triemal04 Posted September 9, 2013 Author Posted September 9, 2013 (edited) What is in her pill minder? Multiple assorted pills. At a glance it doesn't appear that they were placed there at random but in a specific order. What is her muscle tone like? Rigid? (SSRI OD, ect..) Flaccid? (Tramadol, ect..) See above for the initial. Since the 2 doses of narcan she is still flacid but has spontaneous movement of all. How dose her abdomen feel? Choric pain...hepatotoxicity from Tyl? See above. 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. Patient has a weak gag again when you attempt to reinsert the OPA. Ventilations assisted without difficulty, nasal cannula at 25lpm is placed. 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? See above for lung sounds. 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. Still unable to obtain an appropriate waveform to determine a SpO2. Anything you'd like other than phenylepherine? So you have now been enroute to the nearest hospital (level 3 trauma/community hospital) by ground for 10 minutes with a 50 minutes remaining. For those who requested this, why this method of transport, and why this hospital versus the other two? For this scenario we'll say that any change in your destination at this point will add a further 20 minutes to your transport time. At this point you have placed a 20g PIV in the AC, given 0.8mg of narcan IVP, 1500ml of normal saline (with 500ml more still running), and are assisting the patient's respirations with a BVM. Your vitals are now: GCS-9 (2/3/4) p-124 with PAC's, BP-66/30, rr-10 spontaneous/shallow, 12 assisted, SpO2-still unknown, ETCO2-34mmHg with a normal waveform. The patient only responds to deep painful stimuli for brief periods and does not respond appropriately to questioning. Any further tests or treatements anyone would like? If I didn't mention it before the patient is an average appearing early 50's female, about 150 pounds in weight. Edit: and if you aren't sure what I meant by "routinely carried"...just ask. It'll be a judgment call anyway. Edited September 9, 2013 by triemal04
BushyFromOz Posted September 9, 2013 Posted September 9, 2013 i would have witheld the narcan. suspected polypharm OD + other issues i think this patient is better of with their airway protected, their ETCO2 managed and the perfusion supported. I'll let the hospital figure out the cause from this point on.
ERDoc Posted September 11, 2013 Posted September 11, 2013 Even in the hospital, I'd support the airway and let the drugs work their way out of her system, while identifying the pills with micromedex and then changing treatment as needed. Obviously we would get a head CT, cxr, labs etc which may change things.
Just Plain Ruff Posted September 11, 2013 Posted September 11, 2013 Even in the hospital, I'd support the airway and let the drugs work their way out of her system, while identifying the pills with micromedex and then changing treatment as needed. Obviously we would get a head CT, cxr, labs etc which may change things. How many medics out there with Ipods or Iphones or even android phones have an application that can identify the pills. I am pretty sure that there is an app that has this feature bundled in it. But the risk that we run is this, are these the only pills that she took? Did she not take all of one particular pill so we won't have one to identify? I have worked many polyoverdoses where they took a handful of pills and of those pills that patient only had 5 or 6 of a single type of pill and they took them all so we were left with the inability to identify all those pills that they took. That's one risk that we have to think about when we have a pill caddy. Are all the pills that they took in that caddy? Sometimes, but often not.
ERDoc Posted September 11, 2013 Posted September 11, 2013 It may not tell you everything shebtook but it will be a good start. Most overdoses now days are pretty much conservstive management, support airway and vitals until the drugs wear off. Obvious exceptions would be things like tylenol and aspirin, which we can get levels for. We are also narrowing our differential on this woman. Are we sure that this is an ingestion?
