DartmouthDave Posted June 15, 2010 Share Posted June 15, 2010 Hello, The RCMP request assistance at a downtown residence. They responded to a domestic dispute to find a 45 year-old male confused and agitated. They were concerned and requested medical assistance. On arrival you are greeted by an RCMP member. She tells that they have been here many times for domestic disputes. Recently, the wife moved out. She returned to get her stuff and found her husband to be 'scary' and 'nuts'. The wife is in the back of a police car. She was intoxicated and became disruptive and violent as well. The scene is safe. The RCMP escort you and your partner into the living room. The patient is slumped over on the coach with his eyes closed. His hands are cuffed behind his back. One of the RCMP says that he just passed out. But, just before he passed out he was breathing very fast. Around the room you see numerous empty alcohol bottles, pill bottles and pools of emesis. The room smells of stale urine, sweat, and emesis. The patient appears very flushed and his clothing is soaked in sweat. You are an ALS unit. You can call ALS or BLS backup if you wish. Cheers.... Link to comment Share on other sites More sharing options...
BAYAMedic Posted June 15, 2010 Share Posted June 15, 2010 But, just before he passed out he was breathing very fast. Around the room you see numerous empty alcohol bottles, pill bottles and pools of emesis. The room smells of stale urine, sweat, and emesis. The patient appears very flushed and his clothing is soaked in sweat. You are an ALS unit. You can call ALS or BLS backup if you wish. Cheers.... What are the empty pills bottles for, the quantity, and the Dispense date? The puke volume and the contents appearance, Any intact pills and their description? What is the patients current respiratory rate and lung sounds? Fireman1037 Link to comment Share on other sites More sharing options...
Just Plain Ruff Posted June 15, 2010 Share Posted June 15, 2010 Hello, The RCMP request assistance at a downtown residence. They responded to a domestic dispute to find a 45 year-old male confused and agitated. They were concerned and requested medical assistance. On arrival you are greeted by an RCMP member. She tells that they have been here many times for domestic disputes. Recently, the wife moved out. She returned to get her stuff and found her husband to be 'scary' and 'nuts'. The wife is in the back of a police car. She was intoxicated and became disruptive and violent as well. The scene is safe. The RCMP escort you and your partner into the living room. The patient is slumped over on the coach with his eyes closed. His hands are cuffed behind his back. One of the RCMP says that he just passed out. But, just before he passed out he was breathing very fast. Around the room you see numerous empty alcohol bottles, pill bottles and pools of emesis. The room smells of stale urine, sweat, and emesis. The patient appears very flushed and his clothing is soaked in sweat. You are an ALS unit. You can call ALS or BLS backup if you wish. Cheers.... I'm gonna call ALS and BLS backup with a shot of Firefighters and a supervisor for backup But seriously What are the pill bottles? already asked Primary Survey A B C They say just before he passed out he was breathing really fast. Is he breathing now? If so then let's get him on the cot, maybe provide some prophylactic kerlex restraints after uncuffing him if he was acting strange and scary and nuts? Would hate to be in the ambulance when he wakes up. Vitals would be good Did the RCMP frisk him? Did they find any weapons? "It might be a tumah" Link to comment Share on other sites More sharing options...
DartmouthDave Posted June 15, 2010 Author Share Posted June 15, 2010 (edited) I'm gonna call ALS and BLS backup with a shot of Firefighters and a supervisor for backup But seriously What are the pill bottles? already asked Primary Survey A B C They say just before he passed out he was breathing really fast. Is he breathing now? If so then let's get him on the cot, maybe provide some prophylactic kerlex restraints after uncuffing him if he was acting strange and scary and nuts? Would hate to be in the ambulance when he wakes up. Vitals would be good Did the RCMP frisk him? Did they find any weapons? "It might be a tumah" Ok, back up is called for. You do an assessment and your findings are as follows: A - Bad teeth and dry mucus membranes with dried puke B - Rate 8-10 Shallow C- Pulse 120 and rapid and regular. Skin hot and sweaty He is uncuffed and transfer to the cot without difficulty. In fact, he is only moving his arms weakly and won't open his eyes. He is secured to the cot. A more detailed assessment shows: GCS: 7/15 (E1 V1 M5) Pupils: 2mm and non-reactive Resp: Clear Rate 8-10 SpO2= 90% CVS: BP-100/50 HR-120 (Sinus Tachycardia) Temp-39 GI: Soft GU: Incont. of urine The bottles are collected by an RCMP officer. They are two large empty bottles of 325mg ASA tabs. A bottle of MSIR 5mg tabs in a different person's name. It is empty as well. Also, a baggie that is filled with Gabepentin tabs. He was searched by the RCMP and has no weapons were found. Before he 'passed out' on the coach he was screaming in incomprehensible sounds and trying to smash stuff. Cheers What are the empty pills bottles for, the quantity, and the Dispense date? The puke volume and the contents appearance, Any intact pills and their description? What is the patients current respiratory rate and lung sounds? Fireman1037 Hello, The physical findings are as above. Plus the following: --> The emesis look like green bile. No blood note. Quite an impressive amount is all over the living room. No pills seen in the emesis. --> As noted above. The pill are ASA 325mg tabs, MSIR 5mg tabs, and Gabpentin 300mg tabs. Cheers Edited June 15, 2010 by DartmouthDave Link to comment Share on other sites More sharing options...
