EMS2712 Posted April 2, 2009 Posted April 2, 2009 On March 30, 2009 you are dispatched to a report "Out Fire" with possibly 2 smoke inhalation victims. Upon arrival FD advises fire is out, and the occupants of the structure are out side. Patient number 1 is a late 50's male patient who advised he smelled smoke from his upstairs apartment and came downstairs to find patient number 2 lying on floor lethargic. Patient number 1 advises that there is a burning pan on the stove, and evacuates patient number 2. Upon arrival of EMS patient number 1 refuses care. Patient 2 is standing upright still appears to be lethargic to surroundings. Bystanders advise patient number 2 has significant psych history. Upon making contact with patient, he becomes combative. Initial Ax A-patent, B-normal at rate of 18, C-skin ashen warm and dry with positive radial pulses at a rate of 68. Patient has pinpoint pupils at 2-3mm. Patient becomes combative as you move him to cot, and PD is on site with securing of the patient. Where do you go from here? What is your differential diagnoses? Ask any questions you ask, and I will see what I can tell you because I am not sure what to think is going on with this patient.
mobey Posted April 2, 2009 Posted April 2, 2009 RSI him and let the ER deal with it. Bwahaha... kidding (so far) what was the burning pan full of? how does pt #1 feel? How combative is he? Yelling swearing in an organized fashion, or inappropriate words yadda yadda? Does Fire have a "sniffer thingy"? can they tell me what levels of what gases are present? Get the guy on a NRB, SpO2, ETCo2, monitor, I.V., consider some mild sedation after a bit more history. What kind of phyc Hx? Bi-polar? schitzo? etc... I'll stop now
EMS2712 Posted April 2, 2009 Author Posted April 2, 2009 Mobey, I don't disagree with your thinking, however we don't have prehospital RSI as of yet. 1) On fire and EMS arrival, it was a pan of eggs that appear to have been being hardboiled with all of the water evaporated directly catching the eggs on fire. 2) Patient #1 is coughing, but states he feels better outside, and doesn't want to be evaluated by EMS 3) Patient #2 is non-verbal at this point, and taking swings at the EMS crews. Patient is fighting as crew is securing him to the cot. PD physically restrains him to cot with handcuffs x2 4) No Gas monitor available to FD 5) Patient placed on NRB at 15lpm. Sp02 of 100% prior to Oxygen admin. EtCO2 n/a, CO detector showing 1, monitor showing NSR with a VR of 68 in Lead II without ST changes. IV attempted x2 with patient pulling both of them. Protocol doesn't allow for initiating sedation. 6) Patient was recently discharged from area psych unit with bi-polar disorder 7) EMS Crew administer 2mg Narcan via IN x2 doses for a total of 4mg en route to hospital with no response. Pupils remain pinpoint 8) House was also checked by law enforcement as well as the EMS Captain for any drug equipment or pills with none being found.
AnthonyM83 Posted April 2, 2009 Posted April 2, 2009 How is he behaving compared to baseline? Are the constricted pupils normal for self? Try to get a full medication list. Some antipsychotics (among other meds) may cause pupillary constriction. Certain CNS injuries can also cause it. What are his vital signs? And what is a CO rating of 1? I'm not familiar with the readings.
EMS2712 Posted April 2, 2009 Author Posted April 2, 2009 1) Per the neighbors, he is acting abnormal. He normally is talkative and coherent 2) Neighbors say this isn't normal for him 3) No medications were found at the residence. Bystanders were not helpful in obtaining this information 4) Vitals P 60 R 18 BP 172/100 5)CO readings are in parts per million. Normal is 0.5-5ppm. When you hit 25-30, you have to go to a hyperbaric chamber for treatment
p3medic Posted April 2, 2009 Posted April 2, 2009 7) EMS Crew administer 2mg Narcan via IN x2 doses for a total of 4mg en route to hospital with no response. Pupils remain pinpoint What was their rationale for giving this patient Narcan? He's awake, protecting his airway and combative. Regardless of having narcotics on board or not, their is no indication for Narcan in this patient.
emt322632 Posted April 2, 2009 Posted April 2, 2009 I would have said CO poisoning but with your reading on the monitor I'm leaning away from that... Check out the BP and pulse, elevated BP and low pulse could indicate neurologic involvement (bleed) any s/sx of stroke? Patient favoring one arm over another which which to swing at you? :-) Do we have any other medical history besides his psych history? I could see the rationale for narcan here, while right now he's only altered with a patent airway, he could go even further under and lose the ability to maintain it on his own. Stop the drug (if there is one) from working and prevent him from possibly going further downhill.
Eydawn Posted April 2, 2009 Posted April 2, 2009 Blind narcan again... god damn! That's starting to make me CRAZY. Was there something in the eggs? Can samples be nabbed for testing? Are there any chemicals hanging out in the kitchen (stove scrubber near the fire, perhaps?) Any evidence that this person fell and hit their head on the way down? Wendy CO EMT-B Ooh! Recently discharged bipolar... I bet someone's meds aren't agreeing with one so one is not complying well with them... any social history of phobias of smoke/fire that could trip a psychotic episode? Wendy CO EMT-B
chbare Posted April 2, 2009 Posted April 2, 2009 I could see the rationale for narcan here, while right now he's only altered with a patent airway, he could go even further under and lose the ability to maintain it on his own. Stop the drug (if there is one) from working and prevent him from possibly going further downhill. So, we prophylactically turn our patient's into chemistry experiments every time they act strange? Do we have a blood sugar? Take care, chbare.
Paramagic14 Posted April 2, 2009 Posted April 2, 2009 -early hypoxia would be one of my diff Dx based on his new found combativnes. but if he has a hx of bipolar and normally gets aggressive this could be normal if he hasnt taken his meds. -Blood sugar????????????????? -updated vitals? -any trauma noted? -Carbon monoxide will give you false highs on your spo2 so i wouldnt exact rule anything out based on his 100% spo2 - I wouldnt narcan him...no reason..even if his pupils are pinpoint. his airway is patent and he is breathing effectivly. - i would chemically restrain him with versed if no other cause was found.
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