19 Year Old Male ALOC

[Handsome Robb]

So I posted some details of this in the directionless thread, was going to pm it to a select group of people then decided to make it available to the whole world rather than limiting myself.

It's ~1500 on a beautiful Thursday and you and your partner are returning from a somewhat long psych transfer out of town. Tones drop on you for a "priority 2 unknown problem man down, reported as a male in his early 20s laying in the grass in front of the movie theater" at the mall south of town that you just so happened to be coming up on. En route your call is reconfigured to a "priority 2 diabetic problem".

The mall parking lot is huge and there are a lot of little pieces of lawn around, after about 5 minutes meandering about the mall parking lot you find your patient. An ILS fire crew, mall security and the patient's father are already on scene.

Fire reports 19 yo male history of insulin-dependent diabetes was found laying on the grass "acting odd." Father states he was out with some friends but was "normal" at 0900 this morning.

Pt is a&ox0, responsive to loud verbal stimuli, GCS 11 (3/3/5) and mildly combative (think aimless, weak swats at hands and grabbing pant legs).

Initial vitals (per fire, there's my first mistake with this crew) of 110/70, pulse of 130 strong and regular at the radial, SpO2 78% on room air, respiratory rate 50 deep and regular. CBG "HI" with a ketone warning (>600 mg/dL on our glucometers.)

Physical exam shows no signs of trauma, skin is pink, hot and very dry, PERRL but sluggish at 4mm (outside in the 85 degree bluebird day) no JVD, trachea midline.
Chest is without signs of trauma, equal rise and fall bilaterally, clear to auscultation anteriorly and posteriorly, no retractions or accessory muscle usage noted.
Abdomen is soft, no palpable or pulsating masses noted, no guarding. Pelvis is stable, no urinary or bowel incontinence noted.
Lower extremities are unremarkable, upper extremities have a gazillion scars from what appear to be intravenous injections, other than that they're unremarkable, no peripheral edema noted.

History: IDDM and "psychiatric problems", father denied any previous suicide attempts, denies any knowledge of drug or ETOH abuse but states "it wouldn't surprise me."

No known allergies or drug allergies.

Medications: Insulin (father unable to be more specific), Prozac and guanfancine

I wanted to go to the closest facility but father was adamant about going downtown, second mistake. Should have put my foot down but at this point I didn't see anything that lead me to believe he'd take a dump on me like he did.

I will also add another mistake I made was letting dad **** around on the phone for ~5 minutes trying to find out allergies and the name of the patients medications, should've gone and gotten them from the ER.

What I did:

Non-rebreather at 15lpm, still semi-conscious at this point so tried an NPA that he fought viciously so I let him be since he was doing a decent job of protecting his airway. 4-lead, partner did repeat vitals while I worked on a line. This is where I realized this kid is in a much worse situation than I originally had thought but at this point I had already dismissed fire (third mistake before assuring the vitals they gave me were accurate. Some crews are awesome, this one not so much and I knew it but disregarded it.) I somehow managed to fight an 18g through the scar tissue in his right AC with a liter bag + pressure bag running wide open, partner botched the left AC.

Repeat vitals were
100/50
150 BPM, sinus tachycardia without ectopy. I didn't do a 12-lead...it wasn't high on my priority list, frankly it was at the bottom. I didn't see a reason but if I'm missing something please chime in.
87% on 15 LPM
RR 50 still deep and regular. Classic kussmaul respirations.

From this point it went downhill. We started transport routine and upgraded to code 3 soon after I took another set of vitals.


GCS reduced to 9 (2/2/5)
BP 74/p (NIBP gave 70/30, I couldn't hear it on our wonderful freeways so I palped it twice to be sure)
HR still 150 sinus without ectopy
SPo2 down to love 80s on 15 LPM
RR still 50/min, snoring but it was very obvious to me that he was tuckering out.
Lungs still clear from what I could hear, unfortunately the Master Cardiology is a little too good when the sirens are going and I couldn't get a great listen between them and the road nose.

Popped a NC wi 6lpm on, popped him supine, put a pillow behind him and did the most epic head-tilt chin-lift I've ever done and started bag assisting every 4-5 breaths which got him into the low 90s. Again tried an NPA that he fought violently so I again pulled it. Restrained upper extremities at this time because he was going after the only patent line we had and the only other option was an IO, his vasculature was totaled.