Richard B the EMT Posted June 15, 2010 Share Posted June 15, 2010 Establish a patent airway, with tube if tolerated or needed, and place on supplemental O2 via Non Re-breather mask @ 10-15 LPM. Already covered is securing the arms with curlex/kling bandages, if he should regain consciousness and be upset with us EMSers and the RCMP folks. Original poster said his usual domestic dispute partner is in the back of the patrol car. See if the LEOs can pump her for information as to what happened (medically related) prior to EMS and RCMP arrival. I'm BLS and cannot give injections or start IVs, but as the scenario is with first due Paramedics, start an IV to keep vein open, on normal saline, and if protocols allow, go with Narcan propholactically (knowledge is from observation of FDNY Paramedics I am assisting on my job). If the patient has been vomiting bile-like emisis, with no apparent remains of the meds from the empty bottles, he's got something going on. I cannot yet tell what. Keep it coming, dudes and dudetts! Link to comment Share on other sites More sharing options...
CBEMT Posted June 17, 2010 Share Posted June 17, 2010 (edited) BGL? Not that it's probably going to make a difference, but if it does, well, there you go. NPA, if he takes that, try an oral. I doubt he'll take that, but it's a thought. If he takes that, intubate. Large bore IV, wide open. Second if we have time. Careful Narcan trial. Consider, if you have the option and the time, an NG tube for administration of activated charcoal. Rapid transport. Edited June 17, 2010 by CBEMT Link to comment Share on other sites More sharing options...
Richard B the EMT Posted June 17, 2010 Share Posted June 17, 2010 --> The emesis look like green bile. No blood note. Quite an impressive amount is all over the living room. No pills seen in the emesis. --> As noted above. The pill are ASA 325mg tabs, MSIR 5mg tabs, and Gabpentin 300mg tabs. ASA is aspirin. What is MSIR, and what is it's intended use? What is Gabpentin, and what is it's intended use? If our patient is down to bile, and I'm guessing the "dry heaves", again as noted with no pill remnants in the emesis, the administration of either the activated charcoal, or the administration of Ipecac would be contra-indicated. (And a hopefully not needed reminder, never both at the same time as they'd only counteract each other.) Link to comment Share on other sites More sharing options...
snoopy911 Posted June 17, 2010 Share Posted June 17, 2010 ASA is aspirin. What is MSIR, and what is it's intended use? What is Gabpentin, and what is it's intended use? If our patient is down to bile, and I'm guessing the "dry heaves", again as noted with no pill remnants in the emesis, the administration of either the activated charcoal, or the administration of Ipecac would be contra-indicated. (And a hopefully not needed reminder, never both at the same time as they'd only counteract each other.) Was going to ask the same thing about MSIR and Gabpentin. I know I've heard of gabpentin before, but can't put my finger on what it is. Also, forgive me for not knowing this, what is RCMP? Syrup of Ipecac? Really? I didn't know they were in anyones protocols anymore! Link to comment Share on other sites More sharing options...
DartmouthDave Posted June 17, 2010 Author Share Posted June 17, 2010 (edited) Hello, Sorry for the slow response. Very busy at work these days. Excellent responses here. The Wife: She is quite drunk. She is unable to offer any medical history. However, she says he was unable to talk right. Had all his words mixed up and was more violent and disagreeable than usual. It reminded her of her Grandmother when her sugars were low. RCMP: Police MSIR: Morphine Sulfate Immediate Release Tabs Gabapentin: An anticonvulsant that is commonly used now for carious chronic pain syndromes. ASA: As noted above Aspirin. So, it appears that he has taken quite a few Morphine pills and a pile of ASA. The bottle had 50 325mg tabs in it! They are all gone. Plus, washed it all done with liberal applications of ETOH. Some excellent suggestions of treatment. IV x2 and a bolus is started. OK, he is given some Narcan for the MSIR OD. With careful titration his wakes up some. He is reassesses and the following findings are noted: GCS 11/15 (E4 V2 M5) His eyes are open and he is trying to talk but his speech is all mixed up. He has a confused but mean look in his eyes. His arm and legs are quite weak and shaking slightly. PEARL @ 3mm Skin: Diaphoretic BP: 120/60 HR: 90's NSR Resp: 36 Very rapid and deep. His mouth is dry as a bone. His lungs are clear. BGL: 7.5mol (135 mg/dl) What is our field dx here? Second, what impact would this have on airway issues? Cheers... Edited June 17, 2010 by DartmouthDave Link to comment Share on other sites More sharing options...
Kiwiology Posted June 17, 2010 Share Posted June 17, 2010 Aside from the obvious alcohol/MS incuced respiratory depression and hypoaxemia we should look at the aspirin. Now I know we all know this, but aspirin is an antiplatelet aggregator hmmm I do remember something about extrinsic and intrinsic pathways, fibrin, clotting factor X, calcium, coagulatopathy and so forth from my AnP. Along that line I was thinking some sort of circulatory hypoxaemia (sort of like anaemia) where the oxygen itself was unable to be delivered to the body but I dont think thats it. Lets put this chap on some oxygen, get a bag mask out and where is my Intensive Care Paramedic skilled at rapid sequence intubation? Link to comment Share on other sites More sharing options...
Recommended Posts