59YOM - OD, Suicide attempt

[Melclin]

Barring the suicide note...the above SCREAMS sepsis. Which could go hand in hand with the suicide attempt if he aspirated due to altered LOC from the meds.

It screams it from the roof tops. I was not expecting that temp. I was expecting it to be low. I thought, he's been lying here all night in the cold in an altered conscious state and his hands feel icy...hypothermia! Imagine my surprise.

Is it enough time to become septic from aspiration if he's taken the meds last night?

Also, when you have sepsis of a respiratory origin, do you worry about iatrogenic pulmonary oedema when you're talking about a fair amount of fluid. Our service is always so scared of iatrogenic APO, its so hard to tell if its warranted or not in some situations.

I'll swing at it, might be helping this patient acomplish his goal... so...

Okay so I think... so my instincts say... his breathing is probably the most immediat threat and because he's sating at 70 and shallow respirations his tidal volume is through the floor so... cpap? or maybe RSI?

Minimal on scene time and I would opt for the 40min heli transport since I'm concerned that because he's having trouble breathing going higher into the atmosphere which would have less atmospheric pressure may reduce the workload of his labored breathing and help him breath better since both CPAP and Intubation would deliver 100% O2...

You don't want to trial some PPV first? I'm not sure I understand the reasoning behind less atopheric pressure making it easier to breath.

You said all his meds are present and accounted for on his bedside table. Are the actual meds there, or just the empty bottles???? How about a pill count of the bottles to narrow down what he took too much of, if anything.

Yep, good thought. There is certainly a few left of each med in the packets available. The original boxes are nowhere to be found so it is impossible to say when or how many in todal were prescribed.

This and the Reglan are probably more important than the other meds here...

I would say so.



Right so I tried to follow up on this bloke today to give you all some better answers but unfortunately he got moved to a different hospital so I have a lot less info than I'd like.

Anyway, I just got a job. I'll post a little more in an hour or so.

 

[usafmedic45]

I would probably opt to not give him any medications since he's overdosing and I'd be concerned for adverse reactions.

Such as? You know that it's OK to simply admit that something is beyond the scope of your knowledge right? We won't fault you for it but we will take you to task if you try to BS through it.

Minimal on scene time and I would opt for the 40min heli transport

You know that's a contradiction of terms right?

he's having trouble breathing going higher into the atmosphere which would have less atmospheric pressure may reduce the workload of his labored breathing and help him breath better

You do realize that helicopters don't normally fly high enough to do that and....

Just a quick word, research Dalton's law, and how gas moves across the alveolar membrane to see why this would have the opposite effect of what you want. This might seem a little counterintuitive, but trust me, reduced atmospheric pressure is BAD for hypoxic patients.

...see the above. Specifically look up the changes of oxygen tension (levels) in the atmosphere with changes in altitude and you might want to check out "high altitude pulmonary edema" to see why your idea of reduced work of breathing at altitude tends to fall apart.

I'm not sure I understand the reasoning behind less atopheric pressure making it easier to breath.

He's probably going for the idea that reduced altitude equals thinner air which to him might equate a reduced work of breathing. Think why heliox is used but in much more of a half-assed sort of unscientific approach.

 

[usafmedic45]

The drop in PiO2 as the chopper climbs isn't going to help him, he needs more air not less.

As long as they don't get above 5,000 or 6,000 feet or so, it's not going to be a huge difference assuming the flight crew aren't total morons and are paying attention. We regularly fly with cabin altitudes of 4-6K AMSL (the high end of "normal" flight altitudes for most medical helicopters outside of mountainous terrain) and there's no deleterious effect.

 

[Melclin]

Righto, back to it. Called to a woman who was texting the caller and who didn't text back. Didn't text me back? Must be seriously ill. Better call 000 <_<

Anyway,

I think we can all agree this bloke needs some O2. I trusted the original SpO2. We had a good pleth and it matched his appearance.

The most common idea seems to be some supplemental.

You pop on 15 litres by NRBM and his SpO2 rises to between 91-93%. After two failed attemps (he was a difficult stick, thats my story and I'm sticking too it ) you heroicly manage a 20 in his R medial cube. His conscious state does not improve. Surprisingly though, with some coaxing and a little support he is able weight bear and sit on our wheel chair.

