Engineer's Special

[Kiwiology]

Pt is a prime candidate for a CVA, however we only have a 3 lead ECG to look at & the patient is diabetic. With numbers like this, he could be poly presenting with a hypo, CVA & silent infarct.

You could always do a 12 lead you know

12 lead shows anterolateral infarct (couldn't be buggered searching for a copy we know what it looks like)

BGL, 10% Glucose slow IV, it isnt that bad really, lets bring it up slowly. Airway managment, urgent transport. This patent needs a hospital, not an ambulance, no matter how qualified you think you are.

BGL is 4mmol/l; how much D10 would you like? For a symptomatic hypoglycaemic we use 100ml and this guy is certinaly not a sympto hypo and didn't we just get done saying excess glucose in infarct is bad? I'd say ... give him 25ml.

SPO2 is now 91% and his rales are getting worse

[armymedic571]

I woulld guess that the pt is in a postictal state from a seizure caused by the Effexor, as well as the fact that the pt is hypertensive and tachycardic which are both side effects of Effexor.

I like your thought process wit hseizure, but disagree with Hypertension as hypotension is the side effect of choice with effexor.

Your overt attempt at fire bashing aside...

Isn't HR (Heart Rate) and PR (Pulse Rate) the same thing? If so, how can you have two different readings at the same time? Presuming that the vx were assessed at the same time...

Funny..... Although, kiwi already clarified this....heart rate and pulse rate are not the same and can be different. One measures the electrical rate of the heart (HR), as the other measures its mechanical manifestation (PR). But that is a discussion for another thread.

Wow, that whole below 8 - must intubate mind set. Hence the reason for all the studies out there wanting to take intubation away from us. Its not your first tool in this case, or in about 99% of all cases. In reviewing my post, I could have added to my Local tx statment, the fact that I would have used an NPA, and placed the pt on 02 at 15-lpm. This pt automatically buys a 12 lead, which was something else I left out. I would also monitor his EtCO2, which would have some bearing on intubation. Unless there was a staus change with the airway, bagging would have been the most I would have done. The ED would most likely place this person on Bi-Pap, not intubate, but then again, you sometimes can't guess what the Doc is going to do.

AT, I must disagree. Although intubating based off of the patients GCS score would be considered bad form where I am from, I agree with Ruff as airway control is key. An unresponsive patient cannot definitevely control his/her airway (especially as presenting for this scenario), therefore CPAP/BiPAP would be countra-indicated in this case. if RSI is not in your bag of tricks, nasal intubation might be the ticket.

Pt is a prime candidate for a CVA, however we only have a 3 lead ECG to look at & the patient is diabetic. With numbers like this, he could be poly presenting with a hypo, CVA & silent infarct.

BGL, 10% Glucose slow IV, it isnt that bad really, lets bring it up slowly. Airway managment, urgent transport. This patent needs a hospital, not an ambulance, no matter how qualified you think you are.

Phil, I dig your style, but why the glucose? If the patients Blood sugar is 90 mg/dl (~4mmol/l). I would not consider that hypoglycemic, and as we cannot determine whether a stroke type event is hemorrhagic vs embolus. I would be extremely cautious with this. However, if I have misunderstood, please clarifiy for me...please.

You could always do a 12 lead you know

12 lead shows anterolateral infarct (couldn't be buggered searching for a copy we know what it looks like)

BGL is 4mmol/l; how much D10 would you like? For a symptomatic hypoglycaemic we use 100ml and this guy is certinaly not a sympto hypo and didn't we just get done saying excess glucose in infarct is bad? I'd say ... give him 25ml.

SPO2 is now 91% and his rales are getting worse

Another reason to control this patients airway.

[Kiwiology]

Funny..... Although, kiwi already clarified this....heart rate and pulse rate are not the same and can be different. One measures the electrical rate of the heart (HR), as the other measures its mechanical manifestation (PR). But that is a discussion for another thread.

Yes AM is correct, also that atrial and ventricular rates can be different

Another reason to control this patients airway.

