45yo Male...Unconscious

[Fox800]

Dispatched to a priority 1 unconscious party...MDC tells you that you have a 45 year old male, who was last seen awake yesterday.

Upon arrival, you are greeted at the door by an elderly woman who is the man's mother. She leads you to a back bedroom where you find a middle-aged man supine in bed, with his head slightly elevated on pillows. Respirations are snoring and you can see vomit around the mouth.

You and your partner are paramedics. You arrived on scene with four fire department first responders who are EMT-B's.

You direct fire to suction the vomitus, place an OPA (the patient accepts without difficulty) and begin BVM ventilation with 100% O2 at 15lpm.

The patient has a GCS of 3 and is unresponsive to any painful stimuli. You and your partner are unable to obtain peripheral IV access or EJ access after four attempts. The pt. has very poor veins and obvious signs of IV drug use/track marks. After 0.8mg naloxone IM, the pt. awakens to a GCS of 14 (E4, V4, M6). He is awake and will follow commands but is confused. Breath sounds are coarse, with rhonchi in all fields. You suspect aspiration of vomitus. SPO2 will not raise above 88% despite assisting the pt.'s respirations with a BVM.

BP: 140/90
HR: 140
RR: 10-14/min
SPO2: 88% w/BVM assist
BGL: 102
Temp: 98.6
ECG: Sinus tachycardia, no ectopy, normal PR and QRS width
SAMPLE: The pt. is confused and cannot/will not give you any information. His mother does not know anything about his medical history, either.

What's your next course of action?

 

[firecoins]

load him on the stretcher and move to the hospital.

 

[Fox800]

Done. En route to the hospital, RR increases to 40-50 and SPO2 drops to between 65-75% with BVM ventilation. GCS remains the same. Fire is bagging for you. Now what?

I forgot to mention, you found an empty bottle of Amytriptylene on scene.

 

[atropine]

keep bagging nothing else to do really, how far is the hospital?

 

[MrBrown]

How's our transport time?

Drop an LMA and see if we can get an Advanced Paramedic skilled at rapid sequence intubation to locoate us significantly faster than we can arrive at the hospital

 

[firecoins]

is the BVM attached to O2 by any chance?

If he is still confused we might intubate. Call for .3mg/kg of etomidate and tube.

 

[Fox800]

The hospital is about 10 minutes away code 3 (and yes, you are going code 3).

Your pt. will not accept an LMA. He is awake, responsive to verbal stimuli with a GCS of 14 (E4 M4 V6). He will not accept an OPA or NPA. When you "woke him up" with naloxone, he began to gag so (obviously) you pulled the OPA. Pt. vomits again a few minutes after that, while prepping for transport/getting him secured to the stretcher.

Yes, the BVM is attached to the O2 flowing at 15LPM off a giant tank.

 

[atropine]

well then just bag and go easy enough.^_^

 

[Fox800]

Ok you're bagging and...the pt. isn't doing any better. Their SPO2 is in the 60's. Skin is pale/warm/moist so poor circulation shouldn't really be a factor.

 

[atropine]

I got to be honest as long as he has a pulse and isn't turning blu and the hospital is within 10 minutes, I really wouln't do much more^_^

 

[triemal04]

Well because you screwed up from the get go and gave narcan instead of immediately intubating and transporting, now you get to RSI this pt. Etomidate, sux and versed and most likely vecuronium as well. Some suctioning post-intubation would be called for but probably won't have great results.

Oh...and that pesky TCA OD...probably want to go ahead and give 50mEq's of sodium bicarb. You know...if you want to do this right.

As a sidenote, not everyone who OD's on opiates needs to be given narcan; it'll depend on how OD'd they are, and, more importantly, HOW PATENT IS THEIR AIRWAY. If you check their lung sounds and hear rhonchi...especially with signs that they vomitted...maybe giving narcan is a bad idea. Maybe it would be better to intubate them right then so that you can provide at least a little more effective form of ventilation.

 

[Fox800]

Well because you screwed up from the get go and gave narcan instead of immediately intubating and transporting, now you get to RSI this pt. Etomidate, sux and versed and most likely vecuronium as well. Some suctioning post-intubation would be called for but probably won't have great results.

