DartmouthDave

Hello, Her BGL is 16.1mmol/L (296 mg/dl). Not that high but it could be DKA or HONK. If so, she will be acidotic so I would like to increase the BVM rate. Knocking her CO2 down some thereby giving us more to work with if we need to tube her. Acidosis and airway is a tricky situation. Is she on Metformin? Hypotension and Metformin to cause quite a type B lactic acidosis. This was noted by a previous poster. What is in her pill minder? What is her muscle tone like? Rigid? (SSRI OD, ect..) Flaccid? (Tramadol, ect..) How dose her abdomen feel? Choric pain...hepatotoxicity from Tyl? The list is quite long right now. On with the resuscitation: Airway: I would add high flow nasal cannulas in preparation for possible intubation. I would keep going with the OPA and BVM for now. Do an airway assessment and build a plan and let the team know. Breathing: I would increase the MV to bring the ETCO2 down to 35 or so if possible. If I recall correctly the lungs are clear. How is compliance? Do we have a nose or ear probe to see if we can pick up a SPO2? Circulation: Her BP is soft. Tubing her with that pressure (plus possible acidosis) and the typical EMS medications would be a big problem. I would start a second 1000cc NS as pre-treatment for possible intubation. As for the ST depression it could be demand ischemia from the low pressure/hypoxia. Not too much we can do about that now. Phenylepherine IV would be nice but that isn't a common EMS medication. So, I would see if I can get the blood pressure up, CO2 down, and pick up a Sp02. Cheers

Hello, From my expereince I would say 'no'. Sure, you may get it done but getting it 'offically' read is the problem. I know that some larger centres in the US use bedside continuous EEG. But, I don't know too much about that. Now, this is common problem. Getting agreement between the receiving service, the sending Physician, and you own oncall Physician. The patient that I based this case coded due to an electrolytes imbalance. She was cooled and had a full neurological recovery. But, there were issues. An issue that could be worsened by cooling if one is not careful. This months Air Medical Journal has two slightly related case studies. Plus, what effect could hypothermia have on the K? Muscle weakness followed flaccidity? Cheers PS: I hope my post isn't too fragments. I am getting done on the waning hours of a night shift.

Hello, She had a very short down time. The vent setting are correct for the patient. No auto PEEP, high PIP, PLT ect. She is just riding the vent. Ok...on with the scenario!!! In consensus seems to be: keep cooling fix lytes start sedation give some fluids With consideration giver to: PRBC Paralytics Increse Levophed gtts Start Dopamine gtts The sending Physician arrives. You are still here? Yep. You give her a 1000cc bolus of RL. KPhos and MgSo4 are started. An ABG is sent. Sedation (Fentanyl + Versed) is started. The shivering stops with sedation. VS: GCS: 3 Pupils: 3mm + brisk Absent x 4 HR 58-60 BP 90/50 EKG: Slow, wide like before The ABG shows suprenormal PaO2 (110) and a normal PaCO2 (40) with a mild medabolic acidosis (Lactate is 4.5). With the KPhos her K is up by .2 and the Phos is the same. Her Mg is now .8 (normal) her random glucose is 8.0 (normal....I don't want to mess up the Americans with their funny scale..lol) Excellent work Lost of good posts. Point to ponder: Hypothermia a K level?

The patient has a 3 year-old daughter. She has been depressed because she broke up with her common-law husband. She hasn't been eating well and has been obsessed with her body image since the baby. Recent depression. Minor. No suicidal ideation. No medications. Not a smoker. You review the charts. You find this lab report. BOLD means critical low. K 2.0 Mg .40 Phos .40 Na 150 Hgb 85 Interesting. I have never heard of this. I am going to look it up. She has a femoral central line. What you consider a VGB? Agreed. Regarding the correction of the lytes. No history of drug and ETOH abuse. A neuro exams finds her pupils 3mm and responsive. No movement of her arms and legs. They feel flaccid. She has been feeling unwell for a week. Her family wanted her to see a GP. She has been having muscle weakness and numbness as well. Awesome start. Also, I have taken the time to figure out the 'multi quote' option. Cheers PS: Her current temperature is 35.5

