43 female/unconscious

[unleashedfury]

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.

The hospitals in your area will use the blood you drew?? We used to do that around here until the ED's would trash them and get their own labs. So it turned into a wasted expense for us

 

[NomadicMedic]

The hospitals in your area will use the blood you drew?? We used to do that around here until the ED's would trash them and get their own labs. So it turned into a wasted expense for us

Two of the three hospitals that we frequent use our bloods. One doesn't...and we don't draw if we're going there. In most cases, I won't start an IV either, because they routinely pull our lines.

 

[FLdoc2011]

Just FYI, even if a suspected benzo OD and certainly for benzo ODs that come in that I manage we don't give flumazenil. In fact I have never given it, and ONLY seen it given for a hospital patient inadvertently given too much benzos.

Benzo ODs get supported until it's out of their system, if that means they're intubated in the ICU for a day then fine, but we're not reversing those people acutely.

 

[Carlos Danger]

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.

Before I'd forgo sedation for intubation, I'd have to be quite confident that a sedative OD was the cause of the unresponsiveness. Confident as in there there are empty bottles of Klonopin or Ativan lying around that were filled just yesterday. But if a benzo OD was just one possibility on my list of differentials and I really had no idea what was causing the unresponsiveness, then I would definitely sedate prior to paralyzing for intubation. A dose of etomidate or ketamine or fentanyl - or even a benzo - will add almost no risk to the situation, but omitting it could potentially be harmful, if you are wrong about a sedative OD being the cause of the unresponsiveness.

But would not argue against the option of BLS airway management, 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.

Once the diagnosis of a benzo OD is made, why couldn't the ED just give flumazenil and pull the tube when the patient wakes up?

 

[Carlos Danger]

Just FYI, even if a suspected benzo OD and certainly for benzo ODs that come in that I manage we don't give flumazenil. In fact I have never given it, and ONLY seen it given for a hospital patient inadvertently given too much benzos.

Benzo ODs get supported until it's out of their system, if that means they're intubated in the ICU for a day then fine, but we're not reversing those people acutely.

Why would you not use flumazenil?

 

[VFlutter]

Once the diagnosis of a benzo OD is made, why couldn't the ED just give flumazenil and pull the tube when the patient wakes up?

I am sure your experience with Flumazenil is far greater than mine but IMO it causes more problems than it solves. Especially in a patient with unknown history. If this patient was abusing Benzos for sometime it could cause seizures. As FLdoc mentioned I have only seen it used, rarely, for hospital benzo ODs.

 

[unleashedfury]

Most systems and hospitals I frequent that have a benzo OD patient avoid flumazenil as the risks outweigh the benefits.

Usually its just supportive measures. if they are tubed, vent and monitor, if they aren't tubed, allow them to sleep it off and monitor. as long as they are not a risk to themselves or others supportive measures are well played with a benzo OD. Then possibly a trip to a psychiatric unit

 

[unleashedfury]

Two of the three hospitals that we frequent use our bloods. One doesn't...and we don't draw if we're going there. In most cases, I won't start an IV either, because they routinely pull our lines.

Geez sounds like a pack of Nazi's. The hospitals we frequent don't want bloods. and are picky about lines. They get butt hurt if the patient dosen't have one, but then they get moody if you all you got was lets say a 20g,

I have a theory of I'll get what I need, If the patient needs fluid resuc, yeah go big or go home, but the fragile old lady who needs maybe just a medication port for some zofran or something. a 20g will suit me fine.

 

[Carlos Danger]

I am sure your experience with Flumazenil is far greater than mine but IMO it causes more problems than it solves. Especially in a patient with unknown history. If this patient was abusing Benzos for sometime it could cause seizures. As FLdoc mentioned I have only seen it used, rarely, for hospital benzo ODs.

In an unknown history and possible long-term use you are right.

