brock8024

Is the patient White, African American, Native American, Hispanic? I would ask him to remember 3 things and see if he could repeat them to me. Does he have any siblings? Any thoughts of suicide? Shots UTD? Any allergies to foods or meds? Family Medical Hx? Does he take any supplements meaning for sports supplements or vitamins? Does he wear contacts or glasses? Any night sweats, new weight gain or loss? Any change in bowel or bladder habits? Any new skin changes, bites, rashes? Any new SHOB, Chest Pain, Palpitations? Any new muscle weakness or cramping? Any new drainage from nares or ears? Any change in taste, bleeding gums? Any change in hearing? Any new visual changes? Balance problems? Skin Turger? After all of this lets see if he remembers the three things I asked. Lets check all 12 cranial nerves, cardiac monitor, 12 lead, IV, set of vital signs please.

I know we learned that when you intubate it can stimulate the vagus nerve causing some bradycardia. someone please correct me if I am wrong. What was the results of the EKG and other test done. What was the guys Hx? That can tell us alot. I was in the ER once and had this happen. They went to tube the guy and next thing you know in the middle of it he went into arrest. Brock

Ok I will say sorry again. I guess when I said 150mg in 25ml in 10 mins but this time I will say with a 60drop drip set. You have the amount to be infused and the time to infuse it. I would hope that if you are giving a drug and the doctor asked how much was given you could look at the amount left and tell him. I will admit that I did not know we was giving 6mg/min. I know realise that it is easy to figure up the amount given. I will agree with that. I guess my thing was that wether I give it 150mg/25ml over 10 min or he gives it 150mg/30ml ivp in 10 min there is really no difference. I would also hope that all paramedics are taught to give all drugs through a 60 drop micro set. I guess the point I was trying to make was that sometimes we have to be able to figure out drip rates and be able to use micro drop sets sometimes. And your reply makes no real sense to me. I was able to figure out that I am giving 6mg/ml is 15mg/min because you give 2.5ml a min which is 150mg over 10 mins. you just have to do the math to figure it out.

brock8024 - 150 in 25 is 6mg/ml. At 150gtt/min that is what? 80mg per min? 15mg/min? I assume you are using a microdrip? 60gtt/ml? Your second maintenance dosage indicates now it is likely a 60gtt/ml set... If we use this it is 6mg/ml. Now 150gtt/min is 2.5 ml a min which is 15mg/min times that by 10 is 150mg in 10mins. so 150/60= 2.5ml. 2.5mlx 6mg is 15mg/min 15mg x 10= 150mg in 10 mins. I would think this is better than a IV push. they are getting a consentient amount of med over the entire time. with a IV push the med is not as constituent.

brock8024 - 150 in 25 is 6mg/ml. At 150gtt/min that is what? 80mg per min? 15mg/min? I assume you are using a microdrip? 60gtt/ml? Your second maintenance dosage indicates now it is likely a 60gtt/ml set... If we use this it is 6mg/ml. Now 150gtt/min is 2.5 ml a min which is 15mg/min times that by 10 is 150mg in 10mins. so 150/60= 2.5ml. 2.5mlx 6mg is 15mg/min 15mg x 10= 150mg in 10 mins. I would think this is better than a IV push. they are getting a consentant amount of med over the entire time. with a IV push the med is not as constitant.

"Don't use gtt/min when describing infussion of medication. It really means nothing... " I do not understand this comment. How does gtt/min mean nothing, it means alot. Lets say you are using a pump and it breaks and you are in the middle of a transfer. You are going to have to use gtt/min I would think. We are not taught how to use IV pumps at my school for this reason. We can learn that on the job, but they want to make sure we know how to calculate drips the old fashion way and use drip sets incase something goes wrong. We do not get to use drip charts, if we want to use a drip in a code our instructors make us calculate the drug and drip rates on paper. My instructor told us something yesterday that makes a lot of sense. He said give me a paramedic with a good base of understanding and basic materials than a paramedic with a some understanding and high tech materials. I think what he means is iv pumps and monitors that do everything for you is nice, but when they malfunction you got to go back to you basic equipment and know how to use it. So I personally think that Gtt/min does mean alot and works when that pump will not.

