Cold and Twitching

[Just Plain Ruff]

Get the Intubation done, then do any cardiac support measures as needed and then drop an NG tube and do a enroute gastric lavage if you can. The EMS systems I've worked in have all carried the ability to lavage for overdoses.

See what the lavage pulls out

Continue transport

Does your pacing do anything to her? What's the response to the pacing?

How long is the transport to the hospital? IF it's a long way then I'll lavage till clear and then drop one or two bottles of charcoal in her. I'm also going to pull some blood for labs.

I'm drawing a blank but are any of these a MMOI? Any of them a tricyclic? If so then what does her cardiac rhythm and QRS complexes look like? If the QRS is widened then administration of Bicarb would be advised.

[triemal04]

Intubate by RSI for airway protection (consider using roc/vec or whatever your non-depolarizing paralytic is instead of sux).

Suction both the trachea and esophageous.

Warmed fluids.

Epinephrine drip.

Start thinking about high-dose IV glucagon and potentially a calcium chloride or gluconate infusion.

If she arrests use bicarb early.

Polypharm OD with prolonged downtime and hypothermia, maybe compartment syndrome in her left arm. That could potentially case problems if circulation is restored and the buildup of crap starts to move throughout her body.

Effexor is, off the top of my head, a SSRI, but this isn't serotonin syndrome, unless it's maybe at the far end of it. With a history of HTN she probably also takes a beta-blocker or maybe a calcium channel blocker...take the extra couple of minutes and find her prescription bottles.

Monitor her pulse and BP and watch the ecg for any changes to the QRS, check a core temp after intubation to see what her temp really is.

Get her to a hospital that can start lipid therapy and dialysis...though she's probably screwed.

[DartmouthDave]

Hello,

The airway is secured and she is still difficult to ventilated. Her lungs sound course. But, her SpO2 creeps slowly up to 92-93%.

She is given fluid which brings her pressure some.

You slip in an OG and suction out some gastric secretions but no pill fragments.

The Atropine has no effect. TCP brings her rate up.

Her VS are:

GCS 3/15 (pre-intubation)

BP 90/40

HR 60

Your list of Dx are:

PolyOD

Compartment syndrome of her arm

Hypothermic

You are enroute to the ED (15 minutes). You recheck her pupils and you note nystagmus then they deviate up to the left.

Discussion points:

Any comments on the how to tube her? Considering her BP and LOC? RSI?

BP: How much fluids? Epinephrine gtts?

Thanks

Edited March 27, 2013 by DartmouthDave

[scubanurse]

Would you even need to RSI her? I'd attempt it without RSI first probably.... she isn't controlling it so I don't know if there's a need to paralyze her.

Two wide open LR/NS... what's her sugar?

[MariB]

You all impress me. I'm still Herr , venting through a king and waiting to rendezvous with ALS

Edited March 28, 2013 by MariB

[scubanurse]

You would be hauling your butt to rendezvous with ALS.

[MariB]

You would be hauling your butt to rendezvous with ALS.

and cussing under my breath that my medic wasn't with me!

And yes, yes I would use lights and sirens

[DwayneEMTP]

Mike, you've worked in systems that allow lavage for an overdose yet still push charcoal with a long down time?

Triemal, why RSI?

What was her resperation rate, did I miss that?

In answer to your question I would try and orally intubate her first, and then, nasally afterwards.

Does anyone else think that putting her on her side would have been the FIRST intervention?

Would Epi be a superior infusion in this patient when compared to Dopamine?

What is the temp of the home? Is she truly hypothermic or just feel clammy because of retarded skin perfusion?

I don't have the bandwidth to search now, but the deviated pupils, it seems like I might remember that that implies a possible CVA, and/or traumatic brain injury. (Same thing? My meaning is injury initiated inside vs one that's initiated from the outside, but I'm not sure that I've used the proper terminology.)

I had a patient a lot like this once. My first nasal intubation. Bottles of mom's drugs all over, antidepressants, b/p meds, Valium, Percocet, Vodka and Tequila, all empty. I had no idea what to do, so I intubated him and drove him the few mins to the ER. Turned out he was unresponsive secondary to a CVA and had no dangerous levels of drugs in his system. (Theorized that he flushed mom's meds, threw the bottles around to freak everyone out, got shitfaced drunk and had a stroke.) It was also interesting on this call that I didn't push Narcan, only because I didn't really know what to do with the soup of drugs and didn't want to add another one to the mix, but the ER doc told me that he sees, on some occasions, Narcan work on patients with only alcohol onboard.

Ok, that's all of my nonsense for now...

Edit: Holy shit. As soon as I hit submit I thought..."Wait, unresponsive, deviated pupils, bradychardia,...This is a herniation, right???" (The hypothermia even makes sense to me, though I'm not sure if it should, if the brain stem is being compressed.) What is the triad?? Ok, now I really wish that I could Google it, not only so that I could see whether or not I'm being a complete moron, but also so that I could pretend that I know off of the top of my head what the hell I'm supposed to do about it....

In that spirit, this would be my treatment, right, wrong, or indiffernet....I'm going with massive brain injury. The pacing seemed to have taken, so I'm going to leave it in place, but assuming that I can maintain capture I'm going to bump it up to 80bpm, going to try and bring the B/P up as high as I can (Though, I can't remember if this is contraindicated due to increased cerebral swelling) to try and get my brain perfusion back, bag without hyperventilation and go emergent to the hospital and hope that the ER doc doesn't tear me an asshole that you fly Haley's comet through....

My logic...If it's a herniation then we've almost certainly already lost this battle. But if we're going to win then I have to try and force some blood through the pressure that's high enough to force the giant brain out through the tiny little skull butthole. (Foramun magnum? God...I've been in the jungle to long)

I'm going to up my heart rate on the misguided assumption that though my pressure is way too low to push blood into this brain, if it is pushing any, maybe I can circulate this 'little bit' more often. (Probably I'm only increasing the rate of herniation, but, this is what I'm going to do still.) If this battle isn't already lost, though I can't really see how it isn't, then tossing a Hail Mary to try and save any bits of brain that I can seems like my only decent option. And I can't imagine that either intervention won't be good for the other organs as well...should she now be a donor.

No hyperventilation secondary to the rebound vasoconstriction arguments. And I'm happy with her SPO2 in the low - mid 90s. I don't know about steroids, but I'm not going to push them in this patient without medical control (and I'm assuing that as in most scenrious, at least my favorites, that MC isn't available) as it seems that I remember reading about this being contraindicated...but that's maybe just in spinal injuries..and maybe not even that...but I don't want to push something bad that I can't take back as long as I have that "bad tickle" about it..

Man, I've not participated in a scenario in a long while....Let the beatings begin... :-)

[MariB]

I had patient on side until I put KING in... and only did that cuz he said they intubated.

I can't do an ET tube obviously.

[chbare]

Anybody know what the evidence has to say about gastrointestinal decontamination techniques such as lavage, single dose charcoal, whole bowel irrigation and so on? What about official position statements?

http://www.clintox.org/positionstatements.cfm