scubanurse Posted July 10, 2017 Posted July 10, 2017 Dispatched to a nice single family home, you are greeted at the door by the niece of the patient reporting her Aunt woke up and attempted to go to the bathroom but was unable to ambulate. Reported nausea and vomiting x 3 hrs PTA and took an unknown Chinese herb to aid in nausea. PT recently flew in from China for a two month long visit. NKDA No meds No know hx, niece reports possible heart trouble. initial VS: 276/134 HR 80 RR 9 irregular BGL 144 O2 76%RA what's next?
paramatt_ Posted July 11, 2017 Posted July 11, 2017 Ok ill get things started How's she positioned - sitting/laying/slumped/ etc? Skin colour? Consc state - just AVPU Pupils? Also can we confirm that BP...manual if the first was NIBP and the pulse ox pleth
FireEMT2009 Posted July 11, 2017 Posted July 11, 2017 (edited) If she is unconscious I would insert an OPA if she could handle it and start bagging her about 10 to 12 times a minute and probably go ahead and intubate her for confirmed patent airway if she does not arouse after oxygenation for a couple minutes. In either scenario, lung sounds? heart sounds? bilateral pulses (paradoxis?), skin color temp? Bibinski reflex? If she is conscious give her 15 LPM NRB to start with, titrate down to keep her from becoming hyperoxemic. Everything Matt above me stated as well as getting some information on what herb she took if she has the box or bag it came in and also what did she eat over there I.e. Bird meat, beef, etc. This brings St. John's Wart to mind for some reason but I would also consider SARS, bird flu, mad cow, and any other weird disease she may have brought back. How long of a flight? Any hx of blood clots or birth control? Did she get up at all during the flight? And any complaints of CP or SOB? Did she go diving? Edited July 11, 2017 by FireEMT2009 Continued questions as I thought about it
scubanurse Posted July 12, 2017 Author Posted July 12, 2017 On 7/10/2017 at 7:29 PM, paramatt_ said: Ok ill get things started How's she positioned - sitting/laying/slumped/ etc? She is laying limp in a chair Skin colour? Pale/Diaphoretic Consc state - just AVPU Responsive with grunting to deep sternal rub Pupils? 3 and sluggish bilaterally Also can we confirm that BP...manual if the first was NIBP and the pulse ox pleth Manual BP: 248/102 Pulse Ox: 76% on RA On 7/10/2017 at 8:27 PM, FireEMT2009 said: If she is unconscious I would insert an OPA if she could handle it and start bagging her about 10 to 12 times a minute and probably go ahead and intubate her for confirmed patent airway if she does not arouse after oxygenation for a couple minutes. Responsive with grunting on deep sternal rub, has gag reflex present and emesis from the oropharynx In either scenario, lung sounds? heart sounds? bilateral pulses (paradoxis?), skin color temp? Bibinski reflex? Lungs clear and equal bilateral, heart sounds S1S2 no murmur, bilateral radial and femoral pulses 2+, skin pale/diaphoretic, bibinski is positive (good catch!!) If she is conscious give her 15 LPM NRB to start with, titrate down to keep her from becoming hyperoxemic. Everything Matt above me stated as well as getting some information on what herb she took if she has the box or bag it came in and also what did she eat over there I.e. Bird meat, beef, etc. You put her on 15lpm and O2 sat increases to 79%. Niece hands you a plain grey box with yellow Chinese lettering, niece does not read Chinese. This brings St. John's Wart to mind for some reason but I would also consider SARS, bird flu, mad cow, and any other weird disease she may have brought back. Ok, what PPE are you arming yourself with? How long of a flight? Any hx of blood clots or birth control? Pt has been in the US for 5 days, it was a total flight time of 15 hours. Niece only knows her aunt has some sort of heart problem but does not know anything else. Did she get up at all during the flight? And any complaints of CP or SOB? Unknown. Prior to the event, pt reported headache and n/v. Did she go diving? Not known, but highly doubtful.
FireEMT2009 Posted July 12, 2017 Posted July 12, 2017 Well her airway and breathing is an issue.. Suction her airway and start BVM ventilations at a rate of 20 due to possible herniation (see below) since her SpO2 is still bad with BVM. If she continues to show poor airway management then RSI would be my next step in this (I would delay this to see if the BVM ventilations would improve her mental status. I am concerned about a brain bleed or at least ICP so I would stick with Etomidate at 0.5mg/kg and Succ at 1.0mg/kg as initial induction and paralytic as well as an amp of lidocaine for possible ICP. I want to stay away from the ketamine here due to the possible issue with ICP.) I would use standard PPE with N95 respirator. Is there any symbols or letters on the pills that I can see and reference either with poison control or online index? This heart issue is it anything to do with mitral valve or irregular heart beat? Any medical paperwork, Dr notes, file of life, etc. in the residence? Currently I am suspecting either a head bleed or CVA or even a narcotic overdose especially since there isn't as careful FDA requirements in other countries and with her pupils being sluggish and her breathing slow. I would try IV narcan at 0.8mg to see if that effects anything unless we find out something on the pills. At the same time I'm worried about the head bleed due to the two of the three Cushings Triad with the hypertension, irregular respirations. Right now all we are missing is slow heart rate but we are probably gonna get close to it with that or the bradycardia from hypoxia. Did she collapse suddenly and regain consciousness PTA or has she remained semi-conscious since initial syncope?
