'Tis The Season

[J306]

Scratch the antibiotics, forgot that it was confirmed viral. Woops!

[J306]

If this is was an ongoing viral infection it could have led to septic arthritis before seeking treatment.

Painful joints and muscles could have prompted the patient to buy over the counter topical analgesics containing salicylates, such as Ben-Gay or oil of wintergreen causing unintentional overdose.

One teaspoon of Methyl salicylate contains 7000mg of salicylate, 4x the toxic dose.

Would explain potassium and magnesium deficiencies, ARF, metabolic-acidosis, and increased respiratory rate/effort.

So, any topical salicylate containing creams or ointments used recently? Tinnitus?

Sorry for the multiple posts, I'm studying for the ACP national exam and just happen to be studying this topic anyways.

[DartmouthDave]

Hello,

The patient that I based this case on improved enough for transfer but required intubation and admission to a critical care unit. He had DIC and a shocked liver due his horrible BP.

Some excellent questions J306.

J306, on 25 Jan 2014 - 9:24 PM, said:

I say intubate him with Ketamine 0.5mg-1.0mg/kg and Fentanyl.

The patient has responded to fluid boluses, but I'd like to have a Levophed infusion set up and ready to go prior to transport.

I would ask the staff why they gave Lasix to an ARF patient, document how much they gave, and look in the charts to see if that's when our septic patients BP began trending downwards.

How is our patients colour, peripheral circulation, distal pulse quality, mental status and affect after the fluid boluses and initiation of BiPap?

I'd check lungsounds for crackles, if non are present, I'd be comfortable with one more 20 ml/kg bolus of Ringers Lactate to replenish some nutrients and to try to avoid making him more acidotic than with saline. Any chance we could get some whole blood infused prior to transport along with some Tranexamic Acid?

Is air ambulance transport available? If not, I'd get either an RT or RN to join me during transport incase things go south.

J306, on 25 Jan 2014 - 9:48 PM, said:

When placing the patient on a transport ventilator, we should be aware that we'll be taking away his only compensatory mechanism since his renal function is impaired.

This is an other good point. Intubation of any acidotic patient is high risk. But, it is equally important to ensure an adequate minute ventilation. They were breathing 30 times a minute for a reason.

For some types of intra-renal failure Lasix is given. That was the rationale in this case. However, the was pre-renal failure as well. Which you hint at with your post.

Blood products and sepsis is an area of research. Some argue that old and cold blood can worsen the immue response. Older sepsis protocols call for infusions of PRBC if SvO2 is low despite fluid, Levo, and an inotrope (Dobutamine). But, again, I have seen a shift away from this in the last few years.

TXA is an option but the evidence is weak for a non-surgical septic patient butit is worth a discussion. An other option is PCC (Octaplex) for the coagulation issues.

Any chance we could get some whole blood infused prior to transport along with some Tranexamic Acid?

Very good point about the NS. Hyperchloremic acidosis (non-anio gap) acidosis is a complication of excessive use of NS.

In this case, if I recall, abx therapy has been started. Vanco can be given to renal patients. In hospital levels are check to ensure that they do not become toxic.

Cheers

Edited January 27, 2014 by DartmouthDave

[J306]

Thanks for the scenario David.

I hope that you'll continue to post scenarios, I learn a lot from being involved in them, especially being a green medic.

Are you able to give TXA and Octaplex in Nova Scotia? I was thinking about writing a proposal to our College of Paramedics in Sk, and try and get it approved for ground ambulance.

[DartmouthDave]

Hello,

If my memory is correct, EHS NS, is getting TXA. The CRASH2 study is a good place to read about TXA if you have not checked it out yet. It will be a good place to start for a protocol suggestion. Plus, TXA is cheap.

The WOMEN study is looking at TXA for post particular hemorrhage and they should be publishing in 2014. That may be worth a look.

Otaplex (PPC) is a part of the NS Massive Transfusion Protocol (just google ns massive transfusion protocol and they have a 40 page PDF that is quite good....I am using my new iPad and I do not know how to copy and paste yet). PPC is tightly controlled but it should be considered in any trauma patient or surgical patient will an elevated INR.

Cheers

[J306]

I've skimmed over the CRASH2 study and did find it helpful. The best info I've gotten was through informal conversations with the Anesthetists while doing my mandatory intubations in the OR. Learned a lot more through that than I ever did in school looking at power point slides.

