ERDoc

Just to clarify a few things. The absolute systolic pressure for morphine is whatever the doctor feels like it is. It is a matter of how big your cajones are. I would agree that in this case I would probably not give it. Fentanyl might be a better choice. When you have a pt with a suspected or confirmed disection the treatment is to decrease both the blood pressure and heart rate. The pulse acts like a hammer banging on the disection. You want to decrease how hard you hit the disection as well as how often you hit it. For this reason, morphine might not be the best option as you can produce a reflex tachycardia. This is why we give Nitroprusside (reduces BP) as well as esmolol (reduces BP and heart rate). You can reduce the BP enough to minimize the risk of worsening the disection and not compromise the other organ systems. You generally do not have a large loss of blood volume from a disection. Yes there is blood between the layers of the vessel but it is not a large amount. The problems with disections is that they can cut off other important vessels coming off of the aorta such as the subclavians (produces stroke), coronaries (produces an MI), renals (produces renal failure) or mesenterics (bowel ischemia). Aneurysms will become hypotensive and tachycardic when they rupture. Slow leaks will generally not cause any changes in vitals, but you might see an anemia depending on the rate of the leak. Vasovagal episodes can produce vitals such as those that the pt had. A little more experience when you reach 3rd year will show you this. This pt had a great story for dissection and should be treated as such until proven otherwise.

Apparently a huge course of events was set in place when Everrett went down. The following is from an AP article. If we start cooling saline with ice in the ambulance, where are you guys going to keep your lunches? Everett suffered a fracture and dislocation of his spinal cord in the neck area during a game Sunday night against the Denver Broncos. Watching it on television from home was Dr. W. Dalton Dietrich, scientific director for the Miami Project, a spinal cord program affiliated with the University of Miami Miller School of Medicine. The program is among several in the United States that has led research into moderate hypothermia, or cooling the body a few degrees to try to limit swelling, inflammation and the cascade of events and chemicals that cause further damage after an initial neurological injury. Dietrich sent an urgent e-mail to fellow neurosurgeon Dr. Barth Green, who knows Buffalo Bills owner Ralph Wilson. Who did what next is unclear, but doctors say Everett received the experimental cooling therapy in the ambulance, even before X-rays and other tests could show the extent of his injury and the treatment he would need.

Came across this website. I can't imagine why EMS cannot get the respect it should. Feel free to hop in and add your opinion. Maybe you guys can help to educate the poorly educated. Here is another posting on that forum with a similar theme. I'm sure some of our veterans will have a field day with this (cough cough, Dust, cough).

Didn't miss it, just put it off. Good case to remind you that MIs in the elderly can have very atypical presentations. The same is true of diabetics.

I never said anything about the 12-lead (for obvious reasons). This guys only outward sign was the hypotension. He ended up getting a cath which showed significant disease in the RCA. It couldn't be stented and he was not a surgical candidate. His prognosis is extremely guarded.

I will give you the following: wbc 11.2, H/H 32/12.5, plt 220 NA 138, K 3.8 BUN/Cr 24/1.2, Coags wnl, Trop 0.4 (nl for this lab is <0.5), CK 23, UA neg, drug screen neg, cxr as read by the radiologist is clear. You need to justify CT head, ABG, EtOH, ASA and APAP levels. Here is the 12-lead.

Given the circumstances, it seems like we have exhausted the H&P. What do you want to do to/with/for this guy? We can even try to get some labs done.

I didn't say anything specific about Plavix. People were asking about his meds and that was one of them. Then someone asked if he was still on it. It might mean nothing (or it might mean everything). EMSCadet, I will try to answer all of your questions: No exposure, no ingestion as far as the nurse knows. The pt is bed bound and has not fallen. The only ones to visit have been several family members (2 sons, a daughter and a brother). Pt was last seen the night before. He does not self-administer meds. No recent surgeries. The nurse has only known this pt for 3 days and he is not any different from when he arrived. There is no family present. Airway is patent and the pt is breathing and maintaining his sats. There is a weak but palpable radial pulse. No signs of trauma. There is no cyanosis or edema. You are unable to perform orthostatics on the pt. No hives or rash. The pelvis is stable. He is incontinent of both stool and urine. Abd is soft, nontender without masses. Vitals were already given. He can only answer yes/no and when you ask him if he is having any pain, he indicates no.

BPs are the same in each arm. The staff has only known him for 3 days but they do not feel he looks any different. He is still on Plavix. He likes like your typical 80y/o. ABd is soft and nontender. He only vomited once and it did not appear bloody. Stool in the diaper is brown in color.