scubanurse Posted July 12, 2017 Author Posted July 12, 2017 16 hours ago, FireEMT2009 said:wWell her airway and breathing is an issue.. Suction her airway and start BVM ventilations at a rate of 20 due to possible herniation (see below) since her SpO2 is still bad with BVM. If she continues to show poor airway management then RSI would be my next step in this (I would delay this to see if the BVM ventilations would improve her mental status. I am concerned about a brain bleed or at least ICP so I would stick with Etomidate at 0.5mg/kg and Succ at 1.0mg/kg as initial induction and paralytic as well as an amp of lidocaine for possible ICP. I want to stay away from the ketamine here due to the possible issue with ICP.) This is good, lets discuss succynlcholine use with head injuries. It's known to cause fasciculation which can increase ICP right? If we're suspecting she's at risk for ICP based on Cushing's Triad, would Roc be a better choice for RSI? I would use standard PPE with N95 respirator. Not a bad choice given the information you have. Is there any symbols or letters on the pills that I can see and reference either with poison control or online index? No, they are capsules that could have been handmade for all you know. This heart issue is it anything to do with mitral valve or irregular heart beat? No clue...are we still on scene figuring this out? We have zero access to any of her history. Any medical paperwork, Dr notes, file of life, etc. in the residence? Currently I am suspecting either a head bleed or CVA or even a narcotic overdose especially since there isn't as careful FDA requirements in other countries and with her pupils being sluggish and her breathing slow. I would try IV narcan at 0.8mg to see if that effects anything unless we find out something on the pills. At the same time I'm worried about the head bleed due to the two of the three Cushings Triad with the hypertension, irregular respirations. Right now all we are missing is slow heart rate but we are probably gonna get close to it with that or the bradycardia from hypoxia. Not bad, what are some things we can do to assist in preventing further rise in ICP? Did she collapse suddenly and regain consciousness PTA or has she remained semi-conscious since initial syncope? semi-conscious state since. This is a fun case and I have lots of pictures of her CT's and further management in the ED if anyone is interested.
FireEMT2009 Posted July 12, 2017 Posted July 12, 2017 (edited) 1 hour ago, scubanurse said: This is a fun case and I have lots of pictures of her CT's and further management in the ED if anyone is interested. My only issue with using Roc right off the bat is the fact that it has such a long period, which as a continued paralysis med, absolutely but at the same time if we have the issue where she is a difficult airway for some reason you are looking at BVM ventilations through either a king or OPA for about 30 minutes and I don't overly like that idea, which is why I would use the succ for initial induction. For the ICP as I put in earlier since we are looking at a strong indication of ICP with possible herniation we need to increase her vent rate to 20. Also keep her about 45 degrees during transport. If your looking for a medication and your department allows it and you have the right tubing, Mannitol would work great here as an osmotic diuretic. Sounds a lot like a subdural bleed to be honest. If you have the pictures and follow up I would love to see and hear them Edited July 12, 2017 by FireEMT2009 Grammar
Just Plain Ruff Posted July 13, 2017 Posted July 13, 2017 the pictures would be good - sounds like if you have pictures then this was a brain bleed or CVA. You can post them in the images section here or just send them to ruffems@gmail.com and I'll do it for ya.
scubanurse Posted July 13, 2017 Author Posted July 13, 2017 E-mailed them to you ruff... can't seem to get them to upload here.
scubanurse Posted July 13, 2017 Author Posted July 13, 2017 On 7/12/2017 at 2:57 PM, FireEMT2009 said: My only issue with using Roc right off the bat is the fact that it has such a long period, which as a continued paralysis med, absolutely but at the same time if we have the issue where she is a difficult airway for some reason you are looking at BVM ventilations through either a king or OPA for about 30 minutes and I don't overly like that idea, which is why I would use the succ for initial induction. For the ICP as I put in earlier since we are looking at a strong indication of ICP with possible herniation we need to increase her vent rate to 20. Also keep her about 45 degrees during transport. If your looking for a medication and your department allows it and you have the right tubing, Mannitol would work great here as an osmotic diuretic. Sounds a lot like a subdural bleed to be honest. If you have the pictures and follow up I would love to see and hear them You're going to be bagging one way or another unless you carry vents on your 911 ambulances. I understand the concerns with the half life of roc, but it is the safer drug in cases where ICP is a concern. Mannitol is great for these but I don't know many services that carry it. Another thing in addition to elevating the head of the bed, is throwing a c-collar on these guys to maintain neutral alignment. Small things like that can add up and help save brain tissue. This unfortunate patient suffered both a subdural and intraparenchymal hemorrhage. Our working theory was that she had been using some herbs for her "heart condition" and they were either ineffective or made the problem worse. At some point she must have gotten up to vomit (probably from the intraparenchymal bleed and rising ICP) and hit her head on the floor. She was rushed to the OR urgently for a craniotomy. I will try and grab to post-surgical images when I'm at work next.
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