Call didn't turn out the way I expected.....

[okmedic]

First off, I'm not sure if this is the correct spot for this thread and if not I apologize in advance.

So here is how it went down...

Was called to a report of a 34 y/o male unresponsive at home. Pulled up to a single wide mobile home in the county and had family meet us at the truck. They told us they had been trying to wake him up all day (it was about 1500hrs at time of call). Report that last night he had been taking xanax and some prescription pain pills before he went to bed and they think he over did it. They reported that he had no significant history besides a recent back surgery (3months ago) and depression. They led us to the back bedroom where we found the patient laying supine in bed with cyanotic with deep snoring respirations. VS: Sinus Tach at 120, RR10, SPO2 61%, BP 119/70, pupils where pinpoint. Skin was dry and cyanotic in his nail beds and lips. I immediately had my partner insert an OPA and start bagging with supplemental o2. I started an IV and obtained a glucose check which was 126. At this point the bvm had brought his SPO2 to 95%. Per protocol I started with 2mg of Narcan IVP. After no response to that I gave him .5mg of Romazicon. And to my suprise........NOTHING!!! I thought for sure that the problem was a xanax OD. Frustrated I inserted an ETT and he took it like a champ, no gag at all. So we ran him in and at the ER they repeated with 2mg of Narcan and .5 of Romazicon with the same response...nothing. His tox screen came back positive for opiates and benzos, but everything thing was pretty much normal besides a white count that was elevated at 18.3. He also had a negative CT. The only thing I could think of is that his family hadn't seen him awake since he went to bed the night before around midnight and that he laid in bed for the approximate 15 or so hours hypoxic the entire time and had a hypoxic brain injury? Did I miss anything or is that just the way the cookie crumbles?? What do you think?

[Just Plain Ruff]

narcan and romazicon didn't work???? wow if he was positive for the stuff you say he was that should have woke his butt up but I tend to agree with your assessment that he was so profoundly hypoxic that his brain was mush which then leads me to believe that the narcan and the romazicon did their job but his brain was just jello.

The other clue I got was that he had no gag reflex which many of the Opiate or xanax overdoses I've run and had to intubate at least had some sort of minor or very limited gag reflex.

I suspect your patient will be sending you a christmas card from the long term vegetative patient wing at the local nursing home for years to come.

This is just how the cookie crumbles on some calls. You did what you were supposed to do and these things just happen but I suspect that I'm not giving you any new insight on these types of calls or the outcomes. You seem like a pretty smart guy and probably already know this fact.

take care and be safe out there.

[spenac]

I agree with Ruff, sounds like the family waited to long to get help. You did what you could in the field. Glad to hear that you checked glucose level rather than just pushing the old coma cocktail.

[crotchitymedic1986]

You also have to realize that a person who has these kind of habits may not just dabble in the prescriptions at hand. Alcohol, illegal drugs, and other prescriptions may have been involved. And obviously those who abuse multiple prescription drugs have a higher tolerance, and tend to take enough on a daily basis, that would kill one of us.

To the derrogatory comment about the "old coma cocktail", if this patient were an unconscious, diaphoretic diabetic with a normal d-stick, would you withhold D50 ?

[chbare]

You also have to realize that a person who has these kind of habits may not just dabble in the prescriptions at hand. Alcohol, illegal drugs, and other prescriptions may have been involved. And obviously those who abuse multiple prescription drugs have a higher tolerance, and tend to take enough on a daily basis, that would kill one of us.

To the derogatory comment about the "old coma cocktail", if this patient were an unconscious, diaphoretic diabetic with a normal d-stick, would you withhold D50 ?

Depends, what number do you consider normal. Some people have hypoglycemic symptoms/signs with "normal" sugars. However, I am not an advocate of blindly pushing medications as is the case with simply giving coma cocktails to every unconscious patient. I am not sure how you found the comment derogatory?

Take care,

chbare.

[ERDoc]

To the derrogatory comment about the "old coma cocktail", if this patient were an unconscious, diaphoretic diabetic with a normal d-stick, would you withhold D50 ?

Absolutely. There is a reason that the term has become derrogatory. You can do more harm than good. If someone was not in cardiac arrest, would you give them CPR? Here is just one study to demonstrate why the coma cocktail is a bad thing.

[VentMedic]

They reported that he had no significant history besides a recent back surgery (3months ago) and depression.

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He also had a negative CT.

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a white count that was elevated at 18.3

What was the patient's temparture at the ED?

A CT Scan is not always definitive. Even for a hypoxic insult, the patient may require a couple more CT Scans to see changes.

If he was still relying heavily on pain killers 3 months post op and the family did not notice any other symptoms that would lead to a clue about his elevated WBCs, there may be a lesion or infection at the surgical site or just about anywhere in the CNS pathway including the head. Meningitis may also need to be ruled out. The pain killers may have masked some very important symptoms. A neurologist and an MRI would probably be appropriate.

[spenac]

Absolutely. There is a reason that the term has become derogatory. You can do more harm than good. If someone was not in cardiac arrest, would you give them CPR? Here is just one study to demonstrate why the coma cocktail is a bad thing.

Thanks Doc for the answer. It is important that we stay up to date with current findings. I wonder how many more people have been harmed by those doing the coma cocktail because its always been done that way. I would bet if a true unbiased study were done it would find more harm with it that harmed by being denied transport. But thats another problem for maybe another topic.

[crotchitymedic1986]

Yes, D50 is very deadly when given to diabetics. You guys kill me (and your patients). The coma cocktail was invented for medics who treat the equipment and not the patient, because they would not push D50 for patients who obviously needed it, because their glucometer said no.

If you arent familiar there are a host of issues that can cause a false glucometer reading. Here is a small list: Abnormal blood sugar levels can also be found in patients who:

Are pregnant.

Have hepatitis.

Have head trauma.

Are septic.

Have diarrhea.

Exercise strenuously.

Consume large amounts of alcohol or are chronic drinkers.

Are on medications (beta blockers, quinine, prednisone).

Overdose on medications (lithium, acetaminophen, antihistamines).

Have Addison's disease.

Have taken someone else's diabetes medications.

Have expired medications.

Have an unusual Hematocrit Level

Not to mention, glucometers/strips/and control solutions are supposed to be maintained at a certain temperature extreme, which is often violated in ambulances.

If you need a glucometer to treat a diabetic patient, you need to go back to school.

[chbare]

Hmm, cannot say I ever remember using a glucometer that said "no" do not give dextrose. Learn something new every day.

Take care,

chbare.