Unconscious Female

[Mateo_1387]

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?

Probably a funeral If i'm the only one left caring for this patient.... LOL

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.

Good point here. I did start out at a low dose. I think options may be limited to either high doses of Dopamine to benefit from the alpha effects (along with chronotropic and inotropic effects) or if one carries Levophed, using it to benefit from its alpha effects (and inotropic effects). I am going to say it'd probably be better to use the Levophed. Though, I will say I am not the best to probably make this call, so am quite open to criticism on it.

Are you going to continue the fluids or stop at 2L?

I think continued fluids would be acceptable. Though, without looking at a sepsis protocol (which I'm suspecting) I'm not confident on the right amount to taper off the boluses.

Any other tests that would be appropriate for this patient?

I'm going to attempt this, though again not familiar with all the labwork in the world, but.... Cultures if possible of blood/sputum (if available), General blood work to look at serum ion levels, Kidney, and liver function ( I think is a CMP), Urine Tox along with specific gravity, creatine, and such, Blood counts, Head CT, chest X-ray. I'm assuming this point we are kind of taking the scenario into the hospital realm.

If you do decide to RSI this patient, how will you counteract the hypotension?

Hmmm, I am thinking take control of hypotension first beore RSI. Though, if push comes to shove and RSI needs to be performed first, I would think RSI with standard Succinylcholine/Etomidate, and maybe continued sedation with light doses of Ketamine. Though Etomidate may not be the best choice, with sepsis. I'm kind of unsure. If you knew a successful intubation could be performed, maybe just sedate with Ketamine? On the other hand too, though we are unable to obtain SPO2 levels, we know her ETCO2 is near 40mmHg, so I would question weather to use a paralytic or not, maybe just support her own respiratory drive with ventilator pressure support.

How much sedation (and using what med) do you think would be needed for someone this sick and hypotensive?

For sedation I'm thinking Ketamine, maybe something like Fentanyl too. Want to use light doses of medicines that will produce a sedative effect, though hopefully not worsen the blood pressure.

Honestly, this just goes to show that without working at this kind of level, I'm not the best one to be calling any shots, so folks, please help !

[triemal04]

At this point you have placed a 20g PIV in the AC, given 0.8mg of narcan IVP, 2500ml of normal saline, have stopped bagging the patient and placed her on CPAP at 5cmH20.

You have a dopamine drip running at 5mcg/kg/min.
Your vitals are now:

GCS-6 (1/1/4)

p-152 with PAC's, BP-74/32, rr-5 spontaneous/shallow, SpO2-still unknown, ETCO2-48mmHg with a normal waveform.

The patient only will withdraw to deep painful stimuli and is otherwise unresponsive.

You have a nifty istat (that you only have the cheap cartridge for) and a portable lactate meter so...

Sodium-140

Potassium-5.2

Chloride-124

Glucose-301

BUN-30

Hematocrit-48

Hemoglobin-12

Lactate-7.2

Further bloodwork is unavailable.

No x-rays, CT, blood cultures (or the ability to draw them) or a urinalysis are available on your medic unit. You do have the ability to place a foley if you so choose.

You assess the patient's airway as a Mallampati 2.

You are now 30 minutes away from the level 3 trauma/community hospital.

What next?

You're doing ok so far, I'll let it go a bit longer before I finish with a couple comments. I will say that this is a call that every paramedic should be capable of handling and, other than the extended transport time, there isn't anything that extraordinary going on here.

[Mateo_1387]

With the patient's altered mental status and hypotension, I do not think CPAP would be the best intervention to perform. I know I mentioned pressure support on the ventilator, but thats with RSI and hypotension control. In her current state CPAP wouldn't be advised.

I thought we would try a higher dose of Dopamine, or move on to Levophed?

I think RSI would be warranted. Using Midazolam 2 mg, Succinylcholine 100 mg, pass the ET Tube and confirm. Its going to be important to control the blood pressure though.

Looking at the labs (I'll be honest I had to look up a few values) I am not seeing anything spectacular. Glucose and BUN are elevated, the Hematocrit is slightly elevated.

An NG tube and a Foley cath could also be organized.

After RSI Albuterol may be administered to help with lower airway rhonchi/obstruction. Steroids may not be a bad idea either.

[triemal04]

Oops. Missed the part about levo. I wasn't sure what you meant about "supporting her own respiratory drive," glad you didn't mean CPAP. So it should have said:

At this point you have placed a 20g PIV in the AC, given 0.8mg of narcan IVP, 2500ml of normal saline, and are assisting the patient's respirations with a BVM.

You have a levophed drip running at 8mcg/min.
Your vitals are now:

GCS-6 (1/1/4)

p-132 with PAC's, BP-80/36, rr-5 spontaneous/shallow, 12 assisted, SpO2-still unknown, ETCO2-42mmHg with a normal waveform.

The patient only will withdraw to deep painful stimuli and is otherwise unresponsive.

You assess the patient's airway as a Mallampati 2.

You place a foley with return of 80cc of dark concentrated urine.

After giving versed and succynocholine you successfully place a 7.0 ET tube and OG tube. No return of stomach contents with suctioning of the OG tube.

Being quick thinking you place a probe to check a core temperature; 38.4C.

What are the doses of the meds you will use for continued sedation (and paralysis if you so choose), and dose for steroids?

After a couple of minutes you recheck the BP and it's now 70/30. Now what?

[Mateo_1387]

Levophed continued, support BP. For sedation probably just give Versed in small doses, 2 mg as needed for sedation. Probably hold off on the paralytic. As far as steroid, Methylprednisolone 125 mg to start with.