Transport was about 20 minutes. I didn't really get a whole lot done after I started bagging him. The ER tubed him straight away, started a CVC, and shipped him to the ICU. Unfortunately this was two days ago and I didn't make it to that ER today so I don't know any labs or an official Dx. Pop's wedding is mañana so I don't work again until Sunday.

I want the good the bad and the ugly. No holds barred. Criticisms, things to think about, "you're an idiot" or compliments are all welcome. I've had a few DKA patients, none that did anything like this. Only thing I could think of is potential Sepsis combined with DKA? We learned later he a discharged from the ICU within the last two weeks and had a foley, CVC, art line although was not on any antibiotics and the father stated he had not been complaining of anything.

Sparknotes of my mistakes:
1) Should have redone vitals as soon as we got to the pt even with fire already having done them.

2) didn't put my foot down with dad on transport destination and while he was cupcaking around on his cell phone.

3) dismissing the fire department prior to reevaluating vitals and getting a better picture.

4) he made it to the ER, I thought about diverting to the closer facility but they were on a CC divert so he'd have to be transfered out pretty quickly. With that said, I can disregard diverts if I deem necessary per protocol. Should I have diverted? it would have meant a physician with RSI capabilities. Sometimes in situations like this I'm told we can stop, they will control the airway while he's still on our gurney and arrange a rapid transfer to their main facility and we can just continue on our way. When I say rapid transfer though I mean in the range of 20 minutes or so to get through all the hoops they have to jump through.

5) we have nasotracheal intubation capabilities and a protocol to do it. With our 20/20 hindsight this patient probably needed it. Unfortunately, I do not feel comfortable with this procedure, have only been trained on it a handful of times and the general consensus I've gotten is that they're frowned upon by the ER and our QA/I. With that said I have no problem standing up for my actions and being a patient advocate but I felt it would be negligent for me to attempt a procedure I'm not comfortable with, without assistance, jamming down the highway with the disco lights going. Looking back had he gotten much worse or the transport been much longer I would have had to have done something.

Sorry for the novel and the spelling/grammar, iPad keyboards, a bumpy ambulance and a sleepy paramedic make for a fun read Ready, set, GO!

 

[ItsTheBLS]

I don't think you did anything terrible, however you can see where some issues were.

Although I'm a lower cert level than you, I personally wouldn't trust a lower-level provider than myself with obtaining patient vital signs. That is to say, I would not trust the fire department in my area to take proper vital signs. Important things like that I reserve to myself, my partner and higher-level providers.

As for the father- definitely be firm. He was on the phone to obtain this information for you, thinking he's doing you a favor. If the information is not readily available, spending more time on scene will not help.

With regards to the choice of hospital, if you firmly believed he should go to the closer facility, explain that to the father to the best of your ability. He is not a minor, so I am not sure who has jurisdiction over where he goes from a legal standpoint.

Other than these things I'd say it was handled relatively well, you got his sats up and got a line in. These interventions will probably have helped him significantly.

 

[chaz90]

Interesting case for sure...

In regards to onset, what does Dad mean when he was fine at 0900 but is as you found him at 1500? Was he out with his son when he suddenly dropped? That obviously doesn't support sepsis or even DKA, but who knows. SpO2 may not be accurate due to poor peripheral circulation with his BP in the tank. Then again, it may be that low with that profound tachypnea. Also, I'd be inclined to agree with you that his BP didn't end up actually crumpling as you were there. Fire probably didn't accurately take/didn't think what they were hearing was correct with a 19 year old and a systolic BP of 70. I would imagine the hypotension is why this patient is altered too, so I'm trying to think what precipitating event caused the sudden decrease in LOC if he was just walking around at the mall and acting relatively normally.

I know you don't have either of these tools, but if I had this patient I'd put on sidestream capnography and run a POC lactate. If I were a betting man, I'd wager his lactate is elevated and his EtCO2 may be higher than you would normally expect with his marked hyperventilation due to his underlying metabolic acidosis. I really am still leaning towards pulmonary edema due to his tachycardia. To me, this could help explain the precipitous drop in BP that brought him from relatively normal to being your patient. Lung sounds wise, I don't think you could hear the fluid build up due to how low his tidal volume must have been and the road noise.