vs-eh? I will say I am sorry for using the Gtt/Min thing. I asked one of the doctors I work with to read what I wrote and he said I could have written it more clearly. As far as using a drip set or syringe to push it, he said no difference. He said the only difference he seen was with the drip set it would be going in more constitanly and it would free up a medic. He said if you are having to push the drug that medic is unavailable to do other things. That medic has to watch the clock and make sure he is being constituent with the meds. With a drip it is dripping the same amount over the ten mins and the medic is freed to do other things. So I will say I am sorry for not clearly writing, in my head it sounded right. He said though either 150 in 30ml over 10 mins or 150 in 25 ml over 10 mins is no difference since the amount of drug is the same.

In my class we mix up 150mg in 25ml and drop it at 150gtt/min. This is for WCT. Maintaince for v-fib or v-tach if they convert is 540mg in 540ml and drop it at 30gtt/min which gives you 0.5 mg/min. For v-fib or v-tach we give 300mg IVP then in 5 mins we can try 150mg IVP

If we get to order stuff lets do a Ct of head with out contrast and a LP if that is neg just to rule out a bleed or meningitis. I know in the er where I done my clinicals if there was a HA and CT was normal there might be a LP just to rule things out. What does that side of her head look like and feel like. I am still thinking this is going to be something way out there.

I meant pneumonia that is presenting in a a typlical why

Ok has she had a cough anytime in the past few days. Fever? if this has been asked sorry. Spo2? Line and transport. This may sound funny but she could have a atypical pneumonia.

Understand where you guys are coming from. I had seen where others had posted treatment. You guys are also right in the fact that o2 is not a important thing here but truly how many put o2 on while taking the HX. I was multi-tasking but you are right I did jump the gun on the meds.

If you noticed I said I would call for the meds and I would also look at that is the presentation also. As for o2, I have seen ER docs give it for headaches and it worked. o2 is not going to hurt her at all and if it helps why not.???

Any weird smells in the house? Breathing rate and quality? Pulses? PMH? Meds? Is it localized? Hx of HA before? Any nuchal rigidity? Does anything make it better? Has she been under alot of stress? What does she do for a living? Worse HA of life? How long has she had the HA? What was she doing when it started? Any photophobia? Any N/V? Does the pain radiate anywhere? Mother, Father, Siblings with HA problems or other medical problems? Smoke, Drug, Alcohol use? Tx so far will be IV hep lock, o2 at 3l/m via NC, call for either pain med or benadryl, and sometype of antiemetic if there is N/V.

Ok lets do a complete trauma assessment. Head- HEENT Neck,Chest, Abd Arms, Legs Back, Pelvic V/S, Temp LOC Pulses Lung Sounds Bowel Sounds Percusion of Chest and Abd. Sample Hx or at least best we can do. What time of year is this call taking place. Summer, spring, fall, winter. We know we have our IV, O2, and monitor. If this is hypothermia it would acount for the AMS, Bradycardia, and Hypotension. I am just surprised we did not see any J waves on the EKG. I would also give some warmed O2 and IV fluids depending on how the temp is going.

