becksdad Posted November 14, 2006 Posted November 14, 2006 Hey Lithium - we were posting at the same time - great minds must think alike!!!
medic001918 Posted November 14, 2006 Posted November 14, 2006 So you've been with this pt for about twenty minutes and 400cc's of NS have infused. The pts BP is 136/54, HR is still just below 50 BPM, and the Pt is responding normally and looks quite a bit better. What do you think is going on with this pt? And why or why not did you decide to treat aggressively? I think the patient has a combination of things that could be going on with them. A medication interaction is one like has been already stated (including the alcohol use), a volume depletion for some reason (any recent sickness or poor intake?) But the reason that I stuck with treating the hypotension with fluids rather than the rate is that a rate in the high 40's isn't excessively low for a patient on a beta blocker. Most patients that I come across on beta blockers have a rate of 50-60 that can often mask any signs or symptoms of dehydration or volume depletion due to the medication not allowing for the body to compensate. Also, I prefer to start least invasive and continue to more advanced interventions after others have failed unless an immediate need exists. We need to establish an IV on this patient anyway, so why not start with a fluid bolus? Since the patients blood pressure improved along with his mentation and general appearance, the intervention is working. Continue with a fluid bolus to 500cc and then KVO the line, continuing supportive care and reassessment to the hospital. I would also start to question the patient more about the event since maybe he'll offer you some piece of information that the family wouldn't. I would be curious to see what this patients orthostatic v/s would have been if we could have performed the test on scene. That's an often telling indicator of what could be going on with your patient. And becksdad, you're welcome to play in the ALS forum any time. We're all working in the same field and if you can pull some useful information out of the ALS forum, by all means do so. You did a fine job with this scenario. Shane NREMT-P
hammerpcp Posted November 14, 2006 Author Posted November 14, 2006 You guys are pretty good. This seems to have indeed been a medication interaction between the Levodopa and the alcohol, and since the pt is on beta blockers as well his HR could not compensate when his pressure dropped out. On scene the pt's orthostatic VS where the same: HR just below 50 and no BP. So now a question for the smart kids. If Atropine is administered to a pt on beta blockers does the HR increase? What happens when you block parasympathetic and sympathetic impulses simultaneously?
Lithium Posted November 15, 2006 Posted November 15, 2006 What happens when you block parasympathetic and sympathetic impulses simultaneously? People die ... :wink: Becksdad, great minds think for themselves! (as quoted by a person much smarter then me)
hammerpcp Posted November 15, 2006 Author Posted November 15, 2006 Lithium, that question was clearly directed to the smart kids only. What about the inherent attributes of cardiac cells, automaticity, irritability, synchronicity?
Lithium Posted November 15, 2006 Posted November 15, 2006 Ooooo, I just love it when PCPs make the jump to ACP. It just radiates from them
AZCEP Posted November 15, 2006 Posted November 15, 2006 Atropine can increase the heart rate in patients on beta blockers. The beta blockers tend to reduce conduction through the SA & AV node, and Atropine will reduce the influence of the vagus nerve on these portions of the conduction system. It may not be a great increase, but it can work.
Thunderchild145 Posted November 15, 2006 Posted November 15, 2006 I don't know what caused me to spontaneously think of this, but glucagon works to counteract beta-blocker overdose. This isn't a BB overdose per se, but can't it be used to lessen the sympatholytic effect of the blockers? So yea, I'll go with glucagon, 3mg IV and see what that does.
medic001918 Posted November 15, 2006 Posted November 15, 2006 I don't know what caused me to spontaneously think of this, but glucagon works to counteract beta-blocker overdose. This isn't a BB overdose per se, but can't it be used to lessen the sympatholytic effect of the blockers? So yea, I'll go with glucagon, 3mg IV and see what that does. Are you sure you want to do that when the patient's responding rather well to a fluid challenge? His BP has increased and his mentation has improved. There's nothing to confirm that this is a beta blocker overdose. I wouldn't rush into trying to give a medication to counteract any kind of overdose after we've found a treatmen modality that is creating a positive effect for the patient. Shane NREMT-P
Thunderchild145 Posted November 15, 2006 Posted November 15, 2006 It would be something to think about. Did I read wrong that the patient's HR was still in the 50s and there was still no readble BP? If after 250mls the pt is still that bad I think it's probably time to try something else.
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