I would imagine he has been sick for a couple days (possibly a complication from his invasive procedures last week), which brought on his DKA and fluid retention. His HR has been compensating well until now, which may have allowed the edema to begin to affect his sats and cardiac output. Let me add of course that I could be 100% wrong and blowing smoke everywhere.

As far as my treatments are concerned, I'll operate under the assumption that I have at least one assistant, which I know you did not. I'd look for secondary access somewhere, be that EJ or IO. This patient is critical and does need access, so I have no problem drilling him. Having RSI available, I'd intubate this patient as well. He's hypoxic, won't tolerate less aggressive airway management, and I'm not happy with the results just ventilating him with a BVM. In your situation though, I'd try an NPA one more time and continue with the BVM. My experience with NPAs are that even combative patients tend to forget about them with enough viscous lidocaine after the initial shock of insertion. The pt's hand are restrained, so I'd try to slip it in quickly and see if he forgets about it.

With that established and the BP not improving after 1 L of fluid pressure infused, I'd be moving towards a Dopamine drip. There's no way I'd want to keep the MAP around 43 mm Hg (from 70/30). I'd start the Dopamine at 10 mcg/kg/minute as I'm hoping for alpha agonist activity over beta stimulation of his poor tachycardic heart.

As far as your treatments went, I think you did fine considering how hamstrung you were alone in the back. As mentioned earlier, I'd be grabbing someone else on an intercept for this patient. Call dispatch for another medic unit to intercept preferably, or a supervisor, or even a fire station pre alerted by dispatch that you're driving by. NTI would be a nightmare on this patient considering how combative he was to an NPA and how woefully unprepared we are to do that. I've heard it's easier than we imagine, but (anecdote warning) I've only seen it attempted once, and it was a bloody failure. We carry Endotrols here, which are probably used less frequently than crics, and they have a trigger that is supposed to help direct the tube anteriorly. I may have considered diverting for this patient for airway control, but I don't think it would be rapid. This isn't some massive trauma airway that a doc may cric and send on their merry way to a trauma center. The patient would probably be intubated at the divert hospital with a central line placed, pressors, insulin, bicarbonate, potassium, labs (not in that order), and transferred later.

This really is a cool case! Let us know of any feedback you receive and what the final diagnosis is.

 

[Trailrider]

Are we talking kussmauls sign or actual kussmauls? Acidosis explains why this poor guy is breathing so fast, well it makes sense to me as he is trying to blow off of the excess h+. Would insulin be an option here for the dka? I am a new student for any other providers responding. Interesting case, thanks!

 

[Handsome Robb]

Are we talking kussmauls sign or actual kussmauls? Acidosis explains why this poor guy is breathing so fast, well it makes sense to me as he is trying to blow off of the excess h+. Would insulin be an option here for the dka? I am a new student for any other providers responding. Interesting case, thanks!

The problem with just giving insulin is it doesn't fix everything else that's wrong.

Also the body doesn't tolerate rapid changes well. Perfect example is febrile seizures. They don't seize because they're hot, they seize because the spike a temperature.

And kussmaul respirations.

 

[sir.shocksalot]

Well that's quite the case. I agree with your assessment of what could have been improved such as keeping a few extra hands with you. To be honest I don't think the transport time really made much of a difference. While his blood pressure and respiratory status are pretty poopy, they aren't exactly rapidly deteriorating. In all likely hood his blood pressure probably had been in the 70/30 range from the beginning. The pt being "combative" is probably going to skew the results, plus you have some bandwagon effect going on when your partner takes the next set of vitals (who also can't hear it well but picks a number close to fire's number).

