Threw up and can`t breathe

[DartmouthDave]

Hello,

Location:

You are an ALS crew in a small town (population 5000). It is 1000hrs and you are dispatched for an urgent transfer to the local University Hospital. The University Hospital is 125km away.

On Arrival:

You are greeted by the ED staff and are given a report. Mr. Smith is a 67 year-old male with an extensive and complex medical history. He has had a MI in 1993 (NSTEMI),CABG in 1994 (4 vessels), PSVT, HTN, DM I, Dyslipidemia, Depression, Renal Insufficiency, Esophageal cancer that was managed surgically in 2008 with a Esophagectomy as well as Oropharyngeal Squamous Cell Carcinmona (OSCC)in 2009 that was managed with radiation and surgical interventions.

Since 2008 the patient has had dysphagia and numerous aspiration pneumonia. He was made NPO. A PEG was insert in Dec 2009 and the patient was started on bolus feeds. However, he has still had trouble with aspirations. There were plans to advance the PEG in to the small bowel.

For the past five days the patient has been feeling unwell. Chills, myalgia, fever, and a hacking cough with some think yellow sputum. His wife was concerned that he had a pneumonia. The patient has been refusing his tube feeds because he feels unwell.

The patient did not want to go to the hospital and took some old antibiotics he had around the house. This morning he tried to eat. His wife started his tube feed at 0800hrs. Shortly after feeding began he started coughing and threw up. Gagged for awhile and trued 'blue'.

He developed respiratory distress and was driven to the hospital by his wife.

On Exam:

The patient is sitting up in bed (75 degrees) and looks distressed but is lucid. Numerous old surgical scare are seen on the patients neck and jaw. He seems to have a poor range of motion as well.

GCS 15

PEARL 4mm

Strong x 4

BP 180é90

HR 120

Temp 38

EKG: Sinus Tachycardia with an old RBBB

RR 34

SpO2 88% on 100% FiO2(humidified oxygen wide open)

Lungs - course crackles

Abd is soft

Foley is in situ with 20cc of concentrated urine

There are 2 IV. An 20 gauge in the left hand and a 18 gauge in the left arm

CXR shows a white out on the right side and cloudy looking left side.

Labs are limited. They show:

WBC 24

Hgb 84

Na 137

K 2.9

Mg .85

ABG show (100% oxygen):

Ph 7.45

CO 32

O2 64

BE 2.2

He has been Dx with Sepsis and aspiration pneumonia on a preexisting community acquired pneumonia.

Treatment thus far:

1L NS bolus

40mEq KCL IV

NS+20 KCL at 125cc

Vancomycin 1gm

Pip Taz 4.5 mg

Zythromax 500mg

Decompressed his gut via the PEG

Zantac 150mg IV

His medications are:

ASA 80mg od

Lopressor 50mg bid

Lipitor 40mg od

Ramipril 5mg od

Sliding Scales Insulin tid

Tyl prn

Advil prn

Lansoprazole po od

Motilium 10mg po tid

Cheers...

Edited April 2, 2010 by DartmouthDave

[Chief1C]

Wow.. You're just having all kinds of problems. I think you're dying.

[Kiwiology]

I have absolutey no idea, I am going to put him on the stretcher and take him to the hospital; oh wait, he's already at the hospital mm ..... did I mention I have absolutely no idea?

This is a transfer, so, if they want him treated then send a physician with the patient!

[Eydawn]

Kiwi- how farking IGNORANT can you get? Just because you can't treat him doesn't mean you shouldn't try to figure out what's all going on and how it would be treated... what are you going to do if he develops complications during your transport? Say "Oh well, we just figured we were the taxi ride?" I thought you were against having to rely on physicians for everything. Get your story straight!!

I'll puzzle through this and get back to you, have to get to my A&P lab...

Wendy

CO EMT-B

[Mateo_1387]

I am missing something... What is the point of this post? Is there a question or game we are supposed to participate in?

I see a case presentation with diagnosis and treatment already in place. What are we supposed to do?

