Drunk guy w/ possible meds, Tube or not?

[Lifetaker]

So I'm a fairly new medic in a rule area and I could use some feed back on this call. What would you have done different, things like that. Anyway the other night I had an ETOH call. This guy was about 28 with ADD as his only med Hx and Adderall slow release as his only meds. He's also not a drinker so he is pretty intoxicated off about 6 shots of some liquor called Absynth or something. Found him the bathtub with his pants on and quite a bit of vomit all over the place. Pt was very pale warm and VERY diaphoretic. Could'nt hold his head up very well at all. Pt kept vomiting but he was able to spit and move so he wasn't just laying there choking on his own vomit. Pt took his 10mg slow release Adderall earlier in the morning and it is now midnight. Anyway, started an IV, had a firefighter controll his head and sat him up in fowlers, put him on 3 lpm o2 NC with 98% sats. Gave about 1000 ml of fluid on the way to the hospital. We have half an hour transports. Cardiac monitor with normal sinus rhythm at 85. Bp was good and blood sugar was 168. And family denied pt ODing on his meds. Called poison controll and they said he would be a little diaphoretic from the Adderall but not that pale. Opted not to give anti emetic because I wanted him to rid his system of what was in there, in highnsight that probly was'nt that good of a decision. Then handed care over to the ER. So any feed back at all would be helpful. I'm still pretty new. Should I have Intubated the guy or put in an NG tube, or given some anti emetic? Or was he just really drunk and he's fine? Thanks in advance and keep on truckin.

[Bieber]

I'm just a paramedic student about halfway through my field internship, but if you don't mind I'll share my opinion.

It sounds like the patient was able to maintain his own airway, and I'm assuming was also alert if intoxicated. You had good sats on the NC and he was maintaining his airway, and I'm assuming he wasn't in any respiratory distress so I think it was appropriate not to intubate him; it wasn't really indicated if he could manage his airway and wasn't in respiratory arrest.

As far as I know, anti-emetics are no longer the recommended therapy for poisons, the preferred method is activated charcoal or the antidote for the poison, so I think you were right not to administer anything to him--especially if the patient and family are denying an OD. And I don't really think the NG tube was indicated unless you were thinking about giving him some charcoal anyway just to be on the safe side.

Honestly, and this is just my humble student opinion, but I think your treatment was appropriate, and I don't think I would have done anything different. You kept the patient's airway patent, had him on the monitor and had IV access. Adderall's a stimulant so I think if he was having an OD you would have seen an elevated blood pressure, but you said it was fine. I think that hypertensive crisis and seizure would be the two biggest concerns with an OD of Adderall but you had IV access if he seized and his BP was stable.

I don't know about him being so pale, so he definitely needed further eval at the hospital, but otherwise, like I said, I wouldn't have done anything different. The only question I have is why did you give him the fluid bolus? Did he appear dehydrated or what exactly was it that made you give him all the fluid?

[ERDoc]

It sounds like everything you did was fine. NEVER give activated charcoal to someone who is vomiting. It's a bitch to aspirate. Activated charcoal is falling out of favor execpt in a few small cases. Therapy for most overdoses is supportive. Anti-emetics would have been a good thing. He may be maintaining his airway but it is not ideal. Why not reduce the risk of aspiration and make your pt feel better. He is not vomiting because of "poisons" in his stomach, but more likely because he is drunk.

[DwayneEMTP]

I'm not terribly clear on just how responsive he was, but it sounds as if he was 'spitting.' Was this because he wanted to clear crap out of his mouth, or just sort of altered gagging, spitting?

It sounds like you did real well. I would have made the decision this way, for what that's worth. I would have strapped him down LLR (left lateral recumbent) and let him puke off of the side of the cot into a bunch of towels. If this allowed him to keep his airway clear, then I would have done as you did..run a bunch of fluid if there was no reason to believe it contraindicated and transported like that.

On the other hand, if there was a reason that I couldn't lay him LLR, or after doing so found that he wasn't vomiting strongly enough to force the emesis from his mouth, causing a risk to his airway, then I would have nasally intubated him. I had a Doc tell me once what the mortality rate was for people aspirating on stomach contents, and though I don't remember the number, I remember that it freaked me out, so I'm maybe a little over cautious of that.

Bottom line is that we need to keep what's coming out of his stomach from going into his lungs. If you can do that by saying, "Hold this bag and don't puke all over my ambulance!", or by positioning, or by close monitoring with suction, so be it. But if you have any reasonable question regarding that, and your intubation skills are strong, then a nasal intubation seems to be a reasonable choice to me. Of course all opinions are subject to change after input by my betters.

I can tell you that the few pts I've nasally intubated secondary to drug/ETOH issues in my small rural town either freaked out or pissed off the nurses when I brought them in. But in each case the physician seemed to feel that it was a prudent intervention.

A question for our Docs and nurses. Do nurses not train in intubation and/or nasal intubation? I actually had one nurse point to my nasal tube and ask the Doc, "What do you want us to do with...whatever that its?!" He said, "It's a patent tube, just leave it where it is." I'm not poking fun at nurses, I've just wondered since then if they were stating it in that way because they didn't recognize it, or being sarcastic because they thought that it was a poor choice.

And Lifetaker...Kudos to you for having the balls (or ovaries) to post your call, with possible errors included. It can sometimes be tough to ask for constructive criticism...I'm grateful that you were brave enough to do so and allow us all to learn from you.