As far as management I think you did well. I agree with Chaz that drilling him would be totally appropriate. Not sure if you would have much luck with an EJ on him considering his mental state. Fluid is good considering he is probably profoundly dehydrated from osmotic diuresis. I don't think I would start pressers on him personally. To me I don't think I would feel like it was a squeeze or pump problem until I had put in another liter of fluid with no changes and in twenty minutes I don't think I'd feel comfortable gauging his response to treatment to start dopamine. His blood pressure is low but I wouldn't feel comfortable saying that all of his symptoms are secondary to the pressure and not an encephalopathy or acidosis. But that may be a comfort thing as I have never initiated dopamine in the field. Airway wise I think you did what you could. I again agree with chaz and think that maybe the SpO2 wasn't entirely indicative of actual tissue oxygenation. RSI would be ideal to assist ventilations, in leu of that I wonder if you could have given versed/valium/Ativan as procedural sedation? Getting an order would be the trick with his pressure in the toilet though. A nasal tube without sedation in this dude would have been bad news, a slight move of the head can result in your tube going down the wrong hole.

I think there is probably a lot more to this patient's story and the father doesn't sound like he actually knows his son that well. For all we know the patient may have been having DKA symptoms for the past day or two and just left father out of the loop.

Trailrider: Trying to correct DKA in the prehospital setting with insulin doesn't work. One reason being that insulin actually causes hypokalemia (it has something to do with the glucose moving into the cell but don't quote me). Severe hypokalemia can result in cardiac arrest. Another reason is that any rapid decrease in intravascular osmotic pressure can cause cerebral edema which causes deadness. Severe DKA treatment is best left to the ICU.

 

[FLdoc2011]

Yea, ultimately this kid needed to be intubated and fluid resuscitated. If it was DKA (which sounds like it probably was) he was probably at least 4-6L down and needs a LOT of fluid.

DKA is pretty straight forward to treat, but is labor intensive in managing insulin drip, IV fluids and electrolyte replacement while monitoring frequent labs.

Pulm edema is low on my list of issues here. He's currently in shock, likely hypovolemic shock from DKA or septic shock causing his hypoxia and not in pulm edema. Tachycardia of 150 in a young pt shouldn't cause acute heart failure to lead to pulm edema.

I think you did what you could with a very sick guy. Certainly in hindsight going to a closer facility may have been a good choice but you've already recognized some of those decisions.

 

[Arovetli]

All I would add is an extension of what FLdoc2011 touched on: The average DKA pt. is down about 100cc/kg of fluid...so you can being to note the scope of fluid, and subsequent electrolyte, loss.

good article: http://care.diabetesjournals.org/content/29/12/2739.full

 

[Sublime]

Sounds like you did fine, other than that I really don't have much to add.

 

[chaz90]

I'm still trying to figure out the rapid onset. What are your guys thoughts on how he was up and walking around at the mall to suddenly crumping that rapidly?

 

[medicsb]

I agree that this was probably DKA. Likely, there was something else going on. Outside in 85 degree weather could have pushed his dehydration from compensated to uncompensated. 12 lead would have been nice to have, only to assess for hyperK+, which can occur with DKA or any acidosis. (one of the body's responses to a high H+ is to ramp up H+/K+ exchange transporters - basically, cells will take up H+ and spit out K+.)

Also, if he happened to be down long enough, he could have been hyperthermic (cooking in the sun) and have rhabdo (on the ground, not moving, leading to muscle break down adding to H+ buildup and also hyperK+).

I do not think it would have been unreasonable to try nasally intubating him if you had experience with the procedure. But, it is something that could make things worse (worsened hypoxia as you try to place the tube, or, causing a nose bleed that mucks up his airway more). Experience with the procedure would be paramount, and with CPAP basically killing NTI, you, like me, never got an opportunity to do it. So, BVM was fine choice, and likely the best choice for the situation.

As far as going with the hospital further away vs. the closest - it happens. You're going to make a decision that when viewed through the retrospectoscope is wrong. I did it with a PE patient years ago. In retrospect either choice would have pissed someone off and the patient outcome would not have changed. (Lucky for you, your patient didn't code immediately after arrival.)

It sounds like a messy, frustrating call. Any medic with enough time on, will have a number of these calls. Learn from it and move on. All in all, sounds like you handled it fairly well.

 

[Sublime]

I'm still trying to figure out the rapid onset. What are your guys thoughts on how he was up and walking around at the mall to suddenly crumping that rapidly?

Combination of dehydration and acidosis got the best of him while walking in the sun is my guess.

I would think that this really wasn't a rapid onset and rather that this problem has been brewing over the course of the week and finally reached the tipping point while he was walking at the mall.