Hello, You are a fixed wing air ambulance crew. You are dispatched to transfer a post-code patient from a community hospital ED to a CCU in a large teaching hospital. Flight time is 90 minutes. On arrival, you receive report from the nursing staff. A 21 year-old women had a witness cardiac arrest at home. CPR was started and an ambulance was called. A BLS crew arrived and a shock was delivered with an AED and there was ROSC. Once in the ED she was intubated (#7.5 ET 22cm at the lip) and place on a ventilator (AC 12/500/.50/+5). Her BP was low so a femoral line was inserted and Levophed started. Cooling was started as per direction from the CCU. She is unresponsive and on no sedation is running. Anxious family is milling about. Her father wants to come with you. The staff seem keen on having her out the door. You enter the resuscitation bay. The patient is very pale and thin (45kg). She is connected to a monitor. Levophed is infusing at .05mcg/kg/min and NS is running at100cc/hr in a IV in her right arm. Bags of ice are in the bed. She is shivering slightly. She is riding the ventilator (rate 12). You look up at the monitor and see: HR 60 EKG: slow, wide, diffuse ST depressions, PR depressions with a PVC here and there BP 80/40 SpO2 100% Cheers

Hello, How true. This case was based on a patient we had in the ICU. Not an easy situation. The patient was transported to a local ED with a NRB, low stats and his airway was managed by anesthesia. They tube him with a scope and lined him. He had a perforated trachea and a laryngeal tear. This was repaired by the thoracic service. He also had a complicated course in the unit because of sepsis, CHF (he had a STEMI), and a VT arrest. Lucky, he got well enough to go to the step-down and I am not sure what happened after that. He also had stenosis and only would take a 7.0 tube. I learned a great deal. I had considered the risks of PPV or CPAP. I think I would have tried a NPA and some gentle BVM to pink him up. As for position I would have kept him sitting up despite the pressure. But, didn't think bypassing the whole mess, if need be, by intubating the right lung only. Again. This cases has many different possible courses. Oh, I would call ahead as well. =) Cheers

Hello, ALS and BLS are on scene. The patient is very weak and will wake briefly to voice. His lungs are course and decreased to the bases. You feel some subcutaneous air on his upper chest. A #20 IV is inserted and a NRB is applied. Newest set of VS: GCS 14 HR 130 BP 70/30 Resp 40's SpOs 87% on NRB The EKG shows Sinus Tachycardia with St elevations in II, III and AVF I saw a post above talk of a cricothyrotomy. A cricothyrotomy and tracheobronchial malacia is not a great idea. Cheers

Hello, His mother has a sheet with her son's medical history and medications. She says it is too complicated for her to keep track of. Her son has Tracheobronchial Malacia and was having trouble brathing and clearing secreations. He had a sent put in two weeks by Thoracics in the big city (3 hours away) ago but things never improved. Plus, HTN, DPL, DM, Asthma, COPD, MI, CHF, depression, anxiety and a suicide attempt a year ago. He is on ASA, Lasix, Ventolin, Atrovent, Digoxin, ACE, SSRI, Ativan PRN and his GP added Prednisone PO awhile back. The patient is very weak and hot to the touch. He is breathing very fast (40's) and he is having a hard time coughing and clearing his secreations. He gestures to his chest and feels burning. His VS are: GCS 14 HR 130 BP 70/30 Temp 40 Resp: 40's SpO2: 84% on RA EKG: old ant. 'q' was and ST elevation in II,III and AVF. Cheers

Hello, Lots of reading to catch up on. Once we clear up his level of intervention/code status I think intubation is a reasonable step. He has had a general decline in his LOC. If I recall, his GCS is around 8/15. He has respritory failure (oxygenation and ventilation). If there are no indicators of a difficult airway or difficult BVM I think RSI would be the best method. Propofol and Roc. As for the HR. I would get the airway done first and then see how the HR and BP play out. If the monitor is showing a rapid A.Fib post intubation a loading dose of Amiodarone and a ggts could be an option. Sure, cardioversion could be an option. But, this won't last until the underlying medical cause is managed. Maybe, with some post intubation sedation and ventilation support the BP might come down some. Snap a quick CXR when the tech gets in. Draw a ABG after 30 minutes or so to see how ventilation is going. Sort out the logistics. As many poster have noted, perhaps CCT is in order. Cheers

Hello, The scenario sections has been spammed. Therefore, I think I would like to post an 'actual' scenario based on a recent ICU admission. A sick person call. You are dispatched to a nice suburban home for a 57 year-old male who coughed up blood and a piece of metal two days ago. His mother called an ambulance because she is worried because her son is looking gray. You are greeted at the door by the concerned mother. My son has a soft trachea and he had surgery on it a month ago. He coughed out a piece of metal and has been getting sicker since it happened. You enter the living room and see a thin, frail looking middle age man in a chair. He is coughing and spitting up copious amonts of thick yellow secreations. He looks up weakly and drops his head. Have fun. David