Oh...and that pesky TCA OD...probably want to go ahead and give 50mEq's of sodium bicarb. You know...if you want to do this right.

As a sidenote, not everyone who OD's on opiates needs to be given narcan; it'll depend on how OD'd they are, and, more importantly, HOW PATENT IS THEIR AIRWAY. If you check their lung sounds and hear rhonchi...especially with signs that they vomitted...maybe giving narcan is a bad idea. Maybe it would be better to intubate them right then so that you can provide at least a little more effective form of ventilation.

Ouch.

A little judgmental, eh?

We don't have RSI in our system. We do have nasotracheal intubation.

FYI just because an empty bottle of Amytriptylene was found doesnt = TCA OD. So...giving naloxone to a pt. with respiratory depression means we screwed up? Changed a pt. with snoring respirations and GCS 3 to an awake pt. with GCS 14 and an good intrinsic respiratory drive.

So let me follow your logic. Unconscious pt. + track marks + vomit + snoring respirations + GCS 3 = intubation before naloxone? We chose less invasive before more invasive.

Bicarb? Good thinking for a TCA OD and this was considered on scene. Do you think this pt. has signs of a TCA OD? He responded to naloxone. GCS improved 3 --> 14. Respirations 6 --> 14. The QRS is of a normal width. He is tachycardic but is not hypotensive. He was not treated for a TCA OD at the ER.

And I agree not every narcotic OD needs naloxone. If a pt. is altered or unconscious with a good respiratory effort and stable vitals, I am less inclined to administer naloxone. It is administered for respiratory depression, not specifically for mental status changes.

So you would intubate a suspected narcotic OD prior to administering naloxone? Congratulations, now you've probably changed the game from a pt. that would receive naloxone in the ED to one that will require an ICU stay.

This call was crappy, no way around it. RSI would have been ideal...but are you going to immediately RSI a patient with a GCS of 14 who follows commands, with an SPO2 of 88-90%? With a 10 minute transport time? The patient had aspirated, possibly hours prior, and that was the reason for his crappy sats and breathing.

 

[triemal04]

Ouch.

A little judgmental, eh?

We don't have RSI in our system. We do have nasotracheal intubation.

FYI just because an empty bottle of Amytriptylene was found doesnt = TCA OD. So...giving naloxone to a pt. with respiratory depression means we screwed up? Changed a pt. with snoring respirations and GCS 3 to an awake pt. with GCS 14 and an intrinsic respiratory drive.

Bicarb? Good thinking for a TCA OD and this was considered on scene. Do you think this pt. has signs of a TCA OD? He responded to naloxone. GCS improved 3 --> 14. Respirations 6 --> 14. The QRS is of a normal width. He is tachycardic but is not hypotensive. He was not treated for a TCA OD at the ER.

And I agree not every narcotic OD needs naloxone. If a pt. is altered or unconscious with a good respiratory effort and stable vitals, I am less inclined to administer naloxone. It is administered for respiratory depression, not specifically for mental status changes.

Sorry, caught me on a bad day.

I missed the part about no change in the QRS width, but even with that...with a heartrate that high...I'd be leaning towards a TCA OD with the pill bottle present (be nice to know how many were missing for more info). The tachycardia could be due to hypoxia, so it could potentially be worth briefly waiting after intubating (if you were able to increase his SpO2) to see if there was a change. Withholding it or giving it could be seen as right or wrong I suppose, but I'd be leaning towards giving it.

As for being wrong to give narcan...well...you were. You gave narcan to someone who has obvious signs of possible aspiration (low SpO2 with bagging, vomit at the mouth); did you check his lung sounds before or after the narcan? If you couldn't raise his SpO2 with a BVM, what do you think would happen when he started breathing on his own? He accepted an OPA so initially intubating should have presented little to no problem and would have allowed you much better treatement options.

Like I said, not everyone who OD's needs narcan, even if they have a decreased respiratory drive. Look at the whole picture.

 

[triemal04]

Missed you edit. So...what did happen in the ER? How long before he was intubated?

And yes, in the given situation I would have intubated the pt and withheld narcan. Why? Because he aspirated! If his lungs are full of vomit and you can't raise his sat's with a BVM, what do you think will happen post narcan?