Do you take the LMA, standard intubation, RSI or .... the mystery box? (the box, go for the box! It could be anything, even intubation or a new boat!)

Your patient is clenched up and having a seizure, how would you proceed if you are going to RSI (we use fent/ketamine/sux for RSI but can use midaz for neurogenic cause of poor airway/breathing)

[AT-Medic]

I like your thought process wit hseizure, but disagree with Hypertension as hypotension is the side effect of choice with effexor.

You should direct yourself to the following sources of information; Epocrates, medicinenet, and wikipedia. The side effects are a mile long list that could fit any pt.

Funny..... Although, kiwi already clarified this....heart rate and pulse rate are not the same and can be different. One measures the electrical rate of the heart (HR), as the other measures its mechanical manifestation (PR). But that is a discussion for another thread.

AT, I must disagree. Although intubating based off of the patients GCS score would be considered bad form where I am from, I agree with Ruff as airway control is key. An unresponsive patient cannot definitevely control his/her airway (especially as presenting for this scenario), therefore CPAP/BiPAP would be countra-indicated in this case. if RSI is not in your bag of tricks, nasal intubation might be the ticket.

Phil, I dig your style, but why the glucose? If the patients Blood sugar is 90 mg/dl (~4mmol/l). I would not consider that hypoglycemic, and as we cannot determine whether a stroke type event is hemorrhagic vs embolus. I would be extremely cautious with this. However, if I have misunderstood, please clarifiy for me...please.

Another reason to control this patients airway.

Well AT, It's really good that you have bipap but for those of us who do not have bipap, cpap, epap and whatever brand spanking shiny things that your service seems to have Intubation is my only tool. RSI I do have.

I've been involved in Effexor overdoses before and they can get bad really quick.

I did not go on his Glasgow, I went on the thought that he overdosed as well as was unconscious. I did mention bagging him, perhaps I should have said, let's see how bagging works but I have one hospital to send a patient to and the physicians want them intubated. If I were to fly him, the flight crew would have immediately intubated him if he remained in that state.

So to bash me was not a good thing. You have more tricks in your arsenal and I have less. So be it.

We have cpap but it's in a freakin closet because they haven't written the protocol for it. How's that for backwards.

Before you slam other providers with their treatment you might want to get some clarification as to what we have to work with before you go off and make yourself look like a A***

So KIWI how many pills are missing or do they seem to be all there

What are the pupils? Be it a overdose or a Stroke, unresponsive means BAD MOJO

Wow, name calling. After a slight review of my post, I find that in no way was anyone being slammed, so get over it, and go un-Ruff yourself...LMFAO!

[AT-Medic]

I like your thought process wit hseizure, but disagree with Hypertension as hypotension is the side effect of choice with effexor.

Funny..... Although, kiwi already clarified this....heart rate and pulse rate are not the same and can be different. One measures the electrical rate of the heart (HR), as the other measures its mechanical manifestation (PR). But that is a discussion for another thread.

AT, I must disagree. Although intubating based off of the patients GCS score would be considered bad form where I am from, I agree with Ruff as airway control is key. An unresponsive patient cannot definitevely control his/her airway (especially as presenting for this scenario), therefore CPAP/BiPAP would be countra-indicated in this case. if RSI is not in your bag of tricks, nasal intubation might be the ticket.

Based on the airway values given in the very first posting, I'm not going to knock an emt out of the way to get too my ET kit. Which was my whole point to start with, rushing to intubate is not the key. ACLS is pushing basic airway management over advanced management, and I agree. I also indicated in my post that a change in airway status would cause me to intubate. I myself would not place the pt on CPAP based on the first post. I was indicating that the ED Doc might place the pt on BiPAP, which I have seen done to pt's I thought should be RSI'ed, but I'm a P and not an MD so I follow orders and ask questions to better understand the line of thinking afterwards. I think I saw in another post where the pt's status is changing, so this fellow is buying a tube. Ruff missed the point of my post and got all Ruff'ed, LOL! The pt is a work in progress, as most all pts are. I had a feeling that the pt status would change as post came rolling in, and it has.

