AZCEP

As have I, due to vascular rupture. The patient that ruptures a ventricle will be pulseless on presentation. A vascular injury will be able to generate pulses for a period before the fluid builds up in the pericardial sac. Making blanket statements in any one direction is a mistake. Penetrating and blunt trauma are equally capable of creating the problems that present with either Beck's or Cushing's triads.

Yes, the pericardial sac is closed, but the damage to the underlying vasculature causes the tamponade. Blunt trauma can be damaging enough to cause it. http://www.ncbi.nlm.nih.gov/entrez/query.f...p;dopt=Abstract www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=16302943&dopt=Abstract bja.oxfordjournals.org/cgi/content/full/87/2/309 Just a few examples of a phenomena that doesn't actually happen, eh? Small caliber GSW is one example of a penetrating injury that can create a Cushing's response. What would you consider a skull fracture to be? Blunt or penetrating? Apply enough force to the skull to fracture it, and the bone fragments will enter the soft tissue underlying it, and the Cushing's response will result.

Apply enough force and the nature of the insult becomes immaterial. How do you end up with tamponade following an effusion, if there has to be penetrating trauma? The closed head is not an absolute either. If the pressure exceeds the capacity of the structure to reduce it, Cushing's will resutl.

If you are uncomfortable administering a medication, let your preceptor know beforehand. While it is admirable that you've decided to ask the question, keep in mind that the few medications that intermediates may be allowed to use, probably won't be seen much in your rotations. The clinical setting is set to allow you to go through the steps leading up to giving the medication. The "6 R's" so to speak. Actually giving the drug is of little consequence, once you have the dosing, route, patient, time parts down. Now's the time to learn about medications that you've not been exposed to.

How about the flip side? If you know that you might be killed by someone in the event you do something outrageously stupid, might that prevent you from doing it in the first place? Just a thought. :roll:

Glad to help. Particularly when the question(s) is/are well thought out. Atta boy to AnthonyM83 for taking the time to ask it.

Maybe her, ahem, "assessment skills" were what caused the priapism to abate in the first place. :shock: :shock: :shock:

Maybe she was thinking of other causes not related to spinal trauma. :shock: :wink:

Medic2588 gives a good description of the two, but those are the more commonly found signs of the problems. Beck's triad results from an inability of the blood to return and exit from the heart. Narrowing pulse pressures (decreased systolic), increased central venous pressure(JVD), and muffled heart sounds can be caused by other things as well. Pericardial tamponade is the classic textbook cause. Tension pneumothorax and pericardial effusions can also manifest Beck's. The Cushing's triad is related to the degree of herniation on the pons. This area of the brain stem is where the chemoreceptors (respiratory center), baroreceptors (blood pressure), and cardiac center (heart rate) are found. At the top of this progression is the level of consciousness. As the brain stem herniates, the pressure shuts down the individual centers in a step wise progression. Respiratory-->blood pressure-->heart rate-->LOC. It is possible to have a situation that involves them in the opposite direction, but this is less common.

Wait a minute. The tussin that was in the med list was dosed by teaspoons. How can you take a gel filled capsule dosed this way? If that's what he took, then grandma has been double dipping.

An anticholinergic toxidrome is significantly different from how this patient is presenting. http://www.intox.org/databank/documents/tr...ate/trt05_e.htm The antihistamine effects of benadryl are a possibility since the 21 month old nervous system hasn't fully developed it's parasympathetic response. The more likely cause of the problem, if the eight year old is to be believed is the kiddo got into the Tussin DM. Repeated doses of Narcan have been anectdotally effective, but very unreliable for management of the problem. I'd truly consider letting this patient sleep it off. Maintain vital functions and closely monitor, but the specific treatment of a DM ingestion is supportive care only.

Vitals every 5 minutes. Second IV, fluid bolus, and consider a pressor. Perhaps even a follow up Narcan dose. Without being able to gather the information from the parents, this is going to be tricky at best. A normally healthy, 21 month old should not be reacting this way to OTC cough medicine. If in fact he did ingest it, he would have had to suck down a lot to get this reaction. With the airway secured, I'm less concerned about waking him up now. His heart rate and blood pressure are my focus.

