Cold and Twitching

[mobey]

I'm going to go against the ALS grain here and stick with MariB.

I actually don't want to intubate, for fear we may be seeing a bradycardia due to hypothermia. Laryngoscopy will only increase vagal tone, and put the patient at an unacceptably high risk of asystole.

If you do not buy that, how about this: With a BP already incompatible with life, removing the "bellows pump" of the thorax (negative pressure in the right atria on inspiration causing increased preload) could very well kill this patient.

We have to approach these cases from a "most life threatening" position. She has been ventilating (somewhat) up till this point. Adding a BVM with 100% o2 and NPA with OPA may just buy us some time to build up a pressure that will make intubation safer.

That all said..... I see the pressure is up now so I'll quiet down.

Oh ya.... Dwayne, although I do intuitively agree with increased ICP, it is pretty low on my suspects right now with the low BP. I don't disagree with a catastrophic brain injury though.

[DwayneEMTP]

Low though it might be, wanna share what would suspect to be above it? :-)

Or is hypothermia your entire working diagnosis at this point?

[mobey]

I think the primary culprit is OD.

The symptoms of the OD are unconsciousness, resp depression, hypotension, hypothermia.

The result of the symptoms is:

Unconsciousness = Rhabdo

Hypothermia = bradycardia

Hypotension = Neuro event (CVA?)

It is a fair argument to say that cerebral edema and/or swelling is at play here causing increased ICP.... I would just like to see higher BP before I go down the herniation pathway as hyperventilating an already injured brain could be pretty detrimental. But hey.. your the jungle cowboy I don't think there is a right or wrong answer here.

I would like to start flooding her with fluid (foley would be nice). I like Hartmans solution here because it has a higher ph.

I would get the Dopamine up ASAP, Levo would be a great adjunct too, but we don't carry it. The Dopamine will help give the kidneys a little boost too.

[triemal04]

The pupillary changes could be due to herniation or plain cerebral edema, seizure, or I think there are some types of OD's than can cause that. If they are still dilated and sluggish but still equal I think it's less likely it's herniation, so either edema or seizure and maybe a tox issue. Try some benzo's, but that will cause problems with the BP.

She would still get paralytics from me. While she took an OPA without issue, she is still spontaneously breathing and still has some muscle tone, as well as vomit in the upper airway (even if you suctioned there's going to be some left). Paralytics will give you the best chance at a very quick first pass success, which is what you absolutely want in this lady. This isn't someone you want to be dicking around in the airway with, and given the difficulty of mask ventilation and the fact that this is someone who really does need a tube in the trachea and you want to give yourself the best possible chance at success. Have your fluid and pressors running before hand.

Personally I'd pass completely on TCP. At this point it's in the same class as pressors for bradycardia, and there is more to the hypotension than just a low heart rate, so it makes more sense to start fluids and pressors initially. Start the epi at 2mcg/min and titrate upwards to the heartrate and BP. If you are really concerned about giving it through a peripheral line mix up a dilute solution.

She does still need a large amount of warmed fluids as well, just watch what happens to her lungs after you start giving it.

As long as her core temperature matched what has already been given, hypothermia isn't causing all these problems. If she's been that cold for a long time...maybe, but doubtful since her temp would have continued to go down as her body failed.

Without looking far as I know all the evidence says that gastric lavage and charcoal after the fact are just silly; the damage has been done, so why waste time/resources and do something that might be harmful? With my placement of an OG tube I'm more worried about any passive regurgitation from the mask-ventilation. And if we did get pill fragments popping up you get some idea of the downtime.

[scubanurse]

Hello,

You enter the bedroom and and suction thick secretions and dried pill fragments. During the suctioning there is no cough, gag, eye opening, or movement (GCS 3/15). Her pupils are fixed and dilated at 4mm midline.

D

We have no clue about downtime and given that suctioning brought up some pill fragments...why not place the OG/NG tube? They'll do it in the ER anyways so why not start the suctioning now and best case, you prevent some of them from absorbing and reaching her system, worst case, you reduce the gastric contents.