Do you guys have an i-stat machine for Trop, Hemoglobin, and Lactate levels? STARS air ambulance here in SK has capabilities of testing for Trop levels, and a clinic I worked at up north had a Hemoglobin one, and I thought it was the coolest thing.

[Just Plain Ruff]

The benefit of having a trop Istat in the field would be huge for every service that has more than a 30 minute transport to a cardiac center. Think of the needless transports (medics best judgement on non-elevated troponins for transport to a cardiac center) that would not be made initially.

I for one know that some of the patients that I did send to the cardiac center 60 minutes away who did not have elevated troponins might have been served better in a local smaller ER but I also know that those that I erred on the side of no ekg changes and only a gut feeling along with a elevated troponin that I elected to send to the local ER would have been better served at the cardiac center. Having this tool would be one more tool and I say TOOL to help us direct the right patients to the right center.

Having ready use of a helicopter near by sometimes made me send patients who would have done just as well at our small ER but due to presentation or other symptoms, I elected to fly them to the cardiac center. Think of the decreased health care bills for these patients.

Edited January 28, 2014 by Ruffmeister Paramedic

[J306]

I'm going to talk to my boss about getting one, or at least trialing one to show how beneficial it would be.

The company I work for services a large geriatric population and is 45min from a cardiac center. Our air ambulance is also located 30-45 minutes away, so it would be hard to justify taking the only helicopter for the region out of service when the patient could be transported just as easily by ground.

Our college of paramedics has also drafted a proposal for ACPs to be able to administer Heparin and Plavix for patients that show clear STEMI criteria. If we were able to get an trop reading, we could bypass our local hospital and travel straight to the cardiac center 45 minutes away instead of being called back 2 hours later to transfer them code 4.

I also think a istat lactate level would have its place for those with a sepsis protocol in place. As stated in a previous post, we are now able to administer 325mg acetaminophen, 3L fluid challenge, and progress to norepi/dopamine as well as hang broad spec antibiotics. This could likely be managed by most local ERs, but the faster we can confirm sepsis, get that fluid, and administer antibiotics (for bacterial sepsis), the less likely they are to develop MODS.

[DartmouthDave]

Hello,

The ambulance service here (ground and air) do not have iStats. I think geography plays a role (regional and teaching hospitals are never too far away). Second, I think the cost per test is expensive and the need for calibration by bio-medical regularly. However, with longer transport times, like in SK, there could be a role.

In fact, many times during transfers, the air medical crew can get labs run by the labs of the sending hospitals.

As for CRASH-2. I agree, it may not be the most riveting reading but it is worth the time. Especially if you are suggesting a clinical practice guideline change. In your proposal you can note that a large study (CRASH) shows benefit in trauma patients. Second, it is inexpensive and do not require special storage. Also, it could be implemented easily because there are few barriers to change (i.e. cost, training, buy in by staff).

Cheers

Edited January 29, 2014 by DartmouthDave

[systemet]

Thanks for the excellent scenario, Dave.

A few points to add about POC troponin and STEMI / NSTEMI care:

* Troponins can take a long time to bump, so a single negative troponin is not an effective cardiac rule-out

* Conversely, most NSTEMI patients don't require emergent catheterisation

* The presence of absence of STEMI indicates the need for emergent reperfusion therapy. If there's a STEMI pattern, they need to either be lysed or cathed, depending on their risk factors, comorbidities, the availability of cathlab, and the age of their MI.

* In the first 2 hours, field fibrinolysis may actually outperform PCI (*Unless your site is basically always ready to go, and has an open suite 24-7, it is extremtly hard to actually cath someone in the first 60-90 mins of an MI -- a paramedic team can have someone lysed in 25 minutes, sometimes quicker), and has at least comparable benefit in carefully selected patients.

Re: TXA

* CRASH-2 is a great study because it shows that even in a broad, poorly differentiated population, there was no real increase in thromboembolic events. No one really infarcted or stroked out. The only patients who did badly were those with non-recent injuries.

* MATTERS is another good study to look at; this was performed by the military, so it used predominantly younger and baseline-healthier individuals, but they were also much more severely injured. It showed a much greater mortality benefit, suggesting that some of the benefit of TXA may have been masked in CRASH-2 by a subgroup of less severely injured patients who were at little risk of dying, and little risk of benefiting from the TXA, making the effect seem smaller.

* It's a very safe drug, with a pretty large benefit. More places should be using it.