 

[Clare]

This is an interesting one; the patient has a GCS of 9 so technically has coma rather than a reduced/altered LOC and is considered status one.

I would however say that his condition is likely to improve fairly rapidly with the right treatment and even if he gets ventilated for 12 hours or something he is unlikely to need massive ongoing ICU care or something unless he has a had a massive cerebral ischaemic event.

I would take him to the regular hospital and not divert to a major trauma centre.

 

[NomadicMedic]

Rob, doesn't seem like a bad job. Not taking a fire rider wasn't a fatal mistake, but i bet the extra hands would have come in handy.

I wouldn't have hesitaed to drill him and I would have RSI'ed him. Did you get his pressure up with just fluid? After two liters, I'd be moving toward dopamine.

I think everyone else has kicked it around enough. Nobody thinks you did a bad job, you just sent the help away too soon. (Something I think we've all done.)

 

[Carlos Danger]

I agree that this was probably DKA. Likely, there was something else going on. Outside in 85 degree weather could have pushed his dehydration from compensated to uncompensated.

This is basically my assessment as well. DKA might take a day or two to develop, but once it becomes clinically apparent, it can progress very quickly, especially with increased physical activity. He could have gone from not feeling the best that morning (but not feeling remarkably bad, either) + walking around the mall + heat = DFO a few hours later.

Given what you had to work with Robb, I'd say you did fine.

On scene:

I would not have done a 12-lead. Probably would have enroute, if I had time and the patient was cooperating, but definitely not before loading. Because the chances of it revealing anything that would change your treatment at all is very slim.

Labs would have been nice to have, but few of us have that in the field, and again, probably wouldn't changed your treatment anyway.

I definitely would not have intubated him on scene. Just no indication for it, based on your description.

You got an IV and started fluids; that's probably the extent of what I would have done before leaving.
​

Once the guy started to crump when you were enroute:

I think you did all you could do.

RSI was probably not a practical option, since you were alone in the back.

NTI would not have ended well, based on how you describe the situation. I mean, if the guy wouldn't take an NPA, then he certainly wouldn't take a 6.0 ETT....plus, blind NTI is a technically difficult procedure that requires quite a bit of practice. It's certainly harder than orotracheal intubation. There is good reason you never see it done anymore.
​

Sounds like one of those clumsy, difficult calls that you wish had gone better, but really couldn't have done much different. We've all had them and will have more of them.

 

[Dwindlin]

I agree with those saying this is DKA. And as to the suddenness of it, I doubt it was. DKA develops over days/weeks. His likely just caught up with him at the mall.

You did fine, not much to do with these pre-hospital. I'm surprised the ED was so aggressive with the airway, I wouldn't have been. Chances are he'll be doing much better and stabilize out after several liters and an insulin/glucose drip.

While I love pulse oximetry, I wouldn't put too much faith in it with this particular patient. If you're confident about that pressure I'm not surprised it was reading in the 80's, unless you were seeing some other indications he was hypoxic wouldn't put much faith in its accuracy (if he were truly in the 80's there should be some cyanosis somewhere).

 

[abckidsmom]

I agree with almost everyone. Sick guy, very dry.

The only thing I have to add is the thought that usually patients this sick with DKA are profoundly acidotic. I've seen a couple of live people in DKA with pH of less than 6.9. It is worth considering an amp of bicarb if you have it, and being extremely alert for hyperkalemia and keeping that in your Hs and Ts in case of arrest.

 

[Dwindlin]

There is only one (maybe two) good reason to push (and I mean over like 10 minutes) an amp of bicarb, and it isn't for severe acidosis. Absolutely no reason to give an amp of bicarb as a "push" (i.e. faster than 10 minutes).

 

[FLdoc2011]

Would be interesting to see his initial labs (chemistry and ABG) at the ER if you can get them.

I agree, wouldn't recommend giving this kid bicarb pre-hospital without an extremely good reason.

 

[Akulahawk]

I clipped out some...

Fire reports 19 yo male history of insulin-dependent diabetes was found laying on the grass "acting odd." Father states he was out with some friends but was "normal" at 0900 this morning.

Pt is a&ox0, responsive to loud verbal stimuli, GCS 11 (3/3/5) and mildly combative (think aimless, weak swats at hands and grabbing pant legs).

