OP
OP
NomadicMedic
I know a guy who knows a guy.
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ETCO2 is 66, non obstructive waveform.
43 female/unconscious
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abckidsmom
Dances with Patients
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Further evidence of the impact of her non-effective ventilatory status. Does she accept an oral airway?
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Angel
Paramedic
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I agree with everyone else as far as ddx, im suspecting OD on the benzos or neuro event including possible seizure.
any incontinence? oral trauma?
tx would include BLS airway, OPA if not then NPA and bag, if she accepts the OPA id also like to intubate, titrating to an appropriate ETCO2, get a line and transport to the nearest facility. they can stabilize and transfer if needed.
I would keep her as an ALS pt (since you mentioned BLS is nearby)
any incontinence? oral trauma?
tx would include BLS airway, OPA if not then NPA and bag, if she accepts the OPA id also like to intubate, titrating to an appropriate ETCO2, get a line and transport to the nearest facility. they can stabilize and transfer if needed.
I would keep her as an ALS pt (since you mentioned BLS is nearby)
OP
OP
NomadicMedic
I know a guy who knows a guy.
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As you attempt to insert an oral airway, she gags and begins to vomit.
No oral trauma. No incontinence.
Ambulance is now on scene. You've been there for 5 minutes.
No oral trauma. No incontinence.
Ambulance is now on scene. You've been there for 5 minutes.
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Did we get a FSBG off this lady? With the way her mental status is described I'd like to give her a touch of narcan just to cover my bases and if no effect I'd like to intubate her. I don't have RSI capabilities so here I'm stuck with BLS airways or a nasotracheal intubation.
She's hypoxic, hypercapneic and hypoventilating, I'd say an intubation is indicated. Not to mention now she's vomiting cause we were playing with her gag with our BLS airway.
If we do have RSI lets do 2-3 mcg/kg of fentanyl, 0.3/kg of etomidate then your paralytic of choice. I'd be tempted to do a defasiculating dose in her if we're going to use a DPNMB since we have the potential for elevated ICP with an acute neurological insult on our DDx list.
She's hypoxic, hypercapneic and hypoventilating, I'd say an intubation is indicated. Not to mention now she's vomiting cause we were playing with her gag with our BLS airway.
If we do have RSI lets do 2-3 mcg/kg of fentanyl, 0.3/kg of etomidate then your paralytic of choice. I'd be tempted to do a defasiculating dose in her if we're going to use a DPNMB since we have the potential for elevated ICP with an acute neurological insult on our DDx list.
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Angel
Paramedic
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suction and NPA, id transport code 3 to nearest facility.
speaking as a student: Im on the fence about narcan, #1 being pupils aren't constricted and don't point me down narc OD (esp since the buspar is a benzo). On the other hand treating down AEIOU-TIPS this is something we should consider and it wont necessarily "hurt" anything
My decision is TO give narcan 2mg IV once in the back.
speaking as a student: Im on the fence about narcan, #1 being pupils aren't constricted and don't point me down narc OD (esp since the buspar is a benzo). On the other hand treating down AEIOU-TIPS this is something we should consider and it wont necessarily "hurt" anything
My decision is TO give narcan 2mg IV once in the back.
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OP
OP
NomadicMedic
I know a guy who knows a guy.
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Have we all reached the same conclusion? She's altered to the point where she can't protect her own airway.
Okay. My first guess was a bleed, second was an OD.
So, here's what happened. I realized nothing going was going to come of just sitting around, so I started a line, drew bloods and she then was intubated with our standard RSI cocktail; Etomidate, Succinylcholine, Versed and Fentanyl. (I did not use additional paralytics). No issues. 7.5 tube placed on first attempt.
Transported to the hospital, with effective ventilation and stable vital signs.
CT was unremarkable. PT remained on the vent and transferred to ICU.
On follow up ... Benzo OD. The PT had anxiety and depression issues and had begged/borrowed/stolen Ativan from a friend. Took "a bunch" (at least 10 2mg tabs). She was discharged a couple of days later.
Nice job all.
Okay. My first guess was a bleed, second was an OD.
So, here's what happened. I realized nothing going was going to come of just sitting around, so I started a line, drew bloods and she then was intubated with our standard RSI cocktail; Etomidate, Succinylcholine, Versed and Fentanyl. (I did not use additional paralytics). No issues. 7.5 tube placed on first attempt.
Transported to the hospital, with effective ventilation and stable vital signs.
CT was unremarkable. PT remained on the vent and transferred to ICU.
On follow up ... Benzo OD. The PT had anxiety and depression issues and had begged/borrowed/stolen Ativan from a friend. Took "a bunch" (at least 10 2mg tabs). She was discharged a couple of days later.
Nice job all.
Angel
Paramedic
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Off topic but you can draw labs AND RSI?! I'm pretty jealous as we can do neither here. what state do you work in?
Good scenario!
Good scenario!