Usal is ganna give him some fluids.

To those wanting the chopper, what is your rationale for aeromed over ground and for the lev 1 hospital over the 2?

What now *****cats?

 

[usafmedic45]

To those wanting the chopper, what is your rationale for aeromed over ground and for the lev 1 hospital over the 2?

Are the following valid answers?
"Because the girl with the flight suit on and unzipped to her navel said it was a good idea."
"Free pizza and t-shirts"
"I want to be like Rabbit on Trauma!"
"Helicopters give me a stiffy."

 

[systemet]

Are the following valid answers?
"Because the girl with the flight suit on and unzipped to her navel said it was a good idea."
"Free pizza and t-shirts"
"I want to be like Rabbit on Trauma!"
"Helicopters give me a stiffy."

I pick 1,2,4 and 1. And 1 again.

 

[Hunter]

Just a quick word, research Dalton's law, and how gas moves across the alveolar membrane to see why this would have the opposite effect of what you want. This might seem a little counterintuitive, but trust me, reduced atmospheric pressure is BAD for hypoxic patients.

well I understand that but since I would've placed him on a cpap wouldn't the cpap create its own pressure?

 

[usafmedic45]

well I understand that but since I would've placed him on a cpap wouldn't the cpap create its own pressure

Yes, but it still negates your reasoning for flying the patient to reduce work of breathing. More than anything we were just trying to get you to study and understand the "why" and not just the "what".


NO ONE ELSE ANSWER THIS. I WANT HUNTER TO THINK THIS ONE THROUGH:
Can you explain to me why a central-mediated (such as drug induced) low tidal volume is not going to be helped much by CPAP and therefore your choice is a poor one?

 

[Cup of Joe]

NO ONE ELSE ANSWER THIS. I WANT HUNTER TO THINK THIS ONE THROUGH:
Can you explain to me why a central-mediated (such as drug induced) low tidal volume is not going to be helped much by CPAP and therefore your choice is a poor one?

ahhhh....I really wanted to take a shot at that question. :sad:

 

[Hunter]

Yes, but it still negates your reasoning for flying the patient to reduce work of breathing. More than anything we were just trying to get you to study and understand the "why" and not just the "what".


NO ONE ELSE ANSWER THIS. I WANT HUNTER TO THINK THIS ONE THROUGH:
Can you explain to me why a central-mediated (such as drug induced) low tidal volume is not going to be helped much by CPAP and therefore your choice is a poor one?

just writing down my thought proccess so might seem a little messy...
I'm thinking that what you're trying to get to is the way that the respiratory drive is affected by the drugs and cpap is used mostly in edema Pts where theres already pressure from the fluid in the lungs you're just trying to work against it... since its drug induced low tidal volume the person isn't breathing correctly and the cpap isn't gonna help them as far as increasing how the respiratory drive...

okay so just to put the above statements into order, CPAP wouldn't help because of something having to do with the actual respiratory drive? Im just guessing I actually don't know the answer to this.

 

[IBleedJDM]

0834 : “Overdose/poisoning”, unconscious (intentional)”.

You are called to a suicide attempt on a cold morning in semi-rural area. The dispatch information notes that you were dispatched by a third party caller (the pt’s sister), who found a note that had been dropped (ie not posted) in her letter box from the pt, explaining that the pt had taken an overdose and apologising for the grief it would cause.

O/A
You arrive at the pt’s house to find that police have turned out prior to you and found a gentleman in his late 50's in an altered conscious state. They have found a detailed suicide note and a number of empty packets of medications. The note states that he took the overdose last night and that it included oxycodone and diazepam.

O/E
59YOM lying semi recumbent in bed, eyes closed, looking a bit grey. He does not respond to your presence.
He is rousable to a state in which he will nod or shake his head answering yes or not to questions.

-Airway: His airway seems patent, the trachea intact. Nil jugular venous distension.
-Breathing: Shallow breathing is evident. His chest expansion is equal bilaterally. Inspiratory and expiratory phases are equal. There is no accessory muscle use or any apparent respiratory distress. His chest is clear and equal bilaterally on auscultation, perhaps ? reduced air entry to the bases. RR 24, SpO2: 70 (with a good pleth)
-Circulation: He has a regular pulse that appears normal in character and strength. He is greyish in colour and his hands and feet are ice cold. Centrally, he is noticeable warm. P: 120, BP 125/50
-Disability: His GCS is 12 (E3, V3, M6) – he mumbles and groans with the odd few words strung together. He obeys the command to open his eyes and to look left and right, but will not grip your hands. His pupils are equal @ 4mm very minimally responsive to light.

