J306 Posted September 15, 2013 Posted September 15, 2013 You don't need med control for an apneic patient, but sask protocol indicates you need orders to maintain the tube with a sedative. If the patient begins to buck the tube and still has little respiratory effort, it could be helpful to have orders already even if you never end up using them.
Arctickat Posted September 15, 2013 Author Posted September 15, 2013 (edited) I see where you're going Jack. Interestingly enough, had I sedated this patient we would have missed a very important clue as to the underlying cause. So, we will hold the sedation for the moment. Summary: Client calls 911 for chest pain, past Hx of 4 previous MIs, and an infection for the past few days. Code status witnessed by EMS with CPR started immediately. Post resus after 15 min of CPR and 1 defib Pt is intubated ECG is Sinus Tach BGL is 22.8mmol/L Epi 1mg has been given 2 IVs are in place BP 132/70 HR 140 RR 12 with BVM SpO2 98% etCO2 39 Anything else you'd like done prior to transport? Edited September 15, 2013 by Arctickat
triemal04 Posted September 15, 2013 Posted September 15, 2013 (edited) Everything else can be done during the transport, so may as well start. Hook up a vent, 8ml/kg, PEEP-5, FiO2-1 (titrate that down as possible), AC with a rate of 12. Lungs were clear and equal, right? Give 500ml and then tko the lines for now, but be ready to support the BP with fluids and pressors if the BP drops as the epi wears off. Place a probe to get a core body temp. The 12lead is interesting. Those look a lot like flutter waves, and as best I can tell it's actually right at 150 (give or take a beat) which is very common with new aflutter. It does look there are the start of dewinter waves in the anterior leads and elevation in AVR, so a MI is also very possible, and would make sense given the situation. Full assessment of the body and clothes; strip as needed. Any deformities, discolorations, abnormalities? Signs of dehydration? Trauma? Pacemaker/defib in the chest? Check the infected foot too. Anything in the clothes? Are they wet? Discolored? Any response to heavy painful stimuli? If so check each extremity to see if you get a response from all of them. What was the guy actually doing in the field? Fertilizing? Spraying? Any chance of a toxic exposure, or just general farm work? Does he have a preexisting eye condition? Looks more like sudden vf due to a MI. May have an underlying infectious problem (ie sepsis) or undiagnosed diabetes. The pupil is concerning, but at this point there's nothing to be done, so just watch for any signs of herniation. Monitor and reassess every 5-10 minutes (vitals, respiratory effort, 12lead, and responce to stimuli). If the heartrate stays that elevated for a long enough period of time that the epi would have worn off might start thinking about either cardizem or metoprolol if the BP is still normal. Edited September 15, 2013 by triemal04
Arctickat Posted September 15, 2013 Author Posted September 15, 2013 (edited) Nice call Triemal, Transport has begun Lung sounds are clear and equal, vent is hooked up. Core temp is 36.8 C No abnormalities noted, no discolouration besides the foot noted below, clothes are moist around the crotch No pacemaker The skin above the infected foot is red past the knee and the veins in the foot are red lines up the ankle. No response to pain, however there is some respiratory effort now. He was haying, no chemical exposure His left eye is a prosthetic. Client also has a history of Type 2 diabetes and Hypertension. Edited September 15, 2013 by Arctickat
Arctickat Posted September 15, 2013 Author Posted September 15, 2013 Given there is no comment we'll move along. Would you consider an amiodarone infusion? Why or Why not?
paramedicmike Posted September 15, 2013 Posted September 15, 2013 After conversion with a single shock with no antiarrhythmic? I'd hold off on the amio for now. If he had gotten a round of amio while being coded, however, then he'd be getting the drip now. Since he didn't, no drip. Also, given the description of the leg I'm inclined to think whatever is raging in his foot and leg is a big contributor here. Got an iStat? While I think it's safe to say the guy is septic I'd like to see what an iStat would show including lactate. (And yes. Prehospital lactate in suspected sepsis is done routinely here. No, it likely won't change my treatment plan at this point.) I would have pressors ready along with more fluid. He needs aggressive sepsis management including antibiotics with careful monitoring of his heart. We can monitor his heart. The rest will have to come when he gets to the ER.
Arctickat Posted September 16, 2013 Author Posted September 16, 2013 (edited) 3 minutes from the hospital you're congratulating yourself because your patient has been improving since you defibbed and is breathing on his own...when the patient goes into full tonic clonic seizures. Edited September 16, 2013 by Arctickat
runswithneedles Posted September 16, 2013 Posted September 16, 2013 Whats the EKG showing How long does the seizure last Do we have a Istat to check lactate as PM requested what is the BGL in mg/dl Did the EKG change after the seizure Would versed be a choice to control the seizures
scubanurse Posted September 16, 2013 Posted September 16, 2013 Whats the EKG showing How long does the seizure last Do we have a Istat to check lactate as PM requested what is the BGL in mg/dl ~ 410mg/dl Did the EKG change after the seizure Would versed be a choice to control the seizures
chbare Posted September 16, 2013 Posted September 16, 2013 I'd redo the BGL just to make sure... Supportive care and look at benzodiazepines for seizure control. Try to verify a med list and start working through H's & T's if possible. Have toxicological issues on the list of differentials. Lactate is not so high on my list as I am assuming some degree of cellular hypoperfusion. However, chemistry looking at electrolytes would be quite helpful at this point. We have a laundry list of issues to consider from cardiovascular to neurological to metabolic and toxicological.
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