19 Year Old Male ALOC

[RocketMedic]

Most carry the Bayer Contour glucometer but some medics, myself included, somehow ended up with the Precision Xtra as well, so I have two glucometers. Originally the plan was to test the Precision and potentially replace the Bayers but most preferred the Bayer so there are Xtras floating around. We don't have separate ketone strips for the Xtra though so I'm starting to think you're correct when you're saying they just say ketones as a reminder.

I personally prefer the Contour, it's easier to use, doesn't require coding and in my experience more accurate/consistent.

Unfortunately I wasn't able to get lab values, I didn't get a chance to attempt to follow up for a couple days and no one could remember. The only number the nurse remembered was his VBG was >1300 mg/dL. They admitted him with a Dx of DKA + Sepsis.

I'm having a tough time grasping the hyper vs hypo K in these patients, I would think their blood serum would be hyperK since its not glucose that drives potassium into the cells it's the insulin that causes the shift and since they do not produce insulin and are generally non-compliant with their medications it seems like hyperK would be more common.

With that said, as much fluid as these patients require I could definitely see how during long term treatment hypokalemia would be a concern.

As far as bicarbonate, fixing their pH alone won't fix the problem, I could see how it would be beneficial in conjunction with an insulin drip, and electrolyte replacement therapy but by itself it doesn't seem like it would accomplish anything other than attempting to "fix numbers" and as Veneficious has pounded through my brain, "just because you fixed the numbers doesn't mean you've fixed the problem."

We don't carry hypotonic solutions so a drip wouldn't even be plausible here.

Ill try to answer questions that I remember, I'm on my phone so I can't go back and look while replying.

As far as an EJ, I considered it. He had a great one but with how much he was fighting I didn't want him to jerk and get into his IJ or carotid or poke myself, or cause him more harm. I agree I should've probably gone for a second line, I was really hesitant to drill him due to the infection risk and my assumption that he took crap care of himself. Had I been unable to get the first line it wouldn't be a question but I had a patent, large bore IV that was flowing well. Shoulda paid closer attention I the pressure bag, I got so flustered with his airway I forgot to add pressure to it as the bag emptied. Probably could have gotten a fair amount more on board had I been cognizant of this.

I had a question about ETCO2...Could I have put the online probe in between the mask and bag and gotten an accurate reading off of it? I've heard of people doing this but it seems like you wouldn't get enough airflow during exhalation to get an accurate reading. Please correct me if I'm wrong. At the same time I could see it working because PEEP works just fine provided you keep a solid face-to-mask seal so why wouldn't ETCO2 be the same with a solid seal?

Time out while I smoke my roommate in MLB 2K12 and I'll be back to review the thread and get to the questions I missed.

It wont work well with a NRB in that position because the oxygen coming in "washes" any CO2 that may have escaped the vents up high "path of least resistance". Remember, an NRB plastic bag is your next breath. What you can do though is either put it in front of them if they can comply or cut an endotracheal tube to NPA length and drop it down their nose with the sensor mounted as if you were intubating (or go full-on NTI). Its not ideal, but it works.

 

[NomadicMedic]

Actually, the nasal cannula ETCO2 "scoop" prevents washout so you will get a fairly accurate reading.

*As a disclaimer, our ops manager also works for Oridian and is a master in the ways of capography.

 

[RocketMedic]

Actually, the nasal cannula ETCO2 "scoop" prevents washout so you will get a fairly accurate reading.

*As a disclaimer, our ops manager also works for Oridian and is a master in the ways of capography.

They don't have the cannulas, DE, just the inline EtCO2 tube monitors. Weird, right?

 

[NomadicMedic]

Ohhh. My bad. Disregard.

 

[shfd739]

They don't have the cannulas, DE, just the inline EtCO2 tube monitors. Weird, right?

How useless is that? A lot of useless.

 

[Handsome Robb]

How useless is that? A lot of useless.

Obnoxiously useless.

 

[shfd739]

Obnoxiously useless.

lmao. I dont use the nasal ones often but when they do get used its an awesome tool.

 

[Trashtruck]

The Precision Xtra will give you a warning reading 'KETONE' if the reading is over 300 mg/dL.
It's a reminder to check for ketones, not a confirmation of presence.
You have to have separate strips to test for ketones.

 

[BigBad]

I would have slammed 5mg of droperidol or 2mg of versed, if his sats are tanking, i have no trouble bagging him all the way to the hospital. Drop an opa and tube him if needed. Weve all been there man, good job.

 

[NomadicMedic]

Why would you have "slammed" droperidol or versed?

 

[Handsome Robb]

Why would you have "slammed" droperidol or versed?

I was wondering the same thing.

I'm assuming that its because of the combativeness. In NV that would get my card yanked since it could be argued I did a medication assisted intubation which is not in my scope of practice for this state. Now sedating him and using BLS airway techniques could be possible but not exactly ideal.

