chbare

Callthemedic, I do not know of any research regarding oxygen and the clotting cascade. I know there are studies that actually indicate oxygen can be helpful in patients experiencing hypovolemic shock. I think the mechanism is related to the inhibiting of nitric oxide in peripheral tissue, (peripheral capillary beds) that causes shunting and increased peripheral vascular resistance. Studies done on hypovolemic rats indicate this action can result in better perfusion of vital organs. This action is in addition to the sympathetic response to hypovolemia. I can PM you the research if you want to mill it over. Take care, chbare.

Firemedic 78, I think people who have knowledge of anatomy, physiology, pharmacology, and training in the physiological effects of medications are the only people who have any business giving medications. Narcan can be very harmful and cause serious problems when given to patients. (Especially an overdose) I have horror stories about people who have received narcan and started withdrawling from narcotics. I am talking about violent behavior, hypertension, seizures, projectile vomiting, and a whole bunch of other problems. Good airway management at the EMT-Basic level will save the day for a narcotic over dose without all of the adverse side effects. I think the same is true for the combitube. It seems pretty easy to place, however, you are cramming a tube with large inflatable cuffs into an area with many sensitive structures, again, I believe knowledge of A&P and extensive training on the use, indications, assessment, and complications of airway devices is needed prior to placing them on real people. I have seen many people who forget about patient assessment and just give "coma cocktails" to all patients with altered mentation. I think this is bad medicine, (cook book medicine) and encourages people not to assess and try to find the root cause of the patients problem. I am not trying to argue with you or say EMT-B's/EMT I's are stupid, I just wish people could take a step back and really think about what they are doing and just how well do they understand the implications of the procedures they are performing. Take care, chbare.

Miniemt; I think I know the answer to your question. High flow oxygen can dry out the mucus membranes of nasal and oral cavity, this could slightly increase the risk of nose bleed. I would not want a nose bleed to cause airway problems for my patient who has been stabbed multiple times and may already be in respiratory distress. Oh man, I just could not live with causing more blood loss from a small nose bleed on a potentially hypovolemic patient by giving them high flow oxygen. :? (Please note: lots of sarcasm and humor intended.) This is the only possible answer I can come up with. The human brain never ceases to amaze me. Take care, chbare.

Thanks for the clarification ERDOc. What about acute INH overdose? I know this can cause sudden onset seizures. Her CT is negative, labs are negative, (no elevated WBC or left shift or out of whack electrolytes) and she is not febrile. Everything points to acute INH OD. We can check the anion gap and see if it is elevated. I think we need to load her with cerebyx and get Pyridoxine on board. I think pyridoxine dosage is based on the approximate amount of isoniazide taken. What does every body else think? Take care, chbare.

ERDoc, we need to do a CT to rule out intracranial pathology. (Bleeding, possibly a ruptured berry aneurysm with subarachnoid hemorrhage. Bad juju to LP if we have a bleed or increased ICP.) All we have done with paralytics is block the nervous systems ability to tell the muscles to contract and relax. The mechanism will depend on the paralytic. (depolarizing vs non depolarizing) For a long transport without other meds, (ie, diprovan) we will probably be using a non depolarizing blocker after the initial intubation to maintain paralysis if needed. I will be curious to see what the CT shows. Excellent call on the CT Ridryder 911, I did not initially consider a bleed, but now it makes sense after you mentioned getting at CT and with the HX. of sudden onset SZ, I should of considered this earlier. Take care, chbare.

Is she currently taking any medications. I know Cycloserine can cause seizures. CNS TB can result in seizures as stated earlier in this thread. We may need RSI to secure an airway if we cannot control seizures with benzo's. May consider general anesthesia meds if in a more secure environment. Load her with Cerebyx if indicated, however, we need to focus on stopping the seizure at this time. If she is hyperthermic, we can give rectal APAP if indicated. And I would like to put a mask. Take care, chbare.

