zzyzx Posted October 12, 2006 Posted October 12, 2006 At seven o'clock in the morning, you respond to a 82 y/o male, unconscious/unresponsive. The patient's son meets you at the door. "I was supposed to go to breakfast with my dad today, and I found him like lying in the kitchen. He's got heart problems and he just started taking diabetes pills, but he doesn't take insulin. He's breathing okay, but I can't really wake him." You find the patient lying prone on the kitchen floor. There's a pool of coagulated blood on the white tiles of the floor next to him. He has bleed from a small lac on his head. He's wearing pajamas and looks thin and barrel chested. The son tells you that his father has been a smoker all his life and has COPD for which he takes an inhaler. He also says that his father had a CABG done recently but has never had a heart attack. He also takes blood pressure medications. He has diabetes that was diet controlled, but recently he's begun taking glyburide. Your patient is reponsive to pain only. Gag relfex intact. Pupils are equal and responsive. He is breathing at about 10 breaths per minute with adquate tidal volume. Lung sounds CBL and a pulse ox showing 92% on room air. He is sinus brady on the monitor with a rate of 48. His skins are pale, cool, dry. His BP is 94/66. The son also says that recently when has was over at his father's house he had to call 911 because his father experienced a brief period of confusion along difficulty speaking, but it resolved before the paramedics arrived and he stubbornly refused transport to the ER. What else would you like to look for? What treatments do you need to perform?
Connie31079 Posted October 12, 2006 Posted October 12, 2006 Get him on NRB @ 10L/min, see if that'll raise his SpO2 sats at all. Keep close eye on his breathing, since he's only brething 10 times/min, you may need to breathe for him if he deteroriates. Sugars? 12 lead? Hx TIA or CVA? I want to see all the meds he's on, if there are anymore that you haven't listed here. Allergies? IV, bolus 250cc to start, re-assess lung sounds, re-assess BP to see if that helped at all. If not, another bolus 250cc if his lungs remain clear.
Asysin2leads Posted October 12, 2006 Posted October 12, 2006 Strong suspicion of a stroke if the blood glucose is okay. Secure airway as necessary, initiated IV access with KVO, administer D50 25gm if needed, if no response, notification to stroke center, drive fast to hospital. Patient rates very high on the vegetable scale.
bassnmedic Posted October 12, 2006 Posted October 12, 2006 I agree with Asys, looking like astroke to me too. I'd like to know the pupillary response and if he could follow any commands whatsoever. If the BGL was within normal limits, then I'd go with the stroke protocol and consider facilitated intubation(due to the gag)oxygen low flow and IV access with rapid transport to Stroke center for CT. Todd
Thunderchild145 Posted October 13, 2006 Posted October 13, 2006 Something in the back of my head says overdose. What about those BP meds? Does he take Beta Blockers or ACE Inhibitors? I'd also like a CBG and a quick neuro exam.
zzyzx Posted October 13, 2006 Author Posted October 13, 2006 Okay, you have your EMT check his blood sugar. It comes back as 60. You're popping the caps of your dextrose when your EMT partner says, "Dude, are you sure you want to do that? What if he's sustained a head injury or if he's had a stroke! Making him hyperglycemic is just gonna make his brain injury worse!" Do you agree?
zzyzx Posted October 13, 2006 Author Posted October 13, 2006 Per the question about a possible overdose of HTN meds...you're told he takes atenolol and HCTZ but don't find the pill bottles. Your EMT partners says, "Dude, why don't you just light him up with some atropine or start pacing him?" Do you agree?
zzyzx Posted October 13, 2006 Author Posted October 13, 2006 Per the other suggestions, the patient is now on oxygen and his sats improve. You have trouble getting an IV. He moans when you give painful stimuli.
Asysin2leads Posted October 13, 2006 Posted October 13, 2006 As per the dextrose question I'd tell the EMT that an amp of D50 is equivalent to half a Snickers bar and the effect of dextrose on stroke and head injuries patients is still up in the air, so if he questions what I'm doing again I'll duct tape him to a semi-traveling to Phoenix. If its a bradycardia issue due to an overdose of a beta blocker, we could be cute and try a high dose of glucagon, but all of that will be while we are enroute, quickly, to a hospital because this guy is still probably stroking out. If it is a head injury/stroke, glucose will probably not do much difference but a good shot of atropine can increase ICP, so what is this guy's heart rate before we start going crazy go nuts with the anticholenergics? Who the hell is this EMT, anyway? We're going to have a good long talk after the call, that's for sure.
AZCEP Posted October 13, 2006 Posted October 13, 2006 Do we know what his normal blood sugar is? 60 mg% is pretty low. Most places will consider treating it with this presentation. I will be glad to help Asys with the duct taping. Might even provide a UPS label for the trip. Now is not the time for my EMT partner to question my thinking. Later will be fine, but not while I'm trying to figure this situation out. What are his pupil's size? Sinus brady would be expected with the beta blocker. The blood pressure isn't horribly low, and should be plenty to give us a better response than what is there. Atropine won't be much help anyway. It will only remove the restriction on the heart rate from the PNS. With this presentation, vitals where they are, there probably isn't much vagal stimulus present. Pacing Sinus brady doesn't strike me as a good idea either. Figure out a cause of the altered mentation, and try to keep your EMT's hands out of the drug box.
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