Clinical conundrum

[BushyFromOz]

Okay, this i think is an interesting follow on from the ipratropium thread that's kicking around here. I think it will be interesting to see what peoples decision will be because i sure was racking my brain about it.

So.....

You travel to a small rural hospital for a routine transfer, 48 y/o M, going for a chest x-ray at a major hospital 40 minutes away. All your told is he will require 02... this is what you find when you get there......

Arrive 1200 hrs

HX of chronic asthma, ruptured discs c3-7 and L4 with severe 6/10 sciatica

Allergic to morphine, tranadol,

On fentanyl patchs 300mcg, temazepam, 25mg of prednisolone orally at 0800 and a whole lot of other shit, has been given IV fent by the hospital when needed Had an acute asthmatic episode at 0100 and has since had ventolin nebs 2/24 and nothing else.

Obs...

HR 80

B/P 130/100

SPO2 97% 3l/min via nasal cannula

no JVD

RR 34

full field wheezing left and right, diminished sound L base

Temp 37.6

speaking in single words

suprasternal retractions

profusely sweating

You start another ventolin/atrovent neb, whack in an IV and start you 40 minute trip. You cant position them upright because of the extreme pain the pt is in when you do so. There is some improvement in his respiratory state (speaking in phrases to sentences) all other obs the same - until his sciatica kicks in, at which point the pt is unable to speak, RR42, SATS drop to 90, B/P 1010/PALP, still full field wheezing and some JVD now - looks pre arrest, do you

A ) ditch the neb mask and give the only analgesic (inhaled analgesic)you have they are not allergic to to try and get on top of their pain as a method of controlling their SOB (you don't have IV fentynal, just morph)

B ) Airway takes priority, keep up with the nebuliser.

Intensive care truck is about 20 minutes away and has IV fent, dexamethesone etc etc

Think about it

Edited July 3, 2010 by BushyFromOz

[Mateo_1387]

From your scenario, I assume during transport he still has the same lung sounds and but is now able to speak in sentences, so this indicates slight improvement in respiratory status. Either way, you indicate a drastic change in status during transport, all beginning when he has sudden onset of pain.

So, this chronic asthmatic, with narrowed bronchioles, already poorly controlled with steroids and Ventolin, has a sudden onset pain, takes in a deeep breath (I assume), creates in increase in thoracic pressure, causes his heart to reduce Cardiac Output, and makes him look sick.

Well, can he suck on your inhaled analgesic for a few minutes then suck on a neb for a few minutes? I must admit, I have heard of your inhaled analgesic, but am not familiar with its properties, much less its name.

Other questions...

Has this been the norm for him during his hospital stay?

What other pain medications do you have?

Maybe you could let him suck on a Fentanyl patch while receiving a nebulizer....LOL

[BushyFromOz]

From your scenario, I assume during transport he still has the same lung sounds and but is now able to speak in sentences, so this indicates slight improvement in respiratory status. Either way, you indicate a drastic change in status during transport, all beginning when he has sudden onset of pain.

So, this chronic asthmatic, with narrowed bronchioles, already poorly controlled with steroids and Ventolin, has a sudden onset pain, takes in a deeep breath (I assume), creates in increase in thoracic pressure, causes his heart to reduce Cardiac Output, and makes him look sick.

Well, can he suck on your inhaled analgesic for a few minutes then suck on a neb for a few minutes? I must admit, I have heard of your inhaled analgesic, but am not familiar with its properties, much less its name.

Other questions...

Has this been the norm for him during his hospital stay?

What other pain medications do you have?

Maybe you could let him suck on a Fentanyl patch while receiving a nebulizer....LOL

Earlier, when you ask him "what happens when you have morphine" he replies "i stopped breathing and woke up in CCU 2 days later"

Youv'e also maxed out your dose 400mcg of IN fentanyl with nil effect.

This pain + worsening SOB is normal for him, he represents today much worse than before. He has also been intubated within the past 2 weeks for asthma.

[NannieKane]

I'm an EMT-B so I don't have all the other options, but I would still stick with the nebulizer since it was working. If you can't get air in all the other meds in the world aren't going to keep him going. If necessary I would bag him and/or insert an NPA or OPA. My guess is the movement is causing the pain to increase, so I'd tell my driver to keep the ride as smooth as possible even if we slow down. Let the intercept know what's going on.

I might even have the driver stop to see if it relieves the pain and improves the situation. If so, I'd pull over and wait for the intercept.

[Kiwiology]

Hmmm .... I wouldn't have been real keen for this fellow to get in the ambulance with me, he seems pretty crook.

Keep up the nebs and drive towards an Intensive Care Paramedic or hospital with much of the fastness

[BushyFromOz]

Hmmm .... I wouldn't have been real keen for this fellow to get in the ambulance with me, he seems pretty crook.

Keep up the nebs and drive towards an Intensive Care Paramedic or hospital with much of the fastness

Thought about leaving him there for a few seconds, but then realised we were the highest level of care available!

[Mateo_1387]

Earlier, when you ask him "what happens when you have morphine" he replies "i stopped breathing and woke up in CCU 2 days later"

Youv'e also maxed out your dose 400mcg of IN fentanyl with nil effect.

This pain + worsening SOB is normal for him, he represents today much worse than before. He has also been intubated within the past 2 weeks for asthma.

Well, even if morphine just made him nauseated, the associated histamine release on top of his asthma would probably not be a good idea...

What do you think of the one idea of giving the Ventolin for 2 minutes then the Pain med? I know it may not be standard procedure, but this isn't a standard case...

[JakeEMTP]

Yeah, I think I'd try a combivent (Albuterol/Ipratropium), 125mg of Solumedrol IV and perhaps an Epi Drip (here I have to call Med. Control for this intervention, but I have done it on a Anaphylaxis call). Since you maxed out on your Fentanyl, do you have the option of Toradol for pain control?

[Kaisu]

He's got asthma... exacerbated by anxiety. I'd try to calm him down with valium. Its what I got other than versed. You've maxed out on pain control and while I dont have a problem continuing the nebs, attacking on a third front may be useful.

PS.. whats his capillary blood glucose?

edited to add the ps

Edited July 3, 2010 by CrapMagnet

[mobey]

He's got asthma... exacerbated by anxiety. I'd try to calm him down with valium. Its what I got other than versed. You've maxed out on pain control and while I dont have a problem continuing the nebs, attacking on a third front may be useful.

PS.. whats his capillary blood glucose?

edited to add the ps

I'm with you, SL Ativan 0.5mg (maybe repeat once) can only help IMHO. I would not put any benzo's IV since he has narcotics on board and I don't wanna risk any resp depression.

CPAP would be nice if we have it

Continue Ventolin

MgS04 2g over 5min.

How bout an IM epi 0.5mg 1:1000

To be honest if I don't see immediate results, he probably needs intubated, but inubating asthmatics really sucks!