Thank you for the scenario ERDoc. Take care everybody, chbare.

Did she take or is she taking malaria prophylaxis medications.(Hx. of living in Central America) Seizures have been reported with people who have taken Chloroquine. Check her temp. when we get her life threats stabilized. "How long was she out of the country? Rashes, petechia, purpura, skin discolorations?" Excellent question AZCEP. Let us go over some of the diseases from that region of the world, forgive all this typing I am just trying to go other the common disorders to try to rule out other causes. Thinking out loud. Chagas Disease- Heart failure (I do not think this is the problem) Malaria- Fever, Chills, Feel Like poop (Probably not related to sudden onset seizures) Typhoid/Cholera/HEP A/E coli ( No HX of N/V/D, probably not related to sudden onset seizures) Rabies (Seizures can occur with Rabies, any other S/S of rabies prior to the seizure?) TechMedic05, I agree, if we cannot stop the seizure her brain is toast from hypoxia. Have the RSI equipment ready. Take care, chbare.

AZCEP, She is taking the quinine for leg cramps. I agree with your thinking, blindness by it's self is strange when thinking about quinine overdose. I would expect other S/S, HA, N/V, tinnitus, ECG changes, or hearing loss. We have ruled out most of the structural causes and intracranial causes from CT and MRI. Everything seems to keep pointing at quinine toxicity. Fundoscopy should show retinal artery spasm and disc pallor. (should have done this when I first suspected quinine toxicity and definitely when I got hold of the equipment producing fairy dust) Take care, chbare.

Any history of trauma. I agree AZCEP, if there are no contraindications from history or meds we need to stop the seizure with benzo's. If this patient has actually been seizing for 10 minutes non stop, she's headed for status epilepticus. May want to have airway and RSI equipment ready. Take care, chbare.

ERDoc, conversion is a possibility,( but highly unlikely with the dilated pupils not being normal for the pt) but I am strongly considering other causes. There is no way this lady is going home. I am leaning toward some type of structural problem. Perhaps a small pituitary neoplasm putting pressure in all the right places, or perhaps a nasal/pharyngeal neoplasm not evident on the CT scan, or bilateral central retinal arterial occlusion. Hmmm, I will have to look into the possibility of a neoplasm. If the neoplasm is extracranial, (nasal/pharyngeal) this may mean mets. Take care, chbare.

Hmmm... Well, I still cannot rule out conversion. I guess I should have asked this question much earlier, is the pupil dilation a new thing. Thanks, chbare.

What is my general impression, is the patient currently having a seizure and what does it look like? Is there a patent airway and does she have a pulse? What is the son looking for? Thank you, chbare.

Ridryder 911, I agree. If you work in an area that has multiple hospitals, you need to know your protocols and be able to triage your patients appropriately. We only have one hospital in our county, so we get all the calls. We have had problems with ambulance crews that run every call emergent (lights, sirens, speeding like a maniac) regardless of the patients condition, and I feel safer now that people are starting to use common sense. Take care, chbare.

EMS_Cadet, I would call this a trauma. However, light, sirens, and driving like a speed demon could end with me smashing into a soccer mom/dad van full of kids. My ER director has done a good job of decreasing all of the "emergent" calls in my county, and I honestly feel that the patient, EMT's, and streets are safer for this. MedicRN, excellent call on things to assess. I hope this helps. Take care, chbare.

Callthemedic, Hard to say. I hope ERDoc will give us some more info. Or, perhaps were overlooking something. Take care, chbare.

Callthemedic- I see your point. This patient has allot of different problems aside from the confusion and blindness. I have issues with the dilated pupils. This tells me possibly something metabolic (drug metabolites) or structural. I am leaning toward some kind of substance build up like you. I think it is a good idea to look for fresh track marks, maybe she is using drugs again If she is, try to find out what. I am with AZCEP's thinking. Get a thorough neurological exam (As the patients condition allows.) and try to rule out intracranial pathology the best we can. Take care, chbare.