Secure an airway, get enroute to a facility.

Who said anything about glucagon? I think it was a consideration for the possibility of a beta blocker ingestion, but I didn't think we had used it. Heart rate slow, blood pressure well below acceptable, any response to the Narcan?

Any changes following the Narcan/Diazepam? Can we get a blood sugar? While we are doing things, let's get a blood pressure. It's not terribly important, but might give a clue as to what is happening. How about we rule some things out here. Not --anticholinergics: pale skin, afebrile --sedative/muscle relaxants: seizure is unlikely Maybe --opioid receptor agonists, including dextromethorphan: pale, hypoventilating, bradycardic --beta blockers: vitals in the toilet --calcium channel blockers: bradycardia. This is a bit of a reach, but still a possibility --hypoglycemics: don't know what the BGL is yet

The presentation will change a bit based on the involved area(s) of the CNS. The time factor is also going to factor into this one. Let's think this one through: What is the occipital region of the brain responsible for? What will happen when this area is damaged? How is the medulla oblongata organized? Or, what functions will be affected first --> last? Having the opening in the cranial vault will alleviate some of the swelling, partially mitigating the increasing ICP. So why was his respiratory rate so slow, and his BP elevated? How much blood volume do you have to lose to reduce the BP? How does the body compensate for the blood loss in the mean time? It will depend on the degree of the insult. Don't limit your view on this to the blunt/penetrating trauma patient either. A stroke (CVA) will cause the same presentations. We often don't consider them to be a head injury, but they truly are. You may have misread Cushing's triad. This looks like you've mingled Beck's and Cushing's. Equally important, but deals with a decidedly different part of the body. Cushing's triad is an elevated blood pressure/slow pulse rate/irregular or patterned breathing. Also remember, an adult human can't bleed into their cranial vault enough to cause shock. If you have a hypotensive head injury, look somewhere else. Looking for a specific time frame is a mistake. There are some sweeping generalizations that can be made, but you can't really isolate a given time that it takes to cause irreprable harm. Every patient and situation is different. The symptoms of shock do occur to these patients because they are not perfusing other organs as well. After a traumatic injury like you've described, the body will keep the vital areas alive as long as possible, and sacrifice others. The "pecking order" is pretty much set by our DNA. The brain and heart are at the top of the priority list, the lungs, liver, kidneys somewhere lower. The GI,GU,musculoskeletal, and skin come near the bottom. The triggering event is not terribly important. The body recognizes a problem, and keeps the vital areas perfused, and the not-so-vital areas not. All of this results in the signs of shock. I wish more would take the time to understand these things. You are most welcome.

Got to stop the seizure. Kiddo is already hypoxic, and having neuro issues. Could probably use some sugar, particularly following the seizure. All the tools come out for this one. SpO2/EtCO2/ECG/possibly a vent.

Rectal valium to end the seizure, unless it abates quickly. Out comes the Broselow tape, and a dose of Narcan. Vascular access would be a good idea at this point, and a BGL. My guess is this is a DM exposure so I'm not going to expect great results from the Narcan. Just for the information, what size were the pupils?

Can we find anything to support the toxicology assumption? Pupillary response? Pulse rate/quality? ECG? Will he accept an OPA? If not, manual airway maneuver and apply some oxygen as we move out of the house.

This scenario is already not my favorite. Respiratory effort? Signs of trauma? What do the parents know about what happened?

What is "not normal"? How does the kiddo look? How long have they been this way?

I'd suggest not spending the money on a PDA type device if that is all that you are going to use it for. You will find that you aren't using the reference material all that much. Granted, there are thousands of different software options to make it better fit what you need. Check into PDA reviews from any of the major electronics publications. They will give you a good source of the base information for a particular device. Happy hunting.

I applaud anyone wanting to gain more education. The methodology of RN and paramedicine are significantly different, so don't expect things to be taught the same ways. Otherwise, you may find they will complement each other. You will have to make some of the connections, but they are there. Good luck.

This was a big problem on the east coast last summer. Do a search and you will find a number of discussions on this very topic.

In the name of all that is overworked, what is sleddogg trying to say here? :shock: