Unconscious Female

[triemal04]

Head to toe:

Atraumatic throughout the body with no visible lesions, pupils as above (checked with a penlight), and midline, JVD flat, trachea midline, oral mucosa dry with cracked/chapped lips.

Equal chest rise/fall with no abnormalities, coarse rhonchi in L lung, diminished in R.

Abdomen is soft without palpable masses, liver palpable below the costal margin.

Extremities are flacid and unremarkable.

Skin is pale throughout, core warm but extremities cool to touch.

For us non-Americans who can't remember the conversion, is that blood sugar high? Also, is the room bright? (just trying to confirm whether that pupil size is concerning)

That should have read "mg/dL" not md/dL (I blame fast typing not fat fingers), so it's high.

In terms of immediate interventions:

- With GCS 3 and respirations like that, I would suggest an OPA/NPA and ventilating.

OPA placed successfully without apparent gag.

For trying to sort out what is going on:

- If we have the hands, a 12 lead would also be nice.

Sinus rhythm with diffuse ST depression, occasional PAC.

The boyfriend gives you a 4-week pill minder that is still mostly full, is unable to find the actual prescription bottles.

Further history from the boyfriend is unavailable, just repeats that she was "sick" and has blood sugar and pain problems.

- NPA and bag mask to RR of 10/min = can we now get an SPO2?

- Large bore IV access and push through 1L of NaCl = any change to BP or GCS with this?

- 12 lead ECG = what does it show?

- Naloxone 400mcg IV (worth a shot)

- Scoop stretcher for extrication and go to hospital

Which hospital and why, by what method (air/ground), and why if you don't mind.

Something about the husband leaving for a couple of days and coming back to "THIS" just doesn't sit right with my spidey senses. Did they have a fight and did he leave for a couple of days thus setting off aprecipitating event for a suicide or could it be that his being gone allowed her to stop taking her medications/or vice versa took too many, because he's the only responsible one at the home and he makes sure she takes her meds.

Nice line of thinking and good pickup, but the boyfriend is a long-haul trucker so it's normal for him to be gone for several days at a stretch and have no contact with the patient. The boyfriend does deny any recent stress in the patient's life, recent suicidal ideation or previous attempts.

She's truly a GCS 3? Then she needs her airway secured and us to take over ventilation... I'd do that FIRST, even though I suspect some opioid issues here with the hx of chronic back pain. I really, really want to find the pill bottles and see what she's on... if she's got some of the hairier long acting stuff like Nucynta, XL Oxy or Opana, we may not have enough narcan to keep reversing her if she OD'd... I'd also like to know if there's some Metformin at play... (lactic acidosis, anyone?)

Good thought. Also consider polypharm OD as well as just long-acting narcotics. What is your preference here, straight to intubation and completely withhold narcan, or attempt a trial dose of narcan first? If you are going to intubate, how? Specific meds are unknown, but being quick thinking you look in the fridge and don't see any insulin vials.

I'd also love to see the 12 lead and if we can get an SpO2 waveform. Also, do we have capnography by any chance?

ETCO2 with assisted ventilations at 10/min is 41 with a normal waveform.

The patient now has an OPA in place with assisted ventialtion at 10/min, a 20g IV is placed with right AC (your partner says he couldn't find anything else in her arm) and a 1L bolus of normal saline is in progress. The general consensus seems to be for 0.4mg of narcan, so that is given IVP. After about 4 minutes you now have:

GCS-11 (3/4/4)

p-101, BP-70/36, rr-12/shallow, SpO2-still unable to obtain a waveform, and pupils 4mm and reactive to light.

The patient is very lethargic will open her eyes and focus on you, but without constant stimulation (loud voice) is unresponsive. Her answers are very slow and she seems very confused.

[Just Plain Ruff]

Ok, so the first round of narcan is given, let's do a 2nd.

Is she fighting the OPA? I would suspect if she is able to open her eyes and focus on you that the OPA is soon to come out. If we give enough narcan, it might just come out and be thrown at ya.

But I digress, let's give a 2nd round of narcan but then do we run the risk of counteracting the narcotics and then seeing the effects of the other drugs that the unresponsiveness was masking?

Edited September 5, 2013 by Captain ToHellWithItAll

[triemal04]

Ok, so the first round of narcan is given, let's do a 2nd.

Second dose of 0.4mg given.

Is she fighting the OPA? I would suspect if she is able to open her eyes and focus on you that the OPA is soon to come out. If we give enough narcan, it might just come out and be thrown at ya.

OPA was removed as the patient began waking up and showing a weak gag reflex.

But I digress, let's give a 2nd round of narcan but then do we run the risk of counteracting the narcotics and then seeing the effects of the other drugs that the unresponsiveness was masking?

If this was a polypharm OD with a stimulant mixed in (like a speedball) then that is a concern. With what you've seen, in your judgement is that something that you're terribly worried about ? (honest question) If this was a polypharm with other depressants the bigger concern would be that if you had to take over her airway you'd just removed the ability to keep her sedated with narcs (for at least awhile).

Regardless after the second dose of narcan there is no change in her mental status or her pupil size.

[Just Plain Ruff]

I'm speaking from managing her post narcan in the ED which is where I would end up taking over her care since my last two jobs were on hospital based EMS which once done with the transport to the ER I'm the one who gets to continue as her primary caregiver along with a nurse so Yes that is a concern but as a street medic only, probably not a big concern for me as that street medic.

