DartmouthDave

Hello, The pain out of proportion worries me. I have seen folks land in the ICU with soft-tissue badness this way (i.e. NF/Fournier). Also, I have seen pain out of proportion with compartment syndrome. However, I must admit, that I have never seen gluteal compartment syndrome. Besides, how did it develop? The patient did not pass out in one position for a long time from what I have read. Cheers

Hello, Lets get a set of vital signs with a temperature. Plus, a little more history / PQRST plus an exam. How dose he look? Sick? A disproportionate amount of pain without an obvious injury or source is worrisome. It could be a bad soft tissue infection (i.e. Fournier Gangrene / Necrotizing Fascitis). A triple 'AAA' can present with more than back pain. For example, I once saw a fellow who only complaint was a sore left testicle. Cheers

Hello, I know that Ketamine sometimes causes non-purposeful movements and hyperreflexia. But, I have seen two burn patients (one electrocution and the other was spilled gas on a fire) that have had prolonged trismus when Ketamine was used as an induction agent. Needless to say, it cause some moments of anxiety. I have looked at Micromedex (a pharm database at work), spoke with a Pharmacist and checked a few other sources but nothing conclusive. However, it is odd that it happened so profoundly, twice, with two different burn patients. Has anybody had issues with trismus and Ketamine? Thank you, David

Hello, The ambulance service here (ground and air) do not have iStats. I think geography plays a role (regional and teaching hospitals are never too far away). Second, I think the cost per test is expensive and the need for calibration by bio-medical regularly. However, with longer transport times, like in SK, there could be a role. In fact, many times during transfers, the air medical crew can get labs run by the labs of the sending hospitals. As for CRASH-2. I agree, it may not be the most riveting reading but it is worth the time. Especially if you are suggesting a clinical practice guideline change. In your proposal you can note that a large study (CRASH) shows benefit in trauma patients. Second, it is inexpensive and do not require special storage. Also, it could be implemented easily because there are few barriers to change (i.e. cost, training, buy in by staff). Cheers

Hello, If my memory is correct, EHS NS, is getting TXA. The CRASH2 study is a good place to read about TXA if you have not checked it out yet. It will be a good place to start for a protocol suggestion. Plus, TXA is cheap. The WOMEN study is looking at TXA for post particular hemorrhage and they should be publishing in 2014. That may be worth a look. Otaplex (PPC) is a part of the NS Massive Transfusion Protocol (just google ns massive transfusion protocol and they have a 40 page PDF that is quite good....I am using my new iPad and I do not know how to copy and paste yet). PPC is tightly controlled but it should be considered in any trauma patient or surgical patient will an elevated INR. Cheers

Hello, The patient that I based this case on improved enough for transfer but required intubation and admission to a critical care unit. He had DIC and a shocked liver due his horrible BP. Some excellent questions J306. J306, on 25 Jan 2014 - 9:24 PM, said: I say intubate him with Ketamine 0.5mg-1.0mg/kg and Fentanyl. The patient has responded to fluid boluses, but I'd like to have a Levophed infusion set up and ready to go prior to transport. I would ask the staff why they gave Lasix to an ARF patient, document how much they gave, and look in the charts to see if that's when our septic patients BP began trending downwards. How is our patients colour, peripheral circulation, distal pulse quality, mental status and affect after the fluid boluses and initiation of BiPap? I'd check lungsounds for crackles, if non are present, I'd be comfortable with one more 20 ml/kg bolus of Ringers Lactate to replenish some nutrients and to try to avoid making him more acidotic than with saline. Any chance we could get some whole blood infused prior to transport along with some Tranexamic Acid? Is air ambulance transport available? If not, I'd get either an RT or RN to join me during transport incase things go south. J306, on 25 Jan 2014 - 9:48 PM, said: When placing the patient on a transport ventilator, we should be aware that we'll be taking away his only compensatory mechanism since his renal function is impaired. This is an other good point. Intubation of any acidotic patient is high risk. But, it is equally important to ensure an adequate minute ventilation. They were breathing 30 times a minute for a reason. For some types of intra-renal failure Lasix is given. That was the rationale in this case. However, the was pre-renal failure as well. Which you hint at with your post. Blood products and sepsis is an area of research. Some argue that old and cold blood can worsen the immue response. Older sepsis protocols call for infusions of PRBC if SvO2 is low despite fluid, Levo, and an inotrope (Dobutamine). But, again, I have seen a shift away from this in the last few years. TXA is an option but the evidence is weak for a non-surgical septic patient butit is worth a discussion. An other option is PCC (Octaplex) for the coagulation issues. Any chance we could get some whole blood infused prior to transport along with some Tranexamic Acid? Very good point about the NS. Hyperchloremic acidosis (non-anio gap) acidosis is a complication of excessive use of NS. In this case, if I recall, abx therapy has been started. Vanco can be given to renal patients. In hospital levels are check to ensure that they do not become toxic. Cheers