 

[chaz90]

I'm a bit wary of half assing attempts at medication assisted intubation. Right now, the patient is breathing. While it may be nice to have him calm down a bit and accept either an NPA, BVM, or even a tube, I wouldn't be a fan of knocking out the respiratory drive without paralyzing. If I'm planning on taking away a patient's ability to breathe, I'd like to maximize my chances of placing an ET tube. Obviously this person could still be ventilated using a BVM, but still...wouldn't be my preferred course of action.

 

[NomadicMedic]

Agreed. The idea of "some" sedation, no paralytics and a healthy dose of brutane to intubate a patient goes against everything I know. However, it still happens in a lot of places, and I hope that those paramedics look at those "medication assisted intubations" as a last resort instead of an acceptable everyday practice.

As long as your guy was protecting his airway, you could always continue to use BLS techniques and some BVM assistance. It may make for some pucker factor, but if you deliver a breathing patient to the ED where e can be intubated properly, in a controlled environment, you did the right thing.


As an aside, I take issue with anyone "slamming" a medication. But, that's just me.

 

[BigBad]

Why would you have "slammed" droperidol or versed?

For combative behavior but more so to manage the pt airway effectively without documenting it that way.

 

[chaz90]

For combative behavior but more so to manage the pt airway effectively without documenting it that way.

So purposely circumventing protocol for some nebulous belief that it provides better patient care AND not documenting it, aka telling the hospital staff what medications are already on board?? There's a reason Versed and Droperidol aren't primary induction agents for intubation. I'm not the type to blindly follow protocols without thinking, but taking drugs that are provided as chemical restraints and trying to create ad hoc RSI is a whole different animal.

 

[BigBad]

So purposely circumventing protocol for some nebulous belief that it provides better patient care AND not documenting it, aka telling the hospital staff what medications are already on board?? There's a reason Versed and Droperidol aren't primary induction agents for intubation. I'm not the type to blindly follow protocols without thinking, but taking drugs that are provided as chemical restraints and trying to create ad hoc RSI is a whole different animal.

If the pt is combative and impeading proper care im not going to sit and wait for him to crash. The story you painted for me equals droperidol.. Why else did the doctor RSI him?

 

[Akulahawk]

For combative behavior but more so to manage the pt airway effectively without documenting it that way.

I would hope that you have protocols that specifically cover combative behavior with medication/sedation. I would also very much hope that any protocol authorizing sedation also allows you to provide definitive airway management in the even that you inadvertently knock out the respiratory drive. Otherwise, I see some skating on some very, very thin ice.

I also have an issue with "slamming" almost every medication there is... except for one. Adenosine.

 

[VFlutter]

Why else did the doctor RSI him?

I do not think anyone is trying to argue the patient did not need to be RSI'd but it needs to be done the correct way. I am sure the ER doctor did a proper RSI induction and not a half *** sedative only attempt.

And what you described is getting close to that whole "Practicing medicine without a license" thing...

 

[chaz90]

If the pt is combative and impeading proper care im not going to sit and wait for him to crash. The story you painted for me equals droperidol.. Why else did the doctor RSI him?

There's a big difference in sedating a combative patient who's pulling lines out and resisting airway assistance vs. "slamming" the wrong medications in an attempt to make the patient lose his gag reflex (and respiratory drive) to pass a tube. I agree you want to stay ahead of the curve and not wait for your patient to crash, but in this case, the patient at least breathing seems better to me than taking that away and risking still not being able to get the tube. If the patient stops breathing spontaneously and loses his gag reflex, intubate away. Also, you're choosing to fast push IV Versed in someone this profoundly hypotensive? Again, wouldn't be my chosen course of action. The ED doc properly intubating this patient with a full repertoire of drugs is really not the same scenario as you describe.

 

[Akulahawk]

If the pt is combative and impeading proper care im not going to sit and wait for him to crash. The story you painted for me equals droperidol.. Why else did the doctor RSI him?

The last time I checked, RSI usually meant using a paralytic and a sedative of some sort. Using just a sedative such as droperidol or versed isn't going to be anywhere near optimal. The doses needed to snow them enough for either to be effectively induced into anesthesia is going to be quite a bit greater than what you'd need to sedate them enough that they'll never remember what you're doing to them. The paralytic takes care of the musculoskeletal relaxation...

To me, an unconscious combative patient = restraints to prevent further injury to themselves. If I were then to consider using a sedative, I'd use just enough to allow me to use the BVM, not to obliterate the respiratory drive. I would imagine that the reason for the RSI would be greater control of Tidal and Minute Volume as well as definitive airway control. The Doc's going to have a LOT more tools at hand to accomplish controlling the airway than you'll likely have in the back of your ambulance.