And yes, had I have given her the 2nd dose of narcan and the other depressants really shown their stripes, then I'd probably be back at the starting point of having to manage that airway that I just removed a OPA from. Wow, going full circle he he .

So I suspect that with the 2nd dose of narcan we can semi rule out much more benefit of narcan so let's transport her to the closest ed but let's consider the EKG first and see if she qualifies for a Cardiac center. Did you say that each hospital had good bad or excellent cardiac care facilitlies? ah re-read your first post, I'm going take her to the closest facility as it sounds like they have cardiac care as well as the facilities to handle this patient.

I'm also going to transport by ground because the helicopters I'm used to wont' transport overdoses due to security unless they paralyze and intubate them for the crews safety and the patients safety. We have a 15 minute flight to where I'm at and then at least a 15 minute flight crew scene time in order to get the patient paralyzed and tubed and all their ducks in a row so I can be 30 minutes into the trip by the time that the helicopter even gets to me, at a minimum.

This lady now after all our interventions isn't really completely massively critical necessitating a helicopter so I'm driving her.

Edited September 5, 2013 by Captain ToHellWithItAll

[triemal04]

I'm speaking from managing her post narcan in the ED which is where I would end up taking over her care since my last two jobs were on hospital based EMS which once done with the transport to the ER I'm the one who gets to continue as her primary caregiver along with a nurse so Yes that is a concern but as a street medic only, probably not a big concern for me as that street medic.

I meant do you specifically suspect that this patient as presented could be under the effects of something like a speedball (mixed depressant and stimulant), and if so, why? I'm just curious, that's all.

And personally I'd say that EVERY paramedic should be concerned with what happens to the every patient after the reach the hospital, especially as our care can affect that.

Edit: get to the rest when I have more time today.

Edited September 5, 2013 by triemal04

[Just Plain Ruff]

I think we need to get a good idea of what medicines that she is on and what she might have taken. If we don't know, I'm probably leaning towards no speedball but with a presentation like this, you always have to have that thought at the forefront of your mind.

[HarryM]

Well in the city where I work we have 4 ED hospitals within close proximity to each other and 3 of them are capable to dealing with critically ill patients and have ED's, ICU's, stroke teams, cath labs. So unless there was obvious major trauma (which only 1 hospital deals with) then go to the closest hospital by road.

[scubanurse]

Well in the city where I work we have 4 ED hospitals within close proximity to each other and 3 of them are capable to dealing with critically ill patients and have ED's, ICU's, stroke teams, cath labs. So unless there was obvious major trauma (which only 1 hospital deals with) then go to the closest hospital by road.

Part of the reason we work through scenarios like this one is to think outside where you normally are. In the original post, the OP gives you what hospitals you have available to you for this scenario. The hard part for you is making the clinical judgement based on the condition of the patient in the scenario and you available resources.

[DartmouthDave]

Hello,

Her BGL is 16.1mmol/L (296 mg/dl). Not that high but it could be DKA or HONK. If so, she will be acidotic so I would like to increase the BVM rate. Knocking her CO2 down some thereby giving us more to work with if we need to tube her. Acidosis and airway is a tricky situation.

Is she on Metformin? Hypotension and Metformin to cause quite a type B lactic acidosis. This was noted by a previous poster.

What is in her pill minder?

What is her muscle tone like? Rigid? (SSRI OD, ect..) Flaccid? (Tramadol, ect..)

How dose her abdomen feel? Choric pain...hepatotoxicity from Tyl?

The list is quite long right now.

On with the resuscitation:

Airway: I would add high flow nasal cannulas in preparation for possible intubation. I would keep going with the OPA and BVM for now. Do an airway assessment and build a plan and let the team know.

Breathing: I would increase the MV to bring the ETCO2 down to 35 or so if possible. If I recall correctly the lungs are clear. How is compliance? Do we have a nose or ear probe to see if we can pick up a SPO2?

Circulation: Her BP is soft. Tubing her with that pressure (plus possible acidosis) and the typical EMS medications would be a big problem. I would start a second 1000cc NS as pre-treatment for possible intubation. As for the ST depression it could be demand ischemia from the low pressure/hypoxia. Not too much we can do about that now.

Phenylepherine IV would be nice but that isn't a common EMS medication. So, I would see if I can get the blood pressure up, CO2 down, and pick up a Sp02.

Cheers

[triemal04]

I'm also going to transport by ground because the helicopters I'm used to wont' transport overdoses due to security unless they paralyze and intubate them for the crews safety and the patients safety. We have a 15 minute flight to where I'm at and then at least a 15 minute flight crew scene time in order to get the patient paralyzed and tubed and all their ducks in a row so I can be 30 minutes into the trip by the time that the helicopter even gets to me, at a minimum.

Good. Just like there will be a lag from the time of arrival at an ER until further treatements or assessments are done, the transport time of a helicopter is only half the problem. How long will it take them to land/lift-off? Knowing how the helicopter crew will offload personell/load the patient is important; do they hotload? Fully shut down? Disengage the rotors but leave the engine running? What would they likely be doing for this patient, and how long will that extend THEIR scene time? People who call for flight teams should be thinking about all of these things, and not just how long a flight it will be.

I think we need to get a good idea of what medicines that she is on and what she might have taken. If we don't know, I'm probably leaning towards no speedball but with a presentation like this, you always have to have that thought at the forefront of your mind.

Fair enough. All you have to go on is an unlabeled pill-minder, no prescription bottles.