Other bits:
BSL: 5.7mmol/L (102.6 mg/dL). Temp: 39.6 C (103.2 F). Monitored in a sinus tachycardia, with a 1st degree AV block.

Secondary Survey
Entire body is atraumatic. NAD other than a 3 inch vertical surgical scar running across his epigastrum and he is wearing a nappy (diaper). Abdomen is soft with no grimacing or guarding noted on palpation. He has not been incontinent. His skin and mucous membranes look reasonably dry.

Hx: He doesn’t answer any questions other than nodding when you ask if he’s been unwell in any way lately. The suicide note makes reference to a year of disability and to renal cell carcinoma that is in remission. The house is well kept and certainly doesn’t look like the kind of house that a bed bound person might live in. Allergies are unknown.

Meds: Oxycodone, Metoclopramide, Diazepam, Quetiapine, Coloxyl with senna. These are found near the bedside by police, nil other meds evident.


Lets say you are:
- 5 mins from a small rural ED. X-ray, CT for ambulant pts only. No surgical service, ICU or HDU. Gen med wards only.
- 40 mins from what you would call a level two trauma centre I suppose. ICU, CCU, ED with CT. All services except neuro surg and cardio thoracic surg.
- 40 mins by whirlybird from a hospital that has the lot and a bit more.

All of the things i put in bold point to septic shock but then again reglan can cause fever and suicidal thoughts so that may be the issue as well. First things first, his airway is patent but at a 70% sat his breathing is safe to call ineffective. I would begin with a NRB @ 15 LPM and move him to the ambulance rapidly where I would probably transition to a CPAP and that should free up both of my hands to start bilateral large bore IV's probably 18g or 16g and get him on the monitor. Then I would hang a NS drip. Considerations, to me would be romazicon or Narcan, however that would solve only a small portion of the concoction that he ingested and may cause further issues. I would also suffice to say that the rural ED would be fine and I would have the helicopter meet me there.

 

[usafmedic45]

I'm thinking that what you're trying to get to is the way that the respiratory drive is affected by the drugs and cpap is used mostly in edema Pts where theres already pressure from the fluid in the lungs you're just trying to work against it...

You're partly right. CPAP is used primarily for three reasons:
1. To decrease work of breathing through its effects on airway resistance
2. To keep the alveoli inflated
3. To help to minimize or reduce pulmonary edema.

It doesn't have to involve pulmonary edema to be used. It's quite effective as an adjunctive (secondary/assisting) treatment in asthmatic and COPD patients in keeping them from buying themselves a stint on the ventilator.

since its drug induced low tidal volume the person isn't breathing correctly and the cpap isn't gonna help them as far as increasing how the respiratory drive...

Good job. Now what non-invasive ventilation mode (related to CPAP) could be used in this setting and would be a better option (assuming that the patient was able to protect his own airway)?

okay so just to put the above statements into order, CPAP wouldn't help because of something having to do with the actual respiratory drive? Im just guessing I actually don't know the answer to this.

No, you didn't guess. You reasoned your way through it. Nice work. Exactly, the problem- at least not the primary one- is not an alveolar recruitment (inflation) issue, pulmonary edema or increased work of breathing but simply depression of the drive to breath.

 

[Melclin]

Okay, I think we've given this one enough time, and I'm glad to see some students/newbies having and crack and getting something out of it.

I left it at 15lpm. I was happy enough with SpO2 of 92 during transport. My concern was ventilation. I would like to have had an end tidal reading to play with, I was quite worried that he was hypo-ventilating (and had been for quite some time). More correctly, that he was still hypo-ventilating (I think its pretty reasonable to suggest that ventilation was his issue originally). In the end with constant stimulation I could bully him into taking the odd deeper breath and keep him reasonably awake. His end tidal at hospital was 40, so I guess it worked out for the best. As some have said, this just screamed sepsis. All I could think was that he had somehow managed to try and kill himself on top of being really crook. At the same time, fluid resus in this pt would be walking a bit of a thin line, guideline wise. Iatrogenic pulmonary oedema is something we are taught to be ridiculously scared of (rightly or wrongly I wonder?) in any fluid resuscitation, and I felt that if he had a respiratory origin for sepsis, or had some kind of myocardial depression from sepsis or whatever else he had taken, that my fluid might end up in his lungs and I'd get a new arsehole torn for me. So I held off on the fluids What do people think about this? Especially given that I cannot initiate an inotrope, is this a legitimate fear or am I being too much of a wanker about it.

