Clinical conundrum

[Mateo_1387]

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!

Are you sure it is asthma exacerbated by anxiety? It seemed to be caused by pain from Bushy's post. Quite different exacerbation causes and different treatments. The more I think about this scenario, the more I lean towards treat the pain, which I think would help alleviate tertiary anxiety... Not saying you are both wrong, just thinking out loud.

edited a sentence to make the tone nicer.

Edited July 3, 2010 by Mateo_1387

[Kaisu]

Are you sure it is asthma exacerbated by anxiety? It seemed to be caused by pain from Bushy's post. Quite different exacerbation causes and different treatments. The more I think about this scenario, the more I lean towards treat the pain, which I think would help alleviate tertiary anxiety... Not saying you are both wrong, just thinking out loud.

edited a sentence to make the tone nicer.

One of the largest components of the perceived distress level of pain is fear, which is an extreme form of anxiety. Women in labor are taught to breath through contractions... if they "lose it" giving in to the pain will make things much much worse. How many times have you picked up patients extremely distressed due to pain and relieved large amounts of it just by calming them down. You are maxed out on pain meds. This man's pain is chronic. Relieving anxiety and fear will only help.

BTW... narcotic withdrawal rebound will also increase perceived pain and anxiety. Has this patient been on narcs for a long time? He may be addicted.

[Aussieaid]

I have to agree with Mateo here. You had improvements in his respiratory status with pt now able to speak in phrases to sentences. He had wheezing and good sats prior to this sudden distress caused by the onset of severe pain. He is now holding his breath, barely breathing because it hurts so much to even take little breaths, hence the increased resp rate, increased intrathoracic pressure because he is grunting from pain which is causing the JVD and decreased cardiac output.

Since his asthma was improving it is not the major concern right now. His respiratory distress is currently related to his pain not his asthma. He needs to get his pain under control as much as possible as that is affecting his respiratory and cardiac status. If that means giving him the inhaled analgesics and arranging to meet the CCT for optional narcotics then that is what you need to do. I don't know what kind of inhaled analgesic setup you have but is there any way to add the nebulizer to the circuit like with an inline (ETT) nebulizer (McGyver it)? That way you can give both but you would have to be monitoring and titrating the analgesia pretty closely as it may affect the flow somewhat. Once you have given some pain medication and if his BP improves then I would consider giving some benzo's if you think he will tolerate it.

This guy is on chronic high dose narcotics so he is going to be very tolerant of them. He needs very high doses of whatever you can give him to provide any relief. I think you can give him benzos once you see how his pressures hold without worrying too much about him dumping on you. The priority right now is to relax him enough to get him breathing appropriately and that will help the BP anyway.

Anyway I think I just kept repeating myself so will leave it at that.

Happy 4th weekend to all!

Aussie.

[armymedic571]

I have to agree with you guys. His SOB is currently being exacerbated by his anxiety, that is being caused by his pain. If we control his pain, (the underlying cause) the rest should correct itself. Once his pain is controlled, we can them re-assess his respiratory status, and most likely get more accurate findings.

At least it makes sence to me...

[Mateo_1387]

... You are maxed out on pain meds. This man's pain is chronic. Relieving anxiety and fear will only help.

BTW... narcotic withdrawal rebound will also increase perceived pain and anxiety. Has this patient been on narcs for a long time? He may be addicted.

Not exactly maxed out on pain meds, the conundrum is whether to give the inhaled pain med (the only one available) or to continue nebulizers, after the man has a sudden demise.

I totally agree with the idea that relieving anxiety and fear will only help. I assume that is why he is on temazepam too.

[BushyFromOz]

PS.. whats his capillary blood glucose?

edited to add the ps

13mmol

All you have as far as analgesic is fentanyl IN, IV morph and this inhaled stuff.

Anxiolytic therapy is restricted to midazolam only

[Kaisu]

13mmol

hmmm... BGL of 234 mg/dl. Does this patient have a history of diabetes?

[chbare]

What exactly is this inhaled mystery medication for pain? I gather we have nasal fentanyl and parenteral morphine, with a history of morphine allergy?

Take care,

chbare.

[BushyFromOz]

What exactly is this inhaled mystery medication for pain?

Methoxyflurane..... controversial here i know, but its what I've got.....

hmmm... BGL of 234 mg/dl. Does this patient have a history of diabetes?

Nope

[chbare]

Hope his kidneys are in good shape...

Volatile anaesthesia agents are known to have bronchodilating properties. May be worth a go.

Take care,

chbare.