Just Plain Ruff Posted September 11, 2013 Posted September 11, 2013 I think that we went down this route and didn't go down any other route such as Stroke or other issues. Her sugar was high. I'm not sure what her pupils were. Could she have some sort of cardiac issue that we jumped the shark over and didn't explore further? Could she have an infection that we didn't explore? What is her temperature? What did her EKG look like? How bout Pupils and reflexes. Facial droop and the like?
triemal04 Posted September 13, 2013 Author Posted September 13, 2013 I think that we went down this route and didn't go down any other route such as Stroke or other issues. Her sugar was high. I'm not sure what her pupils were. Could she have some sort of cardiac issue that we jumped the shark over and didn't explore further? Could she have an infection that we didn't explore? What is her temperature? What did her EKG look like? How bout Pupils and reflexes. Facial droop and the like? See above for what all of that was initially and after the initial treatements. Currently: temp- 37.4C on her forehead, extremities are still cool, core is still warm. ecg- sinus tach with PAC's and diffuse ST depression, no change except an increase in the number of PAC's. Pupils still 4mm, midline and reactive. Pt is not able to follow commands anymore, withdraws all extremities in response to pain. Deep tendon reflexes intact. Pt is not alert enough for a full cranial nerve assessment, gross neuro's seem to be intact.
Just Plain Ruff Posted September 13, 2013 Posted September 13, 2013 Pt is not able to follow commands anymore, withdraws all extremities in response to pain The above really concerns me but I've got such a migraine that I'm not sure why it concerns me, this must be the dilaudid for my headache that's got me not caring right now. But it will come to me sooner rather than later, maybe during a drug induced coma myself I will gather it together.
Mateo_1387 Posted September 15, 2013 Posted September 15, 2013 I am thinking this patient may also have sepsis, possibly due to a pneumonia. The patient presents with Coarse left lung sounds along with diminished right lung sounds. If she is overdosed on narcotics, she is likely sedentary, breathing slowly, which I think would allow for bacterial growth and/or an aspiration pneumonia. After Naloxone is given thus reversing the effects of CNS depression, we see that she becomes tachycadic and has a slight raise in temperature. I think by this point it may also be prudent to start administering Dopamine. With her low perfusion status, end organ failure may be a real possibility, being we don't know how long she has been like this. Lets say we start out with the standard 5 mcg/kg/min, which at her weight of 150 (using a 1.6mg/mL Dopamine Concentration) would be 13 gtt/min. RSI may be an option, though I'd be weary of administering sedatives in lieu of the profound hypotension.
triemal04 Posted September 17, 2013 Author Posted September 17, 2013 I am thinking this patient may also have sepsis, possibly due to a pneumonia. The patient presents with Coarse left lung sounds along with diminished right lung sounds. If she is overdosed on narcotics, she is likely sedentary, breathing slowly, which I think would allow for bacterial growth and/or an aspiration pneumonia. After Naloxone is given thus reversing the effects of CNS depression, we see that she becomes tachycadic and has a slight raise in temperature. I think by this point it may also be prudent to start administering Dopamine. With her low perfusion status, end organ failure may be a real possibility, being we don't know how long she has been like this. Lets say we start out with the standard 5 mcg/kg/min, which at her weight of 150 (using a 1.6mg/mL Dopamine Concentration) would be 13 gtt/min. RSI may be an option, though I'd be weary of administering sedatives in lieu of the profound hypotension. At this point you have placed a 20g PIV in the AC, given 0.8mg of narcan IVP, 2000ml of normal saline, and are assisting the patient's respirations with a BVM. You have a dopamine drip running at 5mcg/kg/min. Your vitals are now: GCS-8 (2/2/4) p-144 with PAC's, BP-70/32, rr-8 spontaneous/shallow, 12 assisted, SpO2-still unknown, ETCO2-34mmHg with a normal waveform. The patient only will withdraw to deep painful stimuli and is incoherent, only responsive for very brief periods after the stimuli. You are now 40 minutes away from the level 3 trauma/community hospital. What next? Couple questions: Is dopamine really the best choice for this particular patient? At the requested rate the vast majority of the effects will be on the heart rate and strength of contraction. Phenylepherine isn't an option, but there are other pressors out there. Are you going to continue the fluids or stop at 2L? Any other tests that would be appropriate for this patient? If you do decide to RSI this patient, how will you counteract the hypotension? How much sedation (and using what med) do you think would be needed for someone this sick and hypotensive?
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