Camulos Posted April 2, 2009 Posted April 2, 2009 From a prehospital perspective there are many differential diagnoses here for me to even contemplate. Yeah let's get a BSL as that is easily reversible if it is the cause of the agitation. Apart from that I would restrain him. Physical restraint may make this situation worse hence my preference would be chemical in this case, high flow 02 with airway control if mandated, trip to ER and wish them luck. Given he was in a fire I would also have a low tolerance for sending him, and the other pt, to hospital due to the possibility of delayed onset pulmonary edema in such cases. I guess it's all about CYA. In hospital the management of this pt becomes a bit trickier. All the standard bloods, scans etc that these pt's usually mandate however the one thing I would want to rule out quick in this particular pt is serotonin syndrome - given the history of bipolar, agitation, recent admission with ? change of medications and the degree of hypertension. Mind you the clinical picture does not completely fit here as these pt's normally exhibit tachycardia and dilated pupils - neither of which this pt had. Temp may be a clue here also as these pt's can be profoundly hyperthermic. Would also be keen to know what this guy was cooking on the stove if we can determine that. Stay safe, Camulos
wrmedic82 Posted April 3, 2009 Posted April 3, 2009 (edited) Was the bottom of the pot/pan coated with teflon??? I know it sounds crazy. I read in a studyway back when ( sorry this is the fireman in me coming out) that a pot/pan coated with teflon left on a heating element with nothing cooking inside the pot/pan the teflon begins to form a colorless, odor less gas that can cause asphyxiation. I will have to re-research to recall the actual form of gas created. So its possible that the reason for AMS is hypoxia. Of course I havent read the vitals so Im not saying that this is what it is. However just throwing out a possibility. Edited April 3, 2009 by wrmedic82
wrmedic82 Posted April 3, 2009 Posted April 3, 2009 Here is a link that supports what Im talking about. http://lowfatcooking.about.com/od/healthan...onstickpans.htm
AnthonyM83 Posted April 3, 2009 Posted April 3, 2009 Yes, he's protecting his own airway, but the poster gave the impression it patient was making it difficult to assess and treat him. Yes, it's outside the box...but if he got an index of suspicion for opiate OD that could be causing the ALOC, then I can see making the decision to use Narcan. It can also help differentiate which s/s are from opiates versus trauma/hypoxia, possibly. Doesn't quite seem like blind use to me (he's not pushing Narcan on every ALOC trauma)...but like I said, I AM here to learn, so interested in others' opinion.
chbare Posted April 3, 2009 Posted April 3, 2009 If the patient has addiction/dependancy issues with narcotics giving naloxone could in fact exacerbate his already violent behavior in addition to causing other problems such as seizures. Take care, chbare.
OHMEDIC187 Posted April 3, 2009 Posted April 3, 2009 We were always taught that the goal of prehospital naloxone therapy is to simply reverse respiratory depression in Opioid OD. We were taught that if your patient is awake and talking then DO NOT GIVE NALOXONE. Just Sayin.
itku2er Posted April 3, 2009 Posted April 3, 2009 Here is a link that supports what Im talking about. http://lowfatcooking.about.com/od/healthan...onstickpans.htm I would never have thought about that good article.
EMS2712 Posted April 3, 2009 Author Posted April 3, 2009 Good Afternoon Ladies and Gentlemen, I apologize for not answering the questions yesterday, as I was under the house working on some pipes that burst. I will try to answer everyones questions the best that I can. Use of Narcan- I can see both sides of the argument that have been posted on this issue. In talking with the medic the reasoning for this was as follows. The patient has an altered LOC of unknown etiology at this point. Yes the airway is patent, and the patient is combative, but is the altered LOC and combativeness a side effect of a narcotic overdose, hypoxia, neurological, or some other underlying cause? With the pinpoint pupils, one could assume narcotic overdose with the altered LOC and combativeness. I am also of the mindset that if I do give Narcan, I like to slowly infuse the Narcan, as not to induce an instant withdrawal from the drug. Unfortunately, I don't know how every patient is going to present after giving Narcan, maybe he would become violent, and maybe not. I agree that is a potential risk though. Updated Blood Sugar of 152 Updated BP 172/104, P 58, R 18 T 99.1 Yes, potential for CO poisoning would be a diff. dx, but we ruled that out pre-hospital with the use of the Rad 57 handheld units showing 1ppm reading. Patient was found lying in the middle of the room with no apparent items that he would have struck his head. No signs of trauma noted on exam. No abnormal chemicals noted in kitchen. The teflon study, could possibly fit, I read that study as well, and to be honest I didn't really look to see what the pan was made of. I noticed to burned eggs still in the shell in the pan. Patient remained combative throughout transport. Upon arrival at the hospital, patient was moved to ER trauma room and report to staff Patient was initially given 5mg Haldol IM with minimal response. Patient was given 5mg IN with no change in status. IV was established, and patient continued to be restrained by PD handcuffs, under the observation of PD unit. ABG's were drawn with SLIGHTLY elevated PCO2. Due to patient continuing to be combative, patient was selectively intubated with the assistance of 25mg Etomidate, and a Propofol drip. Urine tox screen showing positive barbituates and nicotine. With patient sedated CT scan completed, with no bleeds or masses noted. Patient was subsequently paralyzed, and transferred to University Hospital. Follow up with receiving facility showing subsequent CT scans negative and tox screens showing no changes. Receiving hospitals advised the patient had blood cultures drawn and are awaiting results. What are some other thoughts. I haven't heard anything else, but I will let you know.
Camulos Posted April 3, 2009 Posted April 3, 2009 I hadn't heard of the rad 57 and thought the earlier supplied CO level was an air reading done by the fire dept which didn't tell me anything about the pt. I have since looked it up and must say "Can I have one please mummy?" - I love new toys. Would still like some comment on ? serotonin syndrome (SS) and whether that was actually investigated in hospital. I thought it may have been induced by opiates as was initially suspected by the EMS team. However I note urine tox screen was negative for opiates. Still does not rule out SS though as it can be caused by a combination of many other meds that pt's with a bipolar diagnosis may be on. Would be great to hear the end of the story if possible. Stay safe, Camulos
AnthonyM83 Posted April 4, 2009 Posted April 4, 2009 I think most likely it's going to be constriction from psych meds...as far as what's most likely. Course it could be something totally different or even unknown. Let us know what you find out.
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