Phil, I dig your style, but why the glucose? If the patients Blood sugar is 90 mg/dl (~4mmol/l). I would not consider that hypoglycemic, and as we cannot determine whether a stroke type event is hemorrhagic vs embolus. I would be extremely cautious with this. However, if I have misunderstood, please clarifiy for me...please.

Another reason to control this patients airway.

[armymedic571]

AT ,

I couldn't help but note that you stated Wikipedia as a sourece of factual information...........Sorry dude. FAIL.

I still disagree.....

Do you take the LMA, standard intubation, RSI or .... the mystery box? (the box, go for the box! It could be anything, even intubation or a new boat!)

Your patient is clenched up and having a seizure, how would you proceed if you are going to RSI (we use fent/ketamine/sux for RSI but can use midaz for neurogenic cause of poor airway/breathing)

You sir are hilarious.....

I would personally use our Medication Assisted Intubation (as we are not allowed to use Sux in our system). This is basically drowning our patient with etomidate. So, 0.3 mg/kg of etomidate please. Boujie tube if necessary.

If the patient is still clencked, re-oxygenate and nasal intubation.

When we get the tube in Fent and versed for continued sedation......

[paramedicmike]

I would personally use our Medication Assisted Intubation (as we are not allowed to use Sux in our system). This is basically drowning our patient with etomidate. So, 0.3 mg/kg of etomidate please. Boujie tube if necessary.

Do you really want to give a medication that can cause trismus to a patient with a clenched jaw and is actively seizing?

[armymedic571]

No. I want to stop the seizure and control the airway. Unfortunetly, that is waht I have to work with.

Also, If you give Etomidate to a person with a clenched jaw, and experience trimus ---> back up plan... re-oxygenate and nasal intubation, or NPA and BVM.

So, wait, I guess yes, I would give the etomidate.....

[paramedicmike]

No. I want to stop the seizure and control the airway. Unfortunetly, that is waht I have to work with.

What do you have to work with? Etomidate only? No other drugs? What could stop this seizure and possibly help you better secure the airway?

Also, If you give Etomidate to a person with a clenched jaw, and experience trimus ---> back up plan... re-oxygenate and nasal intubation, or NPA and BVM.

If the jaw is clenched then the patient is already suffering from trismus. Do you want to give them something that will only perpetuate the condition? Or move straight to the backup plan? Or try something that make make your primary plan a little easier?

So, wait, I guess yes, I would give the etomidate.....

Are you sure? Is etomidate really going to relax the jaw when the patient is actively seizing?

I understand what you're thinking. And you're on the right track. I just think there's a better way to go about this than what you've outlined so far.

I should add my apologies to Kiwi. I'm not trying to hijack his scenario.

Edited May 14, 2010 by paramedicmike

[armymedic571]

What do you have to work with? Etomidate only? No other drugs? What could stop this seizure and possibly help you better secure the airway?

If the jaw is clenched then the patient is already suffering from trismus. Do you want to give them something that will only perpetuate the condition? Or move straight to the backup plan? Or try something that make make your primary plan a little easier?

Are you sure? Is etomidate really going to relax the jaw when the patient is actively seizing?

I understand what you're thinking. And you're on the right track. I just think there's a better way to go about this than what you've outlined so far.

I should add my apologies to Kiwi. I'm not trying to hijack his scenario.

Mike,

You are correct. Lets get back on track. I missed when Kiwi stated that are patient was having an active seizure.

In this case my priority would be to arrest the active seizure. My benzo of choice would be ativan IV, or diazepam.

Then, I would control the airway.

I still ned to disagree with you about the etomidate though......

Trismus is a possible side effect from the administration, and usually when it is given to quickely. As I stated before, under the right conditions, I would still consider it if possible. However, as you stated if the conditions were not present, I would go straight to plan B. Which for me would be nasal Intubation.

Hope that clarifies my thought process.

J