mobey Posted March 17, 2012 Author Posted March 17, 2012 Code status is "full code" as she has no past medical history. Anyone want to comment on Ketamine with suspected neuro problem that may include increased ICP? Once the tube is placed, the heart rate drops to 28 and BP is 178/102. Pupils are both dilated and sluggish. She is no longer making any respiratory effort. I'll let a few responses to this change, then wrap this up with final treatment diagnosis and outcome.
Kiwiology Posted March 18, 2012 Posted March 18, 2012 (edited) A question: Do we have any business performing RSI when we do not have adequate post intubation management education or resources? "Adequate" is a subjective term; in NZ people are intubated pre-hospital using RSI on average once every other day using the resources and guidelines we have in place and there have been no significant problems. Do I think we should have an automated ventilator for use on this lady if she's going to be in our care for the next hour or so on the ground and in the air en-route to the hospital? absolutely. Anyone want to comment on Ketamine with suspected neuro problem that may include increased ICP? Apparently that's now been refuted, but ... <insert studies here> Once the tube is placed, the heart rate drops to 28 and BP is 178/102. Pupils are both dilated and sluggish. She is no longer making any respiratory effort. Oh dear, sounds like this lady is Super CrookTM We could flog her ticker along with an adrenaline drip but I doubt that is going to do anything of any significance because her bradycardia is a physiologic response to the massive increase in ICP she has suffered Let's head to the hospital, they have a CT scanner and can do some lookey-loo'ing inside her noggin Edited March 18, 2012 by kiwimedic
chbare Posted March 18, 2012 Posted March 18, 2012 Have we verified proper tube placement? If you believe bagging patients is considered adequate post intubation management, then I suppose "adequate" is going to be rather subjective.
Kiwiology Posted March 18, 2012 Posted March 18, 2012 Have we verified proper tube placement? I'd imagine that has been taken care of when we intubated her, it would never hurt to check that it has not been dislodged however If you believe bagging patients is considered adequate post intubation management, then I suppose "adequate" is going to be rather subjective. I do not and fully agree with you that automated ventilation should be something in the pre-hospital arena; it is used by the HEMS Doctors and the ICU flight transfer teams but it is not a tool available to Intensive Care Paramedics performing RSI. Will it be in the future? I can't say; the rationale for not introducing it here is most likely due to significant cost and low use (relative to other things)
chbare Posted March 18, 2012 Posted March 18, 2012 I just wanted to be sure we verified placement with the usual methods before moving on. I assumed Mobey ment the tube was in proper place, but assuming can lead to all things bad.
mobey Posted March 18, 2012 Author Posted March 18, 2012 I just wanted to be sure we verified placement with the usual methods before moving on. I assumed Mobey ment the tube was in proper place, but assuming can lead to all things bad. Sorry, left out an important point. EtC02 20 initially, good waveform. Sp02 still 98-99% Yes the tube is above the carina in the trachea.
Kiwiology Posted March 18, 2012 Posted March 18, 2012 Sorry, left out an important point. EtC02 20 initially, good waveform. Sp02 still 98-99% An EtCO2 of 20 says to me she is ventilating too fast i.e. expelling CO2 at a greater than normal rate but I don't know and once we get beyond the basics of this stuff I'm out of my depth; so I'm sticking to my original plan and taking her to a hospital with CT and ICU facilities
Just Plain Ruff Posted March 19, 2012 Posted March 19, 2012 (edited) any sign of trauma, like to the back of the head? Maybe a fall last night where they just put her back in bed and didnt call anyone? My rationale of the helo was a three hour drive to the hospital with sutgical capability versus the hour or so drive to the one with no sutgical capability when my gut was saying bleed that could be fixed by neurosurgical intervention. Edited March 19, 2012 by Captain Kickass
Eydawn Posted March 19, 2012 Posted March 19, 2012 I would also want her transported to somewhere with surgical capability. The progression of symptoms here and the significant neuro damage that has already occurred leads me to think "bleed" instead of "clot"- stroke center with no surg suite can give TPA/similar but that's useless here. Odds are she's fairly toast as it is... it seems that this was fairly sudden onset, so acute subdural or subarachnoid are where my brain wants to go based on my past patient experiences. Quite possible she fell and didn't tell anyone- that was always my absolute favorite... Wendy CO EMT-B
mobey Posted March 19, 2012 Author Posted March 19, 2012 When I approached this patient I assumed stroke. I suctioned her, put in an NPA, nasal cannula, and hit the road. Enroute to the stroke centre (without surgical capabilities) I started 2 I.V. at TkVo. 12 lead was unremarkable. I administered 10mg Maxeran IVP I RSI'd using 100mcg Fentanyl, and 2.5Midazolam. I used Succ for paralysis. A 7.5tube was placed and confirmed by ausiltation, visualization, bulb, EtC02 waveform and numerical. I immediatly suctioned as far as I could and got quite a bit of vomit out. Sedation was maintained with 2mg bolus's of Midaz, and 50mcg Bolus's of Fentanyl. No further paralytics were used, and the patient was not making any resp effort. A CT scan was done, and showed thrombolytic stroke with significant swelling. A risk/benefit was weighed as family could not be contacted, and since the mpatient had only a history of glaucoma, TPA was administered. A chest x-ray showed significant aspiration in the left lung. Post TPA the patient did not improve, over the next 12 hrs the HR came up, and Bp decreased (normailized), this could be due to a decrease in swelling. Although I was SURE this was a bleed, I made a pretty good choice by racing to the primary stroke centre to maximize her chances of a positive outcome. This was a good call to make sure my confidence was in check since bypassing to a surgical site based on my theory this was a bleed would have been the wrong choice, as would a helo. Thanks for playing!
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