Initial vitals (per fire, there's my first mistake with this crew) of 110/70, pulse of 130 strong and regular at the radial, SpO2 78% on room air, respiratory rate 50 deep and regular. CBG "HI" with a ketone warning (>600 mg/dL on our glucometers.)

RR=50 and CBG = >600 + ketone warning is a key thing.

Physical exam shows no signs of trauma, skin is pink, hot and very dry, PERRL but sluggish at 4mm (outside in the 85 degree bluebird day) no JVD, trachea midline.
Chest is without signs of trauma, equal rise and fall bilaterally, clear to auscultation anteriorly and posteriorly, no retractions or accessory muscle usage noted.
Abdomen is soft, no palpable or pulsating masses noted, no guarding. Pelvis is stable, no urinary or bowel incontinence noted.

No incontinence noted possibly because he's so very dry now that he's not producing urine.

Lower extremities are unremarkable, upper extremities have a gazillion scars from what appear to be intravenous injections, other than that they're unremarkable, no peripheral edema noted.

Chest clear to auscultation to me means probably not hypervolemia problem or HF problem.

History: IDDM and "psychiatric problems", father denied any previous suicide attempts, denies any knowledge of drug or ETOH abuse but states "it wouldn't surprise me."

No known allergies or drug allergies.

Medications: Insulin (father unable to be more specific), Prozac and guanfancine

Insulin another key med.

Non-rebreather at 15lpm, still semi-conscious at this point so tried an NPA that he fought viciously so I let him be since he was doing a decent job of protecting his airway. 4-lead, partner did repeat vitals while I worked on a line. This is where I realized this kid is in a much worse situation than I originally had thought but at this point I had already dismissed fire (third mistake before assuring the vitals they gave me were accurate. Some crews are awesome, this one not so much and I knew it but disregarded it.) I somehow managed to fight an 18g through the scar tissue in his right AC with a liter bag + pressure bag running wide open, partner botched the left AC.

Probably a good thing to get the IV going wide open like that.

Repeat vitals were
100/50
150 BPM, sinus tachycardia without ectopy. I didn't do a 12-lead...it wasn't high on my priority list, frankly it was at the bottom. I didn't see a reason but if I'm missing something please chime in.
87% on 15 LPM
RR 50 still deep and regular. Classic kussmaul respirations.

I may not have done a 12-lead either. With the classic Kussmaul resps going on, the low BP, and so on... I'd be betting this guy is well into DKA and not going to get better any time soon.

From this point it went downhill. We started transport routine and upgraded to code 3 soon after I took another set of vitals.


GCS reduced to 9 (2/2/5)
BP 74/p (NIBP gave 70/30, I couldn't hear it on our wonderful freeways so I palped it twice to be sure)
HR still 150 sinus without ectopy
SPo2 down to love 80s on 15 LPM
RR still 50/min, snoring but it was very obvious to me that he was tuckering out.
Lungs still clear from what I could hear, unfortunately the Master Cardiology is a little too good when the sirens are going and I couldn't get a great listen between them and the road nose.

Popped a NC wi 6lpm on, popped him supine, put a pillow behind him and did the most epic head-tilt chin-lift I've ever done and started bag assisting every 4-5 breaths which got him into the low 90s. Again tried an NPA that he fought violently so I again pulled it. Restrained upper extremities at this time because he was going after the only patent line we had and the only other option was an IO, his vasculature was totaled.

Is that 6 lpm in addition to the 15 lpm you already have on him? After restraining the upper extremities, perhaps starting an EJ might have been an idea, but he may fight that. If I was worried about not being able to start an EJ safely, I'd have done an IO, as others have suggested.

On the whole, I think you did a reasonably good job with this patient given what you knew of him and what tools you had at hand. 12-lead would have been nice at some point just to watch for signs of hyper-K. Giving him as much NS as you can over that 20 minutes would have at least diluted the K+ level some. I also have no doubt that he's severely acidotic and may have benefited from Bicarb, but certainly if he crumped in front of you, that would have been among the considerations, and (presumably) hyper-K. I probably wouldn't have attempted NTI as that would have been an awful mess and he'd have fought you even more viciously than he did with the NPA.