Welcome to the City.

Dwayne

Edited to repair editor molestation.

Edited October 10, 2010 by DwayneEMTP

[Lifetaker]

Thank you both for your comments. To Bieber, I chose not to give Activated charcoal because there wasn't really any indication for it, he hadn't OD'd or anything and I gave him the fluids because of his alcohol intake which is dehydrating and he had vomited quite a few times which is even more dehydrating. Once I got him to the ER they started a second line and hung 2 more liters prior to our departure from the ER. The ER doc was also very concerned about his paleness and ordered blood work stat. ER doc also asked if I had given any anti emetic like Promethazine and I had not. To ERDoc, You're right, I probably should have given him some anti emetic to lower the risk of aspiration and make him feel better. I'm just so different like that sometimes. My thinking was that, he was vomiting and able to clear his airway so why not let him rid himself of whatever alcohol is left in his stomach, but then hindsight kicks in and I think, Crap I should have done this or I should have done that. The ER staff were also questioning me why I came code 3 with a drunk. Well, I wasn't worried about him being drunk but his profuse diaphoresis and paleness, and even the ER doc was thinking something else was going on. I've seen a lot drunks and never have I seen one that pale and diaphoretic. Then again I am a new medic so I havn't seen that much. Thank you again for your input.

[DwayneEMTP]

My opologies for the appearance of my post. I hit enter and walked away. I really, really hate what this editor does to my posts sometimes...

I'll try and fix it..

Dwayne

[chbare]

Dwayne, nurses receive very little in the way of airway management education beyond bag mask technique and basic airway management modalities. Intubation, ventilators and so on may be covered as part of critical care or respiratory lectures, but it is certainly not covered in any detail. As a nurse progresses and obtains experience in specific areas, they will develop a more specialised base of knowledge. However, it is conceivable that a nurse could work emergency room and never be exposed to nasotracheal intubation.

Initial nursing education takes a generalist approach to care and assumes specialisation through experience and additional education after graduation and initial licensure. Take me for example; I may be reasonably well versed in emergency, EMS and critical care, but have little knowledge beyond a basic appreciation in say operative nursing, dialysis or cancer care.

Hope that helps.

Ta,e care,

chbare.

[Lifetaker]

I'm not terribly clear on just how responsive he was, but it sounds as if he was 'spitting.'

DwayneEMTP, Thank you for your inpu. Greatly appreciated. He was very VERY drunk but every time I called his name he would look at me and answer all my questions correctly and every time he vomited he would move himself to a more sutible possition for vomiting and he would clear his own airway by spitting out the vomit in his mouth. He was pretty drunk but not unconscious, or barely arousable by painful stimuli drunk. I know some medics that would have, and have intubated drunk people for just being very drunk. I can see if this guy was so drunk he was an obvious danger to his own airway or unconscious than I definetly would have intubated him. We have the ability to RSI so we train a lot on intubating and RSI. My hang-up is those borderline pts that you would be wrong AND right going either way, but you should have anyway. If that makes sense. Anyway, thanks again for your input.

[bizar.one]

I'm just a paramedic student about halfway through my field internship, but if you don't mind I'll share my opinion.

It sounds like the patient was able to maintain his own airway, and I'm assuming was also alert if intoxicated. You had good sats on the NC and he was maintaining his airway, and I'm assuming he wasn't in any respiratory distress so I think it was appropriate not to intubate him; it wasn't really indicated if he could manage his airway and wasn't in respiratory arrest.

As far as I know, anti-emetics are no longer the recommended therapy for poisons, the preferred method is activated charcoal or the antidote for the poison, so I think you were right not to administer anything to him--especially if the patient and family are denying an OD. And I don't really think the NG tube was indicated unless you were thinking about giving him some charcoal anyway just to be on the safe side.

Honestly, and this is just my humble student opinion, but I think your treatment was appropriate, and I don't think I would have done anything different. You kept the patient's airway patent, had him on the monitor and had IV access. Adderall's a stimulant so I think if he was having an OD you would have seen an elevated blood pressure, but you said it was fine. I think that hypertensive crisis and seizure would be the two biggest concerns with an OD of Adderall but you had IV access if he seized and his BP was stable.

I don't know about him being so pale, so he definitely needed further eval at the hospital, but otherwise, like I said, I wouldn't have done anything different. The only question I have is why did you give him the fluid bolus? Did he appear dehydrated or what exactly was it that made you give him all the fluid?

I think he is right. There was no reason to intubate this pt. due to the fact that he does not have a compromised airway.. although i would have to question giving him any activated charcoal... 45 minute rule is out of the question the alcohol and medications are already in the system and not in the GI system. Secondly i would probably go with the NG tube if you were concerned with him aspirating any of his emesis. other than that i think you did the right thing. IV O2 monitor. let him sleep it off.

Not only that depending on what anti-emetic you are using. I mean say for example phenergan, well that is going to also help his respiratory efforts due to all the alcohol already in the system and that phenergan having some calming neurogenic effects. But maybe zofran or ondasetron would have worked.

[Bieber]

Sorry about before, I thought you meant emetics like ipecac before. Excuse the brain fart. Yeah, anti-emetics probably would have been indicated. I get what you mean about the fluids for the dehydration secondary to vomiting and alcohol consumption; that time I was just wrapped up in the protocols I'm running under currently. They only allow fluid boluses for hypotension with tachycardia.