Hello, Sorry for the slow reply. The patient is give a couple of boluses and his pressure improves slightly and HR comes down. With some encouragement the patient is able to tolerate Bi-Pap and his SpO2 improves some. With some more encouragement you get a VBG done and the results are worrisome. (pH 7.0 O2 30mmHg CO2 65mmg with Lac of 8) The lytes on the gas show his K is still 7.0. The staff feel the low Mg is due to not eatting much (he was sick at home for awhile before he came in). They are not sure why his INR and PTT are up. They can not do fribinogen at this hospital. LFT have not been done. GCS 15 HR 100 (fib) BP 90/50 SpO2 90-91% on Bi-Pap So, transport or tube? The hospital is not keen on this, of course. Cheers, David

Hello, In my location it is acceptable transfer a patient to the ED for reassessment. Typically, this is done by the receiving service but not always. For example, if their are concerns weather the patient will be going to the ward, step-down, or ICU. It is interesting to see how different systems work. For the sake of discussion lets say it is acceptable to take this patient to the ED at the receiving hospital. Lots of excellent post. I would love to quote from them but for some reason I can not get it to work at the moment. Here is some more information: LOC: He is tired but able to follow command. He is cooperative but anxious. Bi-Pap: It failed because the patient got anxious and kept trying to pull the mask off. A-Fib: New. He had it in the ED and it was converted with a CCB. But, the A.Fib started again last night. They haven't give anything because of his low pressure. Urine Output: Very low. Yesterday, his output was only 200cc. So far today his output has been zero. CXR: Ground glass like, flat diaphragm, consolidation in the lower lobes BNP: Not available at this hospital. ABG: None have been done due to bleeding concerns (see below) Lungs: A wheezing mess Fluid Status: Very dry. The patient mouth looks like leather. His IV is running at NS 125 cc/hr EKG: They have done a few. One shows A.Fib while the other shows an unremarkable Sinus Tachycardia. Labs: You look through the chart. Here are some additional labs: INR 7.0 PTT 80 Tn-I 1.2 mcg/L (elevated) Na is 150 or so. VS: His BP has been trending down and his HR trending upwards during his admission. From the post most people want to give some more IV fluids and consider Levophed. Second, intubation is a possibility but lets get some more support and see if he responds (fluid responsive). Third, lets try the Bi-Pap again. Lastly, the transport time will be around 60 minutes. Cheers

Hello, The patient is SOB but he tells you he has felt like 'hell' a few days before he came to the hospital. Now, he feels worse. He is a heavy smoker and has a history of HTN, DPL, COPD, and a MI 2 years ago. He is on Pip-Taz TID , ASA OD, Ventolin + Atrovent QID, Tamiflu PO BID, Prevacid PO and was given some Lasox last night for low urine output. His K is 6.2, Cr 470, WBC 28, Hgb 95, Random Glucose 22, and Mg .6 He is positive for influenza 'A' and sputum is positive for something that Pip-Taz works on (I don't know micro very well). VS are not so good. BP in he 70-80, HR 120 (Fib), and Spo2 85% or so. Cheers David

Hello, They gave him Kayexulate an hour ago. They have also started him on Tamiflu. The EKG shows a rapid A.fib. Cheers

Hello, Sorry for the delay. The nurse finished on the phone and gives you an update. The patient was going to a medicine floor at the regional hospital but he is now going to be assessed in the ED. He was admitted with community acquired pneumonia but he has been getting worse and his viral swab came back positive for influenza ‘A’. He is in renal failure with a Cr of 470 and a K of 6.2. You put on gowns and face shields and enter the room. The patient is awake, alert but very tired. You can hear him wheezing from the door. He has #18G IV x2. His foley bag has maybe 20cc of urine in it. He has a high-flow face mask on. The RT tried some Bi-Pap but the patient got too anxious to tolerate it.

You and your colleague are dispatched for an urgent transfer from your community hospital to a larger regional hospital. Initially, this was coded as a routine transfer but it has been upgraded because the patient has become more unstable. Mr. Smith is a 67 year-old male who was admitted with pneumonia three days ago. Over the last three days his condition has worsened. On arrival to the medical unit you find an obese man in bed. The head of the bed is elevated to 45 degrees. The patient is pale, wheezing, and diaphoretic and wearing a NRB. He is connected to a telemetry pack. An RT wearing a protective gown and mask is at the bedside checking the patient’s SpOs. He tells you it is 85%. You see a sign posted on the door that says ‘droplet isolation’. The vital signs sheet is on a clipboard by the door and things do not look promising: HR 120 irregular BP 75/45 SpO2 85% Temp 37.6 The nurse is on the phone talking with the receiving hospital sorting out where at the regional hospital the patient is to be admitted. Cheers

Hello, I have seen lipids use twice for -caine toxicity (Ropivacaine I think) from epidurals. It seemed to work quite well. I have seen lipids used for two different mixed OD (CCB and beta blockers). As noted by Triemal04 it was started when standard therapy was failing. One turned around and the other died. Intersting case. By the way, Chris, I like your YouTube channel. It may be time to see if I can find a copy of Goldfrank's Toxicology. Cheers

