1. ABC’s. The patient’s airway is patent, breathing is labored, shallow, and fast. Breath sounds are diminished in all fields with fine crackles in lower lobes. Skin is cold with delayed cap refill. Quickly work on assigning tasks to your team. Someone should be getting vitals, obtaining access, and undressing the patient. Consider BiPAP or a non rebreather if unavailable immediately.
2. Use your facility’s warming devices, such as a Bair Hugger and warm blankets. Ask the provider if a Foley temp probe or esophageal temp probe is appropriate. As you are assessing your patient, keep other parts of her body covered and warm.
3. Septic work up labs - CBC, CMP, Lactic Acid, Coags, Blood Cultures, POC glucose. Consider a stat chest x-ray, VBG/ABG. A bedside echo may be indicated.
4. Small amounts of warmed fluids may support the hypotension, but a plan should be made to start pressors (or at least have them ready).
After getting the patient undressed, under a warming device, placed on BiPAP, a chest x-ray is obtained and shows bilateral diffuse infiltrates in upper and lower lobes. COVID should be considered. The patient’s HR is down to 110’s, but the blood pressure is not improving. MAP is 53 and dropping. The patient is becoming increasingly agitated. The ABG shows a pH of 7.07, CO2 65, HCO3 28, SpO2 99%. The patient is started on Dobutamine.
5. What is the mechanism of action of dobutamine?
6. Why is dobutamine indicated in this scenario? What is your starting dose? Is there a better option?
7. Should the patient continue on BiPAP? Why or why not?
8. The ICU in your facility is full and you are making plans to keep this patient for several hours. What should you anticipate as an ER RN?
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