[DartmouthDave]

Hello,

I based this scenario on a fellow that was transfered to the ICU awhile back. So, as a transfer there is time to sort things out. Also, I like this scenario because the key to its success will be a collaborative approach with the hospital's staff (MD, RN, RT).

Plus, it is a situation that may rurual services may find themselves in. A complex patient in a small hospital in which the Paramedics become an important part of the hospital's team.

Here are a few ponts to ponder:

Resp status... tube or no tube? CPAP/Bi-PAP? What is the ABG telling us?

CVS..... more fluid? less fluids? Look at a sespis protocol and see how it can fix this patient.

Labs..... low K and Mg 40mEq KCL in 100 cc was given once... Needs more or less K or Mg? Any other labs to check?

Social.... He is very sick. Prior to transport what should be addressed?

Support.... The hospital isn't keen on sending staff. Maybe an RT or a RN...maybe =)

Lastly, your ambulance is stocked with a wide range of drugs and equipment (i.e. IV pumps, CPAP, Transport ventilator).

I am missing something... What is the point of this post? Is there a question or game we are supposed to participate in?

I see a case presentation with diagnosis and treatment already in place. What are we supposed to do?

This is true. He has been in the ED for 2 hours. It is an hour or so to the receiving hospital. Is there more than needs to be done? Is he ready to go? Other Dx to be considered. This may not be a 911 scene call however there are few things prior to leaving that may maximize ones odds of success.

I just wanted to give something a little different a go!

Cheers...

Edited April 2, 2010 by DartmouthDave

[VentMedic]

Lactate level? Increasing or decreasing?

BNP?

Sputum C&S?

Influenza swap with H1N1 specifics?

Central line for IVs and CVP?

CVP reading? Monitor fluids and BP MAP per sepsis protocol.

SvO2?

http://www.survivingsepsis.org/SiteCollectionDocuments/2008%20Pocket%20Guides.pdf

We try to avoid CPAP/BIPAP on patients such as these especially if they have had extensive grafting both internally and externally. They may also have TE fistulas which will creative more abdominal problems even if the G-tube can be vented. Also, many ALS/EMS CPAP machines can not achieve the FiO2 and flow necesary to maintain a patient like this for very long. One would also have to consider the CPAP pressures and what the ALS team is capable for meds and titration (U.S. concerns more than Canada).

The ABG indicates a large A-a gradient which will make this patient unstable for transport by ALS without a definitive airway. The patient is attempting to maintain his own homeostasis with a high RR and will evenually fatique.

If the patient wants to be a Full Code, a definitive airway via fiberoptic would be the tool of choice. This can help identify anatomical defects from reconstruction and possibly the fistula. A trach of some type will probably be in his future. Once ETI is established the ventilator and pressors can be adjusted for a modified ARDSnet protocol depending on the ventilator used. If ALS only has an ATV, a specialty team (RN/RRT) may need to accompany with their equipment. This may also be an issue for the CVP monitor and hopefully and A-line can be established as well. If the patient is on the ventilator, sedation and possibly paralytics might be considered. Diprivan (propofol) would be our drug of choice for a Specialty team transporting a high level ventilator patient. Again, right meds, right equipment and right team.

Plateau pressure on the hospital ventilator if the decision is made to intubate?

The other Dx to consider would be more involved and concerning his CA. Many of these patients will require some type of surgical procedure at least once a year.

This is a transfer, so, if they want him treated then send a physician with the patient!

Another warm body, no matter how educated they are, would be of little use unless they have the right equipment and the right expertise. This would only get you a request for a really fast transport with the L&S thing.

Edited April 2, 2010 by VentMedic

[DartmouthDave]

Hello,

The patient wants to be a Full Code. A triple lumen subclavian is inserted and checked with a CXR. The RT inserts an arterial line and a ABG and VBG is drawn. A CVP is transduced and it is 6. The ABG shows pH 7.35 CO2 45 CO2 60 and the VBG shows an saturation of 59%.

A sputum C+S was not sent. Swabs have not been done. These are collected. Also, the patient is given Tamiflu PO as well.