Hello, First, thank you for posting a scenario. It is a little crazy that a CVA patient was transfer back to a small community hospital from the stroke centre so fast. Thrombolytic CVA can convert to a hemmorrhage hemorrhagic at the 24-48 hour mark. Basically, the ischemic tissue dies and a bleed can result. This is the same reason the ischemic changes do not show on a Head CT for the first 24 hours. This could explain the new neurological finding and the HTN. HR=190 What dose the monitor show? Also, what is the code status/ level of intervention? lastly, this is not a BLS transfer. Thank you,

Hello, Perhaps you could convince him to allow you to do a quick assessment. Vital signs and an EKG for example. Maybe then you he would consent to going to the hospital. Odds are he is a rational man who is angry or afraid because of his health issues. You may have a longer than average scene time but in the end I have found most people will come around. However, if he says 'no' then it is time to go. As an adult he is allowed to make poor decisions. If he becomes unconscious and there is no advanced directive present then his wife will become the 'substitute decision maker' and it will be her decision. Well, at least that is how it works in my area. Cheers

Hello, I am going to check that channel out. I have just discovered lots of great educational stuff on YouTube. Thanks

Hello, This fellow has been feeling unwell for a couple of days. The three AAA I have seen in the field all had sudden onset pain followed by a rapid decline. The rest have been post op AAA in an ICU. Not very helpful in this situation. I was unaware only 1/3 of AAA have the classic presentation and the other 2/3 have a slower onset. I will have to read up on this some more. The distended abd could be from the liver failure and acities. Or, the distension could be from a AAA. Looking back, it was noted that the patient was cool. So, lets try and warm him up and give warm fluids if possible. Hypothermia is the last thing we need. I may be changing my tune here a go with a AAA. Cheers

Hello, What type of access dose this patient have for their hemo? I know that Dopamine is the only option foe most services. But, a little fluid and a little Levophed would be useful in this situation. I would like to give some pain control. But, I agree we need some more pressure first. If we get the pressure up perhaps some Fentanyl. Cheers

Hello, Pressure typically runs on the low side for liver failure patients due to vasodilation. However, this is too low. If the renal failure is due to Hepatorenal Syndrome things are not looking too good for this patient. I do not like the low SpO2. Pleural effusions are common in liver failure as well. However, for some reason not well understood (more so by me) these patient can develop Hepatopulmonary Syndrome. Massive vasodilation of the pulmonary vessels causes a huge shunt. If I recall, laying these patient flat helps with oxygenation. BUT, I am not sure of this last statement. Plus, as noted above, this risk of bleeding, infection et al. I think I would give some fluid. I would start with a NS 500cc bolus. Plus, getting moving. Cheers

Hello, With a history of malaise (fever, runny nose, fever) he could have GBS. Back pain, neurovascular compromise of his right leg could be an AAA. What is his BP like? Cheers

Hello, What is the axis? Cheers

Hello, First, I would like to get some more assistance. An other ambulance and drum up some staff if you can. I think we will be needing them. Do we know the code status of this patient? When was she last seen well? Basic medical history? COPD? Asthma? CHF? With a clear airway we can lean away from an allergic reaction, Ludwig Angina, Reinke edema, or a penut With course lungs it could be COPDE, pneumonia, CHF, or the standard PE. Dose she still have a pulse? Her GCS is worrysome as well. Time to get moving. I would insert an OPA and a NPA and attempt two-person BVW with some PEEP. With a slow and steady rate. Getting a line would be nice as well. Put her on the monitor as well. Of course, this will be hard with just two people and MIA rehab staff. =)

Hello, The American Academy of Clinical Toxicology (AACT) website is quite good. I read the single and multi-dose Activated Charcoal (AC) pdf. When I started AC was used all the time and now it has fallen out of favour. In a nutshell the AAT (2004) stated that the evidence is mixed in animal, volunteer, case studies and clinical series is mixed. The major issues with AC are asperation (even with an ET), OD related ilues worsed by AC or AC with sorbitol, and limited enhanced clearance of a medication. The AACT suggested that AC should be considered in extended release medications, medications with a low volume of distribution or OD that lack an antidote or treament options. They noted a few OD that AC may be useful but I can not recall. So, basically, not useful. Whole bowel irrigation (WBI) works well the few times that I have sen it. However, I must admit, that I haven't read the AACT arctile on it. One WBI was for a Lithium OD with a bezoar of pills in the bowel. An other was a massive Dilantin OD. I am not sure of the term....I think it is 'zero order kenetics'....but with some medications a massive OD overpowers the body's ability eleminate a medications. Thereby dramatically increasing the half-life. This is the case with Dilantin. It blocked the NA channels in the CNS and the patient wasn't waking up. Cheers, David