 

[Fox800]

Missed you edit. So...what did happen in the ER? How long before he was intubated?

And yes, in the given situation I would have intubated the pt and withheld narcan. Why? Because he aspirated! If his lungs are full of vomit and you can't raise his sat's with a BVM, what do you think will happen post narcan?

Interestingly enough, he was started on CPAP in the ER. I didn't catch the whole story as this was at the end of the shift...so I don't know what happened next. He was treated for opiate OD + aspiration. And I agree with you, I would have given sodium bicarbonate 1mEq/kg if we could have established IV access. We were considering IO, but at that point our pt. had a GCS of 14, was awake and responsive to verbal stimuli, and had an SPO2 of 88-90% with BVM. I'm very hesitant to intubate a pt. prior to administering naloxone in an opiate OD, unless there are extraordinary circumstances. If we can save a pt. from being intubated --> ICU stay, shouldn't we try that? It seems to me that if it's a problem you can reasonably fix with naloxone, I'm going to try that.

 

[triemal04]

Interestingly enough, he was started on CPAP in the ER. I didn't catch the whole story as this was at the end of the shift...so I don't know what happened next. He was treated for opiate OD + aspiration. And I agree with you, I would have given sodium bicarbonate 1mEq/kg if we could have established IV access. We were considering IO, but at that point our pt. had a GCS of 14, was awake and responsive to verbal stimuli, and had an SPO2 of 88-90% with BVM. I'm very hesitant to intubate a pt. prior to administering naloxone in an opiate OD, unless there are extraordinary circumstances. It seems to me that if it's a problem you can reasonably fix with naloxone, I'm going to try that.

I don't disagree with any of that. Once he was awake if you had CPAP that wouldn't have been a bad idea either. But if his sat's were dropping and respiratory rate was increasing...a trial run of CPAP while getting everything ready (assuming you can RSI) wouldn't be bad, but unless there was a big turn around... Plus you lose the ability to do any suctioning.

I agree, most OD's, even the ones that need initial assistance breathing don't get intubated. This would count as extraordinary circumstances though. You can't just look at what's happening right then, but what will happen after you do something; in this case, with an OPA and BVM (and assuming good technique) you can't raise the pt's sats, due to the vomit in his lungs. If he starts to breath on his own, the vomit is still there, and likely won't have any change in SpO2, and now you've got someone who's in respiratory distress and awake. Tube him. Especially if you are lacking RSI; what happens when his sat's start to drop like that?

 

[triemal04]

And for your edit: He's aspirated...a pretty large amount it would seem. Where do you think he's going once you get to the ER?

 

[Fox800]

I don't disagree with any of that. Once he was awake if you had CPAP that wouldn't have been a bad idea either. But if his sat's were dropping and respiratory rate was increasing...a trial run of CPAP while getting everything ready (assuming you can RSI) wouldn't be bad, but unless there was a big turn around... Plus you lose the ability to do any suctioning.

I agree, most OD's, even the ones that need initial assistance breathing don't get intubated. This would count as extraordinary circumstances though. You can't just look at what's happening right then, but what will happen after you do something; in this case, with an OPA and BVM (and assuming good technique) you can't raise the pt's sats, due to the vomit in his lungs. If he starts to breath on his own, the vomit is still there, and likely won't have any change in SpO2, and now you've got someone who's in respiratory distress and awake. Tube him. Especially if you are lacking RSI; what happens when his sat's start to drop like that?

You're on the same track as me. Unfortunately CPAP per our protocols is not authorized for overdose/aspiration. We were not able to get a hold of an MD prior to arriving at the hospital. And yes I agree...aspiration equals ICU stay.

 

[triemal04]

You're on the same track as me. Unfortunately CPAP per our protocols is not authorized for overdose/aspiration. We were not able to get a hold of an MD prior to arriving at the hospital. And yes I agree...aspiration equals ICU stay.

Well...uh...then why did you give him narcan?

 

[Fox800]

Well...uh...then why did you give him narcan?

Because by reverse logic...prehospital endotracheal intubation isn't indicated just because we suspect the pt. may be going to the ICU...