Hello, A GABA deficiency will cause an elevation of the resting membrane potential. In effect, they will be less refractory and more prone to deploarization. In this case the status epilepticus. In this case, I think an RSI and deep sedation may be in order. I would keep going with the benzodiazipines. I would also ensure a good minute ventilation because odds are the patient is quite acidotic. That temperature is a worry as well. If I recall, INH theapy causes a vitamine deficiency. I don't know which one. Needless to say it won't be on an ambulance. Good case. Excellent brain gym. Cheers

Hello, Isoniazid can cause seizures. Looks like TB medications to me. The temperature is worrying as well. Dose he have abnormal muscle tone? Cheers

Hello, Ouch....that is around 2.1 for the BGL. I have no idea. I guess that it could inhibit gluconeogenesis somehow? I have no experience with peds toxicology. If the pills were extended release we could have a big issue. Or, a big bezoar may be in the bowels as well. I would start a dextrose infusion to correct the low BGL. I would also stock up on Glucagon and see if are any bags of lipids 20%. Dose octreotide fit in here? I have seen it for Glyburide toxicity? Overall, I am stumped and a little embarrassed that I don't know 'how' beta-blockers actually work. Cheers

Hello, She converts to a sinus tachycardia with diffuse ST elevations. She has a weak pulse. Her BP is around 70mmHg. Still, the airway is open and she is easy to ventilate. Cheers PS: Maine is awesome!

Hello, No, the epi pen was used correctly. You get her on the monitor and skillfully pop in an IV while CPR is done. The monitor show VT. She feels cool and looks gray. Her airway is still clear and she is easy to ventilate with a BVM and OPA. Cheers

Hello, Any other good place to start is checking out the local hospitals care bundles or packages. For example, the hypothermia protocol. Sepsis protocol. Sedation protocol. etc........ Plus, it is nice when the pre-hospital and the hospital are on the same page. I would also read the Barr article on the current evidence on sedation, agitation, and delirium. http://www.ncbi.nlm.nih.gov/pubmed/23269131 And, the new surviving sepsis 2012 guidelines; http://www.sccm.org/Documents/SSC-Guidelines.pdf Lastly, as I ramble on, the AIME textbook is a nice resource for airway protocols; http://www.amazon.ca/Airway-Management-Emergencies-George-Kovacs/dp/0071470050 Oh...wait. The CRASH2 study for TXA in trauma patients. Cheers David

Hello, She is there with her boyfriend. They came to the farm to pick berries to make jam. There are 4 FD First Responders and a few others milling about. She is allergic to bees. She was stung by one and started to panic and scream. He boyfriend injected her in the arm with her EpiPen immediately. Then her colour got bad and she collapsed. Her face is not swollen and there seems to be no signs of an allergic reaction. Her airway is open. The First Responders have an OPA in and are bagging her without difficulty. CPR is ongoing. Bystanders did effective CPR before the Fire Department arrived. The AED has not been attached yet. The chickens have cleared out but they have been replaced by angry and aggressive honey bees. Bzzzzzzzzzzzzzzzz!! Cheers

Hello, You are staffing an ALS ambulance in a rural farming area. There is a local community hospital with an ED. The main medical centre is 45 minutes away. You are dispatched for an 'unwell person'. A 31 year-old female was at a u-pick when she started to feel weak. En route the call is upgraded to 'cardiac arrest' and the local volunteer FD has been dispatched as well. You arrive at the farm and the FD is on scene. The MFR are doing CPR on a women in the middle of a raspberry field. It looks safe other than a few shady looking chickens roaming about. Cheers

Hello, I think in HONK your pH is as low because insulin resistance is as profound. But, I am not sure. The criteria where I work for DKA is a pH below 7.3, elevated BGL, and ketones. Nice case study. David

Hello, Opps. I was mistaken on the AF. Looking at the UA and the elevated GBL DKA seems reasonable. The infection could have caused the DKA as well. Sepsis is a safe bet with the foot and the elevated WBC (32). The is a touch of renal failure as well. As for the seizure, I am not sure. Cheers

Hello, Sepsis is a concern here. So, let’s get some cultures and then start the antibiotic therapy as soon as possible. A urine tox could be a good idea as well. The seizures are worrisome. There could be a CNS infection. Or, is he on any medications that could lower a seizure threshold? (Haldol, Cipro, ect…) Or, any medications that can cause seizures? (Demerol) Also, I agree that an Amiodarone isn't a good idea here. The AF is due to a critical illness and in these case, from what I have seen, Amiodarone isn't very helpful. Hypothermia. Consult with the critical care service of the hospital this fellow is going to. If the code is due to sepsis then hypothermia may bad idea due to the suppression of the immune system. Especially if it is in his CNS. Lastly, from my point of view, in most cases a little sedation is a good idea. Sure, you may have a depressed GCS but this doesn’t mean the negative effects various interventions shouldn't be blunted. But, in this case, I might have missed the seizure. Cheers

Hello, As noted above. I would get a report and assess the patient. Cheers