I'm surprised at home many people put this guy on the chopper. I'm still a newbie, and I'm still very much in the process of learning, but I have no doubt that I would have had my arse handed to me if I had the chopper out for this bloke. I wasn't even thinking intensive care paramedics, although, I'd like to have nicked their monitor for capnography.

Anyway, he start shivering quite a lot on the way to the level 2 hospital, with some movements that I couldn't identify but that looked like some kind of neuro posturing (it didn't seem like normal shivering anyway, I figured maybe the metaclopramide was at fault, but it wasn't dystonic either), was fluid resuscitated in hospital to good effect, received 200mcg IV naloxone, which affected a mild change in conscious state but changed nothing else (resp status, BP etc). His saturation remained at 92%.

At last look, Neuroleptic Malignant Syndrome (due to the seroquel) with an unknown combination of other affects re polypharmacy OD, was the working diagnosis. I was expecting to be able to give you all something more solid when I posted this scenario, but as I mentioned I was disappointed to hear he was moved to a different hospital and I was not able to follow up further. I only know that he was not tubed, and not admitted under ICU, but that he was moved to the other hospital for a specialist bed which would have been either HDU or Mental health.

I will post more I come across the treating docs or nurses again.

 

[Hunter]

sorry this has taken me so long, lost my internet for a few days.

Good job. Now what non-invasive ventilation mode (related to CPAP) could be used in this setting and would be a better option (assuming that the patient was able to protect his own airway)?

Honestly have no idea.

 

[bigdogems]

Not sure of what the protocols are of the OP. But it sounds like multiple problems in one pt. It is actually a really good example of why a good assessment is required. Its easy to get tunnel vision on the whole suicide attempt part. But a suicide attempt isnt going to give you a 103 temp.

Id go with 15L NRB.Nasal airway. If that didnt increase his SPO2 move to BVM. 18g IV. If your concerned about fluid overload you can start with small 250 boluses and reassess. Some Narcan to see if it helps with the resp depression. If your protocols allow for it I would be very careful before considering Romazacon due to possible seizures. The 1st degree block in itself isnt a problem. Id ground transport to the higher level ER. The pt doesnt sound like there are any issues that would require the care of a level 1 trauma center. Plus depending on the ETA for a lifeflight you may be able to have him to the hospital quicker by a quick load and go rather than waiting on the bird.

 

[KingCountyMedic]

ABC's

Two big lines and a ET Tube/ETCO2/Ballard ET suction cath every time.

Blood draw, 12 Lead ECG. Then you got your bases covered now you can think about other things.

Put in an OG/NG tube and suck out that gut.

My policy is suicide patients DO NOT fly in choppers. I won't risk a flight crew for someone that wants to die in the first place.

:beerchug:

 

[systemet]

My policy is suicide patients DO NOT fly in choppers. I won't risk a flight crew for someone that wants to die in the first place.

That's a joke, right?

 

[Smash]

ABC's

Two big lines and a ET Tube/ETCO2/Ballard ET suction cath every time.

Blood draw, 12 Lead ECG. Then you got your bases covered now you can think about other things.

Put in an OG/NG tube and suck out that gut.

My policy is suicide patients DO NOT fly in choppers. I won't risk a flight crew for someone that wants to die in the first place.

:beerchug:

Is that the same dangerous, suicidal patient you have just intubated? Do you not provide sedation and analgesia to all intubated patients?

 

[epipusher]

That's a joke, right?

Wow, written or unwritten policy, that's horrible. They probably do not fly homeless people either.

 

[Aidey]

Wow, written or unwritten policy, that's horrible. They probably do not fly homeless people either.

WTF does one have to do with the other? If you are going to criticize the policy go ahead, but making wild emotion based accusations is silly.