AZCEP, I am not sure about the vertical vision loss. Quinine is toxic to the retina. I think retinal artery spasm is the current theory behind the S/S. S/S include; loss of visual fields, scotomata, progression to complete blindness, and pupil dilation. I think the vision loss starts around 9-10 hours following ingestion. However, I would also expect other S/S. The confusion can be related to quinine but are there C/O N/V, tinnitus, HA, or hearing loss. From a prior post we learned that she does not C/O HA. We have put her on the monitor and I would be curious to see what her Q-T interval is. Good call on checking for other Nero S/S and working the intracranial pathology route. Callthemedic, I agree, this lady may be a little "cuko for coca puffs," and she is on some pretty potent medications. RaceMedic, good call on the script and additional background. Too bad this isn't the land of OZ and I could sprinkle magic fairy dust and produce a tonometer, slit lamp, portable lab, 12 lead ECG, and CT scanner!!! On a side note, HX of HEP C. is she getting interferon TX? I have heard of people developing retinal hemorrhage after receiving interferon. Is she jaundiced? Could some of this be related to encephalopathy? Ammonia LV? Take care everybody, chbare.

I think we may be on to something with the quinine medik8. However, I cannot rule out other causes with the information I have. Does the patient c/o tinnitus? Is there a history of cinchonsim related to the quinine use, or a history of G-6-PD deficiency? (I hope there is no hx. of G-6-PD deficiency, but you never know) I doubt we would be able to obtain this info in the field, but you cannot go wrong trying if the situation permits. At this point I think transport would be a good idea. Put the patient in position of comfort , give her supplemental oxygen, establish an IV life line, and put her on the monitor. She may be prone to cardiac rhythm disturbances if this is in fact related to quinine, or any number of medical problems on that note. Hopefully this will help us get to the bottom of this case. chbare.

Quinine toxicity may account for the blindness and confusion. Has she taken more than her perscribed doses of medications or more than her usual doses of meds? chbare.

Can we get any medical history on the patient? Does she take any medications or have any history of trauma? I would also like to get a set of vital signs and a blood sugar. I am thinking out loud about the ddx's; Allot of obstructive causes of vision loss result in sudden onset not gradual over days. Perhaps an atypical presentation of glaucoma, acute closure with no pain or undiagnosed chronic angle closure. I know a fixed pupil in mid position with vision loss may suggest angle closure. History of methanol ingestion? I also know this can cause vision loss and fixed/dilated pupils. This may help us reach a diagnosis. Take care, chbare.

Ridryder 911, I completely agree with you. I think ETI is the gold standard for securing the airway and all of the various airway devices out there are backup/rescue devices, or devices that can be used in the OR by someone who has the ability to transition to ETI if required. I actually fear that some people who have pull in the medical community (and who live echelons above reality) will look at these devices as a replacement for ETI in the prehospital environment. I know you are pretty busy with your studies, but I could PM you with some of the data I have on the King LT. Take care, chbare.

Spock, I think we are getting our King LT's form http://www.narescue.com. There is allot of info and even some research data about the King LT on this website as well. The King seems to be getting allot of good press, but I am always a little skeptical about the latest and greatest devices, so I am happy to hear that someone experienced in airway management gives the King LT two thumbs up. It looks like I will get to use the King LT on cadavers at SLAM next month, I am looking foreword to that experience. Thanks again, chbare.

Spock, Thank you for the information on the King LT. My National Guard unit is looking at using the King LT over the Combitube. I have been prowling around the posts looking for someone that has first hand experience with the King LT. I have used the airway on a simulator and found that it was pretty easy insert and manage. chbare

zippyRN, I could not give you an exact number. Your best bet is to check out the NLNAC's (National League for Nursing Accrediting Commission) web page. The address is http://www.nlnac.org/. The Department of Education recognizes the NLNAC as the national accrediting body for nursing programs in the USA. I hope this helps. Take care, chbare.