Actually, HPI, and h/o are pretty standard. HPI=history of present illness h/o=history of PE can have several uses, but from the way I used it here it is physical exam and not pulmonary embolism or pulmonary edema.

The nurse tells you that his BP has been running 110-130/70-90 since he has been at the NH. His temp is 98.3 tympanic.

No abnormal med administration. Pt has h/o htn as well as an MI about 20 years ago. He denies any chest pain or trouble breathing. FS is 115.

Keep it simple. CC HPI PMH PE Interventions Responses Keeps it simple and straight forward. The more he does it, reguardless of what format he uses, the better he will get.

The pt denies being in pain. He did vomit once this morning. He denies being nauseous now. He has not had breakfast due to the vomitting. He is in a private room. He has been bed confined since being hospitalized due to deconditioning and the Parkinsons. Other than the Levaquin he is on no new meds and his doses have not been changed. Your vitals are 62/30, 68, 16, 96%RA. He has NKA and is on atenolol, simvastatin, plavix, Levaquin and Sinemet.

You are called to the local nursing home for a pt that is hypotensive. The nurse that is waiting for you at the door (hey, it could happen) tells you that the pt was discharged from the hospital 2 days ago. He has a h/o Parkinsons and has difficulty verbalizing anything more than yes/no, but he can fully understand what is said to him. He is currently on Levaquin for pneumonia (which is why he was admitted to the hospital about a week ago). They tell you that when they woke him up to check his vitals, his BP was 70/42. What else do you want to know?

Wow, that sucks. To treat hyperK, the best options are calcium chloride (first and foremost as this will stabilize the caridac issues), if you can push only one drug this is what you want. After that, 10 units of insulin IV which will help push the K intracellularly (don't forget to give an amp of d50 so that we don't make him hypoglycemic). Bicarb also helps push the K into the intracellular space. Albuterol is also an option, but not pracitical in this situation from the sounds of it. In an emergency, dialysis it the last line of defense. Your pt will not make it to dialysis if you have not already started to take care of the problem and it may not be indicated if you can correct it with meds.

It looks like the iris is the cornea. It's difficult to explain and I haven't been able to find a good picture online, but you'll know it when you see it. Take a few minutes to look at someone else's eye to see what it looks like. The eye may be small be small, but there is a lot of anatomy and complexity to it.

Sorry about the delay, but this is indeed acute angle glaucoma. As someone stated, there is nothing you can do about it in the field, but it is good to recognize it. I was looking for a good picture, but 2D just does not do it justice, you need to see it in real life. The classic symptoms in this case were the red, watery eye with the iris looking like it was pressing against the cornea with a mid sized, fixed pupil.

I would have to agree with Shane, avoid it at all costs unless you absolutey cannot. The site is painful and an IV will hurt even more. Burns are a huge risk for infection and you are also providing direct access to the systmeic circulation for any bugs that might want to make their way in. You are seriously increasing the risk for sepsis. We don't even put central lines in over a burn and they are done under sterile conditions (gowns, masks, surgical drape, etc).

Ahh. Finally some good questions. I guess no one is up for a good ophtho case (or is it? :wink: ). The pain wasn't sudden in onset. I developed gradually as I described. The daughter called EMS because she became concerned when the pt told her she couldn't see in the eye anymore. "It's not a big deal, I've got another." Has a history of hypertension and cataracts. She had surgery on the other eye to correct her cataract. She was supposed to have surgery on the left eye, but never followed up. Takes Lisinopril. No allergies. Vitals are 126/72, 82, 14, 99%RA, 98.6. Has never had anything like this before. No pain at this time. The right pupil is irregular in shape and minimally reactive. The left pupil is round, 6mm and nonreactive. The eye is very red and tearing. Extraoccular muscles are intact. Both lids are swollen slightly. The iris appears to be touching the inside of the cornea.

"I'm 82. I'm lucky I can walk, much less bend over to clean." No eye drops use.

She tells you that she had a sharp, throbbing pain for the last 3 days that is gone now. The daughter noticed that the eye was red and swollen since yest. Today the pt noted she could not see out of the eye. She said her vision was "milky" for the last 3 days. There is no history of dinnerware induced trauma.

You are called to the residence of an 88y/o woman c/o left eye pain. When you arrive on scene you find a very friendly little old lady with a gauze eye patch. After you think of all of the possible pirate jokes you can think of, what do you want to know?

How does getting a CT scan cause lactic acidosis?