BNP is not available at the lab. Small hospital with limited resources. The EP isn't keen on intubation due to the difficult airway and the frail status of the patient. Though failing the patient should be able to tolerate the transfer on high flow O2.

Cheers...

[Kiwiology]

Another warm body, no matter how educated they are, would be of little use unless they have the right equipment and the right expertise. This would only get you a request for a really fast transport with the L&S thing.

I should clarify, this sort of job here would be undertaken by a physician or some specalist as even our Intensive Care Paramedics are not trained to take care of somebody this crook.

The hospital would send somebody because he is on a lot of meds and things Ambulance Officers have no experience in.

[VentMedic]

This is a good thread since some here probably want to be "CCEMT-Ps" and believe the 80 hour class along with their 600 - 1000 hour Paramedic cert is more than enough to do CCT. Few get past the skills to understand the whys and hows of the patient. Sometimes the words "critical thinking" are not fully understood.

Hello,

The patient wants to be a Full Code. A triple lumen subclavian is inserted and checked with a CXR. The RT inserts an arterial line and a ABG and VBG is drawn. A CVP is transduced and it is 6. The ABG shows pH 7.35 CO2 45 CO2 60 and the VBG shows an saturation of 59%.

A sputum C+S was not sent. Swabs have not been done. These are collected. Also, the patient is given Tamiflu PO as well.

BNP is not available at the lab. Small hospital with limited resources. The EP isn't keen on intubation due to the difficult airway and the frail status of the patient. Though failing the patient should be able to tolerate the transfer on high flow O2.

Cheers...

Fluids to get the CVP over 8 mm Hg and hopefully that will improve the SvO2 and urine output. This is not a good time to be in renal failure.

What is the BP now? There might be a pain issue that can be addressed without interfering with the respiratory drive. The BP MAP should be maintained over 65 mm Hg.

If the ABG was drawn on a NRBM, we would use 0.85 or 0.90 as the FiO2 for the PaO2/FiO2 calculation. That gives a PF ratio of 67 which is very, very serious. Some should take not that the SpO2 was mentioned at 88% which is possible but in this situation, the SpO2 does not reflect the seriousness of this patient.

If this patient is on a humidified high flow system delivering an FiO2 of 1.0, that may be difficult to transfer. BTW, if you see a standard humidifier running of a standard flow meter (not one capable of 70+ L/M) that device will not be delivering an FiO2 of 1.0 to an adult breathing at a RR of 34. It would take at least two ("Dual") humidifiers to get a little closer to an FiO2 of 1.0. The standard humidifier with an aerosol mask, even though it may say 100% on the adjustment, will probably be delivering an FiO2 of around 0.60 for an adult with a high respiratory rate and MV.

Now, how to deliver high flow O2 during transport without using a mechanical ventilator for CPAP/BiLevel....

The O2 supply system would have to be addressed since many of the devices require a flow meter capable of delivering at least 70 L/m. Some of the easier and more comfortable high flow devices such as the high flow NC can deliver 30 - 40 L/m but at this time I don't believe any of them are battery powered and the heating element must have keep the humidifier delivering at 37 degrees and a relative humidity of 44 mg/L. The MistyOx or TheraMist can deliver high flows but require a high flow meter to power them at 30 - 40 L/min. The Oxymask can be considered high flow must the standard flow meter may need to be ran at flush. In the hospital I have used a high flow nasal cannula at 30 L/m along with the Oxymask at well over 15 L/M to oxygenate a patient with a good respiratory drive preintubation. The RSI is done very quickly since bagging a patient who has progressing ARDS is very difficult with the standard self inflating BVM. I would probaby suggest taking something like a Jackson Rees bag along with the self inflating BVM.

What do those of you from other countries have available on your CCTs for high flow O2? I know Canada and Europe will generally have the better meds and technology available to them long before the U.S. Even our ICU equipment and especially the ventilators are usually at least 5 years behind your latest and greatest.

Edited April 3, 2010 by VentMedic