Clinical conundrum

[Paramagic]

Hope his kidneys are in good shape...

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

Take care,

chbare.

Hmmm... volatile agents in an ambulance, curious. Lungs will kill him before the kidneys will, so it may be worth a shot. IV morphine, IM fentanyl, no IV fentanyl? Odd. Can you get on to OLMC and get permission for some IV fentanyl?

[Kaisu]

Is the patient febrile? Absent lung sounds on the left base, sweating, and high blood sugar suggests BGL pneumonia.

[Kiwiology]

Can you get on to OLMC and get permission for some IV fentanyl?

NZ/AU does not have any online physician contact. I know MAS has a "Metro Clinician" who is an Intensive Care Paramedic but I dont know about rural, and I don't know if they can authorise out of scope of practice anyway.

Have we started driving toward Intensive Care with much of the fastness yet?

[speedygodzilla]

So in the first post it said the patient "has been given IV fent by the hospital when needed"

So we are not carrying Fentanyl? What are we giving nebulize for pain?

I would like to treat both, but since that is not a choice let’s try treating pain and watch for improvement or deterioration and go from there.

[BushyFromOz]

Have we started driving toward Intensive Care with much of the fastness yet?

Yep

So in the first post it said the patient "has been given IV fent by the hospital when needed"

So we are not carrying Fentanyl? What are we giving nebulize for pain?

I would like to treat both, but since that is not a choice let’s try treating pain and watch for improvement or deterioration and go from there.

IV fentynal is not part of my scope, weve given 10mg salbutamol and 500mcg of atrovent

[speedygodzilla]

Yep

IV fentynal is not part of my scope, weve given 10mg salbutamol and 500mcg of atrovent

I looked up salbutamol and found it to be albuterol?

10mg? Normal dose is 2.5mg repeating as needed.

So what are you giving for pain? Morphine?

If pt is allergic to that than looks like you'll just have to stick with breathing treatment. What other drugs do we have at our disposal? I know some one was considering versed earlier.

Edit:Added content after rereading 1st post.

Edited July 6, 2010 by speedygodzilla

[Mateo_1387]

Is the patient febrile? Absent lung sounds on the left base, sweating, and high blood sugar suggests BGL pneumonia.

What in the world are you trying to say?

[BushyFromOz]

it seems that most people are for treating the pain as a method of treating the SOB, is that right?

[MSDeltaFlt]

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

it seems that most people are for treating the pain as a method of treating the SOB, is that right?

Chronic asthma and chronic pain in which he has acquired a tolerance of all kinds of things and is allergic to what you carry. In 40 mins you're not going to fix this guys pain. I doubt you'll even be able to take the edge off. Also pain is not mentioned in the primary survey. You are stuck on "B", my friend. Stick with the nebs. You'll be fine. So will the patient.