 

[NomadicMedic]

Geez sounds like a pack of Nazi's. The hospitals we frequent don't want bloods. and are picky about lines. They get butt hurt if the patient dosen't have one, but then they get moody if you all you got was lets say a 20g,



I have a theory of I'll get what I need, If the patient needs fluid resuc, yeah go big or go home, but the fragile old lady who needs maybe just a medication port for some zofran or something. a 20g will suit me fine.

The hospital that doesn't accept blood is the one that pulls our lines. Nobody else does. I should have been more clear.

And I very rarely start anything larger than a 20.

 

[FLdoc2011]

Why would you not use flumazenil?

I think it was already mentioned above, but with unknown history, unknown ingestion, etc I'm not giving flumazenil at the risk of putting them into acute withdraw/seizure.

It's a little different if your sedating someone for a procedure and are using it as a reversal if they just got a little too sedated and there's really no risk of acute withdraw.

But in this case we 're talking an unknown ingestion in someone who possibly abuses this stuff.

And no, the ER is not going to extubate anyone. If they do start to wake then they're probably just going to be put on diprivan and re-sedated.

 

[abckidsmom]

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.

In these mystical altered mental status cases, it's a challenge (especially in the nicer neighborhoods) to go to overdose, but I've found that people with normal skin, altered mental status, and depressed respiratory drive are usually not neuro issues.

Warm, dry skin, AMS, I'm thinking toxicology every time. There are lots of options. We are seeing a really powerful batch of heroin in our small little rural area, and people continue to be abusing Benadryl, as well as benzos and oxycodones. I try really hard to leave them asleep and manage their airways, because these people wake up in the most obnoxious manner.

The other night I had a guy who was so anxious after I woke him up that I ended up sedating him (we don't RSI- all we have is Versed) because I thought he was going to jump out of the truck on the interstate. I am not a big fan of the situation we're in, and I hate mixing known stuff with unknown stuff- his head flopped back and that was all she wrote, Jim.

Time of year matters too. I think that the likelihood that it's some sort of overdose is much higher this time of year. Between the winter solstice and the vernal equinox, people are insane. All of them.

 

[Rialaigh]

Once the diagnosis of a benzo OD is made, why couldn't the ED just give flumazenil and pull the tube when the patient wakes up?

In my experience I have never seen a patient extubated in the ER even if it was probably the right thing to do. Once a tube is placed its automatically the ICU's problem...It's really a poor way to do things in some cases and results in extended intubation times for some patients that clearly don't need it but the ER doc doesn't want the liability involved and throws it on the ICU doc to wean from a vent and pull the tube.

 

[Handsome Robb]

The ER isn't sitting there bagging a patient like this whole they do stay labs either, they're intubating and protecting the patients airway then searching for causes. The only time I've ever heard of romazicon used was in a situation like halothane described above. Our crew brought in an obvious benzo OD, along with all the empty bottles of Valium and Ativan they found next to the patient, and the ER have romazicon. Other than that I've never heard of it being used.

Most definitely isn't used diagnostically.

 

[Ironman]

My 2 cents

Oxygen.
Air evac.

 

[chaz90]

Oxygen.
Air evac.

Nope

 

[NomadicMedic]

Nope

Quoted for truth.

 

[Wheel]

Oxygen.
Air evac.

Can you explain your choice here? It's probably not what I would do, but since you're a student, talking through your thought process could help you a bit.

 

[Akulahawk]

Oxygen.
Air evac.

Please explain your rationale behind these choices. None of us want to dog-pile on you, rather we want to know your thought process on this.

Personally, I'm not going to fly this patient.

We don't carry Romazicon out here, as far as I know, and even if we did, I'd be very reluctant to use it. I would want to start with BLS airway stuff and go from there, possibly rapidly up from there to other tools. She doesn't need to be there, she needs to be where she can be monitored and supported until she wakes up and we can't do that in the field.

 

[NomadicMedic]

I believe it was a troll post.