Endometrial Hyperplasia

[vquintessence]

You are a dual Paramedic unit.
Approximately at 13:00 you're dispatched to intercept with a FD BLS Rescue already en route to local level 3 facility. Call comes in as syncope. En route the Rescue provides no updates, but asks you to continue.

U/A you find a 37 y/o female AOx3 speaking full sentences and semi-fowler. Woman presents very pale and notably lethargic; pt has to be continually prompted to answer questions and remain alert. Pt only offers a complaint of abd pain.

BLS relays pt was about to under go a biopsy in a physicians medical office for endometrial hyperplasia. They state the physician had ordered/given: diazepam 10 mg PO (this morning self administered by pt) and demerol 50 mg IM.

About twenty minutes after demerol, pt found by staff to be profoundly lethargic, at which point EMS was activated.

BLS relays pts only PMHx is "thickened uterus", takes no medicates, denies allergies. Their vitals prior your arrival: 120/62, 72 HR, 15 RR. The EMT teching denies any changes in status while in their care, and the driver offers a nearly inaudible apology for "wasting your time".

How would you proceed based on your initial findings, and the story relayed to you? Transport time is completely irrelevant...
[After a few treatments and options are followed, I'll go with the crews actual findings and field treatment.]

[Kaisu]

IV, O2, monitor and narcan. The endometrial hyperplasia is a bit of a red herring, as the pts vitals do not support hypovolemic shock.

[Griff]

I would need detailed assessment findings and an ECG to make a more definitive treatment decision. Regardless, I agree with the above poster; IVO2Monitor (one word ) and transport. I wouldn't give narcan in route unless noted respiratory depression was observed (which it doesn't seem to be), and that is the protocol here (it might be different somewhere else).

[RyanMidd]

I would also give the "driver" a smack, because no altered LOC is a "waste of time".

But second the previous Tx - Narcan, O2, position of comfort, and keep an eye on BP change.

[JPINFV]

If V/S are good and the patient is A/Ox3 (Guess here, this is a location that favors A/Ox3 over A/Ox4), why Narcan?

Originally Posted by RyanMidd

I would also give the "driver" a smack, because no altered LOC is a "waste of time".

Sorry... can't find a Gibbs head slap LOLcat picture.

/I can haz Caterday?

[RyanMidd]

Originally Posted by JPINFV

If V/S are good and the patient is A/Ox3 (Guess here, this is a location that favors A/Ox3 over A/Ox4), why Narcan?

Because you asked her if she had taken any of her own medications, and she said no. Obviously she's a liar and a thief!


But really, though? In a case of altered LOC with recent physician interaction, perhaps the Dr. made a "whoopsie", and the Narcan will cancel out that mistake.

[mycrofft]

It's dark in there, get her to a hospital.

No pupillary info, no capillary refill, no belly exam or ausc, no chest ausc. No characterization of pulses (bounding, regular, thready, irregular,) nor resps. Not to fault you, probably fine and discounted mentally, but I'm not there. Back or shoulder pain? Pedal pulses compared and characterized? Gums or mucosae pale or red? Temperature?

C/O plus signs suggests something is interfering with brain perfusion, maybe all over.

If the pt has endometriosis then her menstrual hx would be of interest to the ER staff.

OK...GIVEN transport time no matter, O2 can't hurt,monitor is good idea along with frequent BP's, Naloxone not indicated strictly by this hx and could cause repercussions with demerol, IV not indicated since VS ok and no parenteral route tx indicated so far. If transport time is a factor, get a line started with large bore needle. Fingerstick glucometry not a bad idea if obtunded but VS are good. Ask if pt has been sleeping ok.

[Griff]

Originally Posted by RyanMidd

Because you asked her if she had taken any of her own medications, and she said no. Obviously she's a liar and a thief!


But really, though? In a case of altered LOC with recent physician interaction, perhaps the Dr. made a "whoopsie", and the Narcan will cancel out that mistake.

Narcan is used in my region solely to correct respiratory depression secondary to opiate overdose. Perhaps your protocols are different, but I agree with JPINFV that naloxone isn't indicated in this case based on the available information. I would guess that benzodiazapine/opiate administration has caused potentiation of limbic system inhibition, resulting in the AMS without the pronounced respiratory depression noted with opiate overdose. I would certainly monitor vitals and keep the narcan handy, but I would only give it if protocols indicated (which mine do not). Just my $0.02.

[mycrofft]

Unilateral signs? Speech slurred, or slow but distinct?

[JPINFV]

Originally Posted by RyanMidd

Because you asked her if she had taken any of her own medications, and she said no. Obviously she's a liar and a thief!


But really, though? In a case of altered LOC with recent physician interaction, perhaps the Dr. made a "whoopsie", and the Narcan will cancel out that mistake.

That's my question, though. Given that some systems use A/Ox3 as being fully alert and oriented, it doesn't sound like she's altered any more based on the scenario as given. Additionally, her respiratory system isn't being depressed. Altogether, this makes me question whether administering Narcan would produce any positive benefits short of being one step closer to being able to bill ALS2.

Similarly, let's assume for a second that she's A/Ox1 (hence clearly altered) with the same vital signs. Still, what benefit would be had by giving Narcan? Sure, she's more alert and oriented, but you haven't changed her ability to load oxygen and unload carbon dioxide. The only thing you've done would be to bring her more into the world of the living while increasing her pain level by decreasing the effectiveness of her pain control.