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If I knew nothing more, I'd still be able to make a pretty decent guess based on his username...
Drawing labs doesn't mean we can run any tests though. We routinely draw a set of blood tubes at IV initiation just to facilitate the process of running them at the hospital.
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They didn't know it was a benzo OD.
DesertMedic66
Forum Troll
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Welcome to EMS outside of CA. We can draw labs in my area of SoCal but RSI is unheard of around here.
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While I see why, I don't agree with this. She still is responding to painful stimuli thus needs to be treated for pain (tube/blade in her throat) and needs to be sedated for the simple fact that I refuse to intubate someone I don't know isn't totally out. If her vitals support it why wouldn't you sedate this patient along with paralytics?
Angel
Paramedic
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haha duh.
and yea CA is pretty restricted as far as protocols go, I know of one ER that lets medics draw blood as part of some pilot type program for catching [sepsis? cant remember] earlier...not my county so I cant do it but thought it was interesting.
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Not to mention that given the initial presentation, a head bleed is not out of the question and RSIing without sedation is certainly capable of increasing ICP, as other potentially detrimental physiological responses.
I wouldn't use more Benzo's in a suspected benzo overdose. If Benzo overdose is #1 on my suspect list then I am probably just assisting with ventilations via BVM and not intubating either. Once you intubate you kind of tie the ER doc's hands about using flumazenil and the patient might end up taking up an ICU bed for several days on multiple drips when it all could have been avoided with a bit of reversal medication in the ER.
If I suspect neuro event more (which based on patient findings and vitals I really don't at all) then I think RSI with a paralytic and a narcotic are understandable but I will wouldn't use a benzo if benzo overdose is remotely likely. That said there are plenty of systems where it is an all or nothing procedure so I can't fault people who have to.
Unless her RR is really really shallow I think it would be perfectly safe to transport this patient in on a cardiac monitor with a non rebreather for 25 minutes. If I am having to make a longer transport to a neuro capable facility or a chopper is needed for longer transport then I think a tube is perfectly good for a suspected neuro event.
Not to say it has never happened, but in years working within a hospital system I have never heard of or seen a head bleed with a BP that low unless they are an imminent cardiac arrest. I don't really see any information or vitals or patient presentation in this case that point be towards a bleed at all.
Wasn't questioning need to intubate really. From what it sounds like, intubation was indicated here. If you're truly going to RSI then goal is to not use BVM and achieve rapid induction/paralysis.
In this case if she's basically unresponsive for an unknown reason I still agree with RSI, You don't need etomidate AND versed.
In this case if she's basically unresponsive for an unknown reason I still agree with RSI, You don't need etomidate AND versed.
OP
OP
NomadicMedic
I know a guy who knows a guy.
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In all honesty, my first guess was some sort of catastrophic cerebral insult. It didn't seem to add up to me. He had been on the phone with her 20 minutes before, there was a hot pizza sitting on the table. The house didn't seem to scream "overdose" to me either. I know it's a bad idea to diagnose by ZIP Code… But sometimes you get tunnel vision. The lack of medications and any medical history also didn't scream that she was a psych patient or might have been overdosing on benzo's.
As far as the RSI drugs, she did have a gag reflex, and I was unsure as to the depth of her sedation. I drew labs before I gave any RSI meds, so they would have a clean sample to determine the amount of benzo's in her system before I started piling meds on top of her.
As for the ventilatory status, an end-tidal in the high 60s would immediately indicate that she was not adequately ventilated. Could I have managed her with a nasal trumpet and bag valve mask? Sure. Remember, it was 20 minutes to the ED. Did I feel as though intubation was the right method of airway control for this patient? I absolutely did
We don't carry Romazicon, and even if we did, I certainly wouldn't have used it in this case. There was absolutely no indication that she had taken any benzo's nor were there any empty bottles in the house. Her husband related several times that she didn't take any medications currently and didn't have any medical conditions that she saw a physician for regularly.
So… Was it the right call for me? I believe so. I protected her airway, transported her to the hospital. She got a CT and eventually discharged.
As far as the RSI drugs, she did have a gag reflex, and I was unsure as to the depth of her sedation. I drew labs before I gave any RSI meds, so they would have a clean sample to determine the amount of benzo's in her system before I started piling meds on top of her.
As for the ventilatory status, an end-tidal in the high 60s would immediately indicate that she was not adequately ventilated. Could I have managed her with a nasal trumpet and bag valve mask? Sure. Remember, it was 20 minutes to the ED. Did I feel as though intubation was the right method of airway control for this patient? I absolutely did
We don't carry Romazicon, and even if we did, I certainly wouldn't have used it in this case. There was absolutely no indication that she had taken any benzo's nor were there any empty bottles in the house. Her husband related several times that she didn't take any medications currently and didn't have any medical conditions that she saw a physician for regularly.
So… Was it the right call for me? I believe so. I protected her airway, transported her to the hospital. She got a CT and eventually discharged.