Well I think this is a funny scenarios due to the fact that two or three people have asked for a 12 lead, but it was never said what it showed. 1)Ok he was found in his pj's, he is 82 so when did gramps normally get up out of bed? 2)When was the last time he was seen in his normal state of mind? 3)Sinus brady on the monitor but what does our 12 lead show. 4)The blood was clotted so that means he could have been laying there for a while. 5)He is skinny and barrel chested which means COPD, but we all knew that 6)His Blood Pressure is low but what is normal for him? 7)FSBS of 60 could just mean that he has not had breakfast. 8)So he urinated and or defecated on himself that could be many things, Like I said how long has he been laying in the floor. 9)He has a AMS but that could be from poor cardiac output or hitting his head. 10)Does he have any pedal edema? 11)He has what sounds like a GCS of about 7 or so giving him the benefit of doubt. 12)When did he have his CABG? I am thinking that this guy might be having a Inferior and Right Sided AMI. This could acount for the hypotension, rate, and the AMS. Right venticle infarct means decreased pre-load which leads to decrease cardiac output. Like I said his FSBS could be from just not eating yet. The urination or defecation from just laying in the floor for a while. The lac to the head secondary to the fall from the AMI. I have not seen many 82 year old smokers that have COPD that breath 10 times a min and have a normal tidal vol. Most are working at it to breath while they puff on that cig. TX- Bag pt with BVM IV and give fluid challenge. If I could not get anything in the arms, I would be looking at the neck. I would consider some type of vasoconstrictor, possible Dopamine or something. I want to help his heart work easier not harder. Monitor with 12 Lead Drop a Nasal ETT down. He might have a gag reflex but I have been told you can intubate someone nasally while they are still awake. This is all I can think off. Personally I think he clogged off one of his new bypass vessels and is in caridogenic shock.

No but I would love to know. LOL

That is awesome ERdoc. See in our book it tells us not to active rewarm due to the possibility of vascular colapse due to vasodilation. See this is a great reason to have doctors on here. So we should try to rewarm but carefully i guess.

Look it up to make sure I am not wrong but that is pretty much what the book says.

I will have to dissagree that you could not make this DX out in the field. We are covering this in our paramedic class right now. In our book there are S/S and how to treat this and many other conditions. It is tue that we are not robots and can not remember everything that we are tought but it is our duty to our patients to read up on our down time and make sure we are up on this stuff esp. the things we do not see everyday. Hell doctors have to do that to keep up on things and I would hope that even nurses do. By the way active re warming in the hyopthermic myxedema coma is contraindicated. It can cause cardiac dysrhythmias and cardiovascular collapse secondary to vasodilation. Or at least that is what is in my book. Brock

Are you sure you want to actively re warm her?

That was to easy. You are right with the myxedema coma. How are you going to treat her hypothermia though?

Your on the right track. On assessment you find the pt to be very very cold. You just happen to have a themomoter on the truck. Her temp is 90F and her skin kind of feels like dough. Pt does have some swelling in her ankles very mild though. Her husband states that over the last few months she has had to use pillows at night to help her breath. Pts husband said she does not drink any acohol. You get in a 7.5 ETT with some difficulties due to her large tongue. You have gained vascular access. BP now 84/p With ventilation her pulse increases to bout 48 and there is no real change in her LOC. Before bed she told her husband she was just not feeling well. He states that there was some SHOB but he did not think it was any worse than normal. As far as a stroke it is hard to assess due to her being intubated and unresponsive. What you going to do for her temp and what is he DX.

You remove the pillows and assist with BVM. What airway are you going to use, and how much O2 On the monitor you see low voltage brady rhythm. Husband said about 4 hours ago pt was not feeing well and went to bed. Pt is over weight about 350lbs. Can walk and is normally responsive. Husband has to help with normal things like cooking, bathing and helping pt dress. PMH- husband states she has not been to a doctor in years. The husband states that she gets tired easy and has not been eating much. He also states that her face has been kind of puffy the last few years but and been a little forgetful but they thought that was due to getting older. Also he has noticed some thinning hair but that runs in her family. What else you want to know

You are dispatched to a residents for a 54 female. All the dispatch can give you is the pt feels cool and is not responding to her husband. When you arrive on scene you find a over weight female in bed with approximently 4 pillows behind her. She is unresponsive and will slightly respond to painful stimuli. You notice loud noisy respirations. V/S- HR 40 BP- 80/palp RR- 6 and labored Spo2- 80% on RA. Capnography- 55 Skin - Very Very cool to touch. What else you want to know and how you going to treat her.