompensated respiratory acidosis. That's correct. So she was unable to maintain adequate oxygenation and ventilation independently. So at this point, our solution was to intubate. So basically between you and a respiratory, you're getting all the equipment needed, pre-oxygenating the patient, and then of course, grabbing the meds. Yep, and capnography was set up. So we medicated with etomidate and succinylcholine. The ED physician intubated successfully, and we had a positive color change. Radiology was then called to verify placement, and the charge nurse stayed with the daughters in the family waiting room to explain everything to them. All right, let's recap medications for us. What did you give? We'd given the fluid bolus at 30 ml per kg, rectal acetaminophen for the fever, started norepinephrine at eight mics a minute, and then I used the 16 mic per ml, and it came in a 500 ml bag of D5W, and titrated it in increments every 10 minutes or so until I achieved a MAP of 65. I also started a broad spectrum antibiotic. Were you able to hit that golden hour of the antibiotic? I was. Yeah, I know you did. That's awesome. That's actually the goal, to get the antibiotics. When you know shock is present, get the antibiotics started within an hour of recognizing it's sepsis. The ICU resident happened to be in the ED, saw the patient, and deferred the ART line until the patient was in ICU. They were gonna place a central line once the patient was upstairs, because we don't want the norepinephrine running through the peripheral IV for a long time. Yeah, it's a pescant. All right, so you intubate, medicate, and now you're looking at labs, getting the patient ready for ICU, placing your OG urinary catheter, what else? Yep, we place the urinary catheter, and guess what was it? Bingo, the source of the infection. Dark amber urine that was cloudy with red streaks and pungent. Yeah, possibly the source. So it makes sense, given she was complaining of abdominal pain and back pain. Yep, and once we were able to stabilize her pressure, we took her to CT. So really at this point, you're back from CT, pressures are better, you're checking the patient's reaction to the fluids, ensuring that you're not overloading her, seeing how she responds to the vasopressors and checking all the labs to prepare to give report to ICU. Exactly. So can you update us on the vitals at this point after all the meds? All right, so at this point, pressures were about 90s over 50s. Heart rate was around 90 to 100 per minute, 100% with the ventilator settings of a PEEP of five, respiratory rate of 12, and 100% O2. She was breathing over the vent a little at 24 breaths per minute. What about the labs? All that talk about the lactate, now I'm curious, what was it? Are you ready for it? Yeah. 6.6. It's pretty elevated. Wow, that's pretty high. I've seen higher. Bet you have. Agreed. The only ones I really recall as being abnormal were her white count of 28,000, the BUN of 56, her glucose spiked to about 320, which is actually a lot better than being hypoglycemic. That can also happen as you progress in septic shock. And then her potassium was 5.2. So what did they order at this point to treat the glucose and potassium? I gave insulin, and while the potassium was right on the cusp, by giving insulin, we were pushing the potassium back into the cells. So no treatment required at this time for her potassium. But I wanted to make sure I noted it for report to ICU so they could keep an eye on both the glucose and the potassium levels. I mean, it sounds like you guys were able to hit the target metric. So you identified sepsis immediately, you called the alert, and you got all the right treatment for this patient in a timely manner, right? That's awesome. I was pretty proud of ourselves. Yeah, I bet. I was eventually assigned a bed, and then we called report to ICU. Well, it sounds like you really did a nice job, Amy. And as someone who has been a sepsis coordinator, if you could give any advice to novice nurses in recognizing sepsis, what would you say or how would you actually recap this lessons learned from today? I would say stop and think. The question in your triage screen is, do you suspect an infection? What are the family members telling you? What is the patient saying? What are their complaints and what are their vitals? Because chances are, that is the biggest question always missed is, do you suspect a source of infection? Because we- And don't doubt yourself. As nurses get so clicky with click charting that we just kind of get in the habit of saying no. But you wanna cast a big net in order to capture as many patients as you can by calling sepsis. That's awesome. I think that sums it up for today's episode. Thank you, Amy and Greta for sharing your insights and experience on this case of sepsis and septic shock. And to our listeners, we hope you find this episode informative. Remember to always follow provider orders and your individual hospital's policies and procedures. Make sure you go to your ENA learning profile and complete the post episode evaluation. And as always, if you have any questions or wanna share your own experiences or cases, we would love to hear from you. Reach out to us at residency at ENA.org. Until next time, stay safe, stay compassionate, and remember that as emergency nurses, we play an essential role in saving lives and making a difference. Thank you for joining us today on From Novice to Nightship. Enjoy listening to the next episode. ♪♪♪

emergency nursing

sepsis recognition

critical thinking

patient outcomes

nurse's role

medical condition