[Just Plain Ruff]

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

Yeah Dwayne, I've worked in a system that with a long down time the docs have ordered Activated charcoal, not my call though. I probalby misspoke on the charcoal without having medical control give the orders. NOw that I know the transport time is only 15 mins, I'm not even going to lavage her because I'll only get the NG down her and the prep work to get the saline fluids to lavage would take all the time of the transport and I'll never get to the charcoal.

And do we really know how long she's been down? I don't remember reading that a long down time has been confirmed has it? But in all probability, I'm not goign to have the time to drop the AC let alone get her lavaged.

[DartmouthDave]

Hello Everbody,

Sorry for the slow reply. It seems that work always flares up when I try to do a scenario.

The patient has taken a massive overdose of Baclofen. Which, as it turns out has a narrow theraputic window. According to the maryland Posion Control Centre:

"Severe toxicity is associated with bradycardia, hypotension or hypertension, respiratory failure, hypothermia, seizures, coma and death. Rarely, status epilepticus, rhabdomyolysis, and conduction disturbances may occur." ( http://mdpoison.com/publications/toxtidbits/2012/February%202012%20ToxTidbits.pdf )

If I recall, Life in the Fast Lane or Broom Doc has a Baclofen case study as well. In which the patient looked brain dead until the Baclofen cleared. I will try to track it down.

She also took Ativan as well.

The hypothermia as Modey noted is due to the low BP, OD and as other have suggested laying on a cold floor. The warmed fluid is a great idea.

The eye twitiching were seizures like Trimak04 pointed out.

The difficult ventilation was due to a massive asperation.

The Effexox XL is a SNRI that loweres seizure threshold. It was felt that the Effexor + Baclofen that was causing the seizures for this patient.

Serotonin Syndrome was considered as well. Theie is the Hunter Scale is useful for S.Syndrome. Here is a good link: https://www.mja.com.au/journal/2007/187/6/serotonin-toxicity-practical-approach-diagnosis-and-treatment

The airway is the complex part. I would not be keen intubating this patient with her initial blood pressure. I know that the ABC happen at the same time. I would be keen on keen giving fluids, pressors (Dopamine, Levophed or Epi et al..) to get her BP up first. Unless you tube her without medications.

The OG is a good idea. I know that AC or AC with sorbitol is fallen out of favour. But, suction sounds like a good idea to me. Plus, sometimes, whole bowel irrigation can be useful with bezoars or some extended release medications.

Thanks,

David

Back to work.....

Edited March 29, 2013 by DartmouthDave

[chbare]

Dave, did you see my link on gastrointestinal decontamination techniques?

[DartmouthDave]

Hello,

The American Academy of Clinical Toxicology (AACT) website is quite good. I read the single and multi-dose Activated Charcoal (AC) pdf. When I started AC was used all the time and now it has fallen out of favour. In a nutshell the AAT (2004) stated that the evidence is mixed in animal, volunteer, case studies and clinical series is mixed.

The major issues with AC are asperation (even with an ET), OD related ilues worsed by AC or AC with sorbitol, and limited enhanced clearance of a medication. The AACT suggested that AC should be considered in extended release medications, medications with a low volume of distribution or OD that lack an antidote or treament options. They noted a few OD that AC may be useful but I can not recall. So, basically, not useful.

Whole bowel irrigation (WBI) works well the few times that I have sen it. However, I must admit, that I haven't read the AACT arctile on it.

One WBI was for a Lithium OD with a bezoar of pills in the bowel. An other was a massive Dilantin OD. I am not sure of the term....I think it is 'zero order kenetics'....but with some medications a massive OD overpowers the body's ability eleminate a medications. Thereby dramatically increasing the half-life. This is the case with Dilantin. It blocked the NA channels in the CNS and the patient wasn't waking up.

Cheers,

David

Edited March 30, 2013 by DartmouthDave