Hello Everbody, Sorry for the slow reply. It seems that work always flares up when I try to do a scenario. The patient has taken a massive overdose of Baclofen. Which, as it turns out has a narrow theraputic window. According to the maryland Posion Control Centre: "Severe toxicity is associated with bradycardia, hypotension or hypertension, respiratory failure, hypothermia, seizures, coma and death. Rarely, status epilepticus, rhabdomyolysis, and conduction disturbances may occur." ( http://mdpoison.com/publications/toxtidbits/2012/February%202012%20ToxTidbits.pdf ) If I recall, Life in the Fast Lane or Broom Doc has a Baclofen case study as well. In which the patient looked brain dead until the Baclofen cleared. I will try to track it down. She also took Ativan as well. The hypothermia as Modey noted is due to the low BP, OD and as other have suggested laying on a cold floor. The warmed fluid is a great idea. The eye twitiching were seizures like Trimak04 pointed out. The difficult ventilation was due to a massive asperation. The Effexox XL is a SNRI that loweres seizure threshold. It was felt that the Effexor + Baclofen that was causing the seizures for this patient. Serotonin Syndrome was considered as well. Theie is the Hunter Scale is useful for S.Syndrome. Here is a good link: https://www.mja.com.au/journal/2007/187/6/serotonin-toxicity-practical-approach-diagnosis-and-treatment The airway is the complex part. I would not be keen intubating this patient with her initial blood pressure. I know that the ABC happen at the same time. I would be keen on keen giving fluids, pressors (Dopamine, Levophed or Epi et al..) to get her BP up first. Unless you tube her without medications. The OG is a good idea. I know that AC or AC with sorbitol is fallen out of favour. But, suction sounds like a good idea to me. Plus, sometimes, whole bowel irrigation can be useful with bezoars or some extended release medications. Thanks, David Back to work.....

Hello, The airway is secured and she is still difficult to ventilated. Her lungs sound course. But, her SpO2 creeps slowly up to 92-93%. She is given fluid which brings her pressure some. You slip in an OG and suction out some gastric secretions but no pill fragments. The Atropine has no effect. TCP brings her rate up. Her VS are: GCS 3/15 (pre-intubation) BP 90/40 HR 60 Your list of Dx are: PolyOD Compartment syndrome of her arm Hypothermic You are enroute to the ED (15 minutes). You recheck her pupils and you note nystagmus then they deviate up to the left. Discussion points: Any comments on the how to tube her? Considering her BP and LOC? RSI? BP: How much fluids? Epinephrine gtts? Thanks

Hello, The husband runs to the bathroom to collect his wife medications. He can't find all of them but there is an empty bottle of Baclofen and Effexor (filled two days ago) and he tinks most of her Ativan are gone as well. An OPA is inserted and you start to ventilate her with a BVM. With an adequate seal and good technique you are having a hard time to ventilate her. Her breath smells of ETOH and the pills and secretions have been suctioned out. Her SpOs creeps up 90-91%. Her left arm was pinned under her body and feels hard and firm to the touch. The rest of her body is flaccid and cold. Her temp is 33.4 C. A second ambulance is on route to give you some more help. Cheers

Hello, You enter the bedroom and and suction thick secretions and dried pill fragments. During the suctioning there is no cough, gag, eye opening, or movement (GCS 3/15). Her pupils are fixed and dilated at 4mm midline. Her respiration are slow and irregular. Her skin is cold to the touch and you can feel a very weak carotid pulse. You partner quickly attaches her to the monitor. Her SpO2 is 84% with a HR of 35 - 40. Look like a sinus bradycardia with a 1st degree block. Her BP is 70/P. A quick BGL is 8.7 mmol/L. Her husband say he was away on a business trip for the last 2 days. He hasn't spoken to or texted his wife for two days because they had a fight. She has a history of MS, HTN and anxiety. She has recently recover from a major depressive episode. But, she has been angry about her MS and has been drinking too much. He is unsure of what medications she is currently taking. Thank you, D

Hello, You are dispatched to a suburban home for a 47 year-old female found unresponsive by her husband. The scene is safe and you are greeted by the patient's husband. He tells you that he has been out of town for the last 48 hours for work. When he came home today he found his wife laying on the bedroom floor. When you enter the bedroom you hear gurgling respriations and the patient appears pale and gray. Good luck