Mystery case.

[Melclin]

Hey guys,
I'm interested to see how everyone would treat the following case at all the different levels of qualifications we have here and what you think the problem might be.

Called out at 3:53am, CODE 1:Severe SOB. Arrive on scene to find 19yo male unconscious. Found by parents on the floor in the living room.
No response.
Trismus present, but breathing.
Palpable pulse.
No haemorrage.

I'm told triple airway was affective and OPA was "partially affective". Ventilated with closed circuit 100% O2.
Pulse: 130
ResRa:<6
3 lead ECG: Atrial Fibrillation (uncontrolled)
BP: 140/90
GCS: 3

Temp: 35.5 (tympanic)
Skin: Cool, dry cyanotic
Pupils: equal and reactive, but pinpoint.

Chest: L and R sounds clear + shallow, decreased effort, equal expansion, UA snore.

MICA (Intensive care paramedics) arrived four mins later.

etCO2: 75 mmHG, normal resp waveform.
SP02: 100 (with oxysaver).
RBG: 15.3 mmol/l

OPA swapped for NPA after, it appears, it was decided that vents were inadequate. Not sure if that was done before or after the SPO2 of 100. After affective vents, ResRa increases to 20.

IV access: 18g AC, 500ml sodium lactate TKVO

According to parents, pt has a history of depression and self harm. A veritable pharmacy of medications exists in the house. Pt. has Xanax and Effexor prescribed, but many others are available.

No known allergies.

No evidence of narcotics, no track marks, parents adamant no illegal drugs (aren't they always).

Pt loaded into ambulance where airway is successfully suctioned. The kid then wakes up bolt upright and rips out his NP.
Pulse:128 BP:136/88 Skin: cool, pink, dry.
GCS: 8 (E-2, V-1, M-5) ResRa: 20 Pupils: pinpoint, reactive

10 mins later the pt drops back down to GCS 4 (eyes open to pain) and pupils were no longer pinpoint. Skin noticeably hot and and Resra:20 and uncontrolled A-Fib continue. BP:136/88, etCO2: 65, at handover.

I'm fairly tired right now but I think that's everything I can remember.

So, What do we all think happened, and more interestingly how would you have treated the situation. Would you do it differently? I might add that we were about 4 mins from a mid level hospital.

 

[Scott33]

No evidence of narcotics...

Pupils: pinpoint / ResRa:<6

You sure about that?

First thing I would be thinking.

 

[rhan101277]

You sure about that?

First thing I would be thinking.

Same pinpoint usually indicates overdose. The patient has respiratory depression is a sign, the type of drugs he has available and his history. Wonder why narcan wasn't considered?

 

[rmellish]

Could have tried a bit of narcan, especially given the lack of spontaneous respirations and pinpoint pupils.

Anyone check a BGL? Doesn't seem to be the problem, but never bad to check.

 

[maxwell]

Has to be drugs! A-Fib for 19 year old? You sure? That's strange. MAT makes more sense to me if he took weird drugs to deplete his K, Mg. I woulda intubated with an ETT (sounds like it coulda be done w/o RSI drugs, too). Woulda given naloxone (while avoiding romazicon). If the QRS was wide, I would have given sodium bicarbonate (TCAs?). Woulda checked a blood sugar.

 

[redcrossemt]

I'm told triple airway was affective and OPA was "partially affective".
Ventilated with closed circuit 100% O2.

What's a triple airway? What does partially effective OPA mean? What's being used? The triple or the OPA or an NPA or what? What rate are you ventilating the patient at, or are they just on O2 via mask?

Chest: L and R sounds clear + shallow, decreased effort, equal expansion, UA snore.

What is UA snore? Snoring respirations? Are you sure you had a patent airway?

ResRa:<6
Pupils: equal and reactive, but pinpoint.

With the patient history provided, level of unconsciousness, slow respirations, and pinpoint pupils I would have been thinking narcotic or polypharmacy overdose. Definitely need a BGL, could try nalaxone, but I would focus on airway management. You mentioned that the patient needed to be suctioned. I wasn't there, but a consideration would be intubation, possibly RSI if the trismus prevents access. Whether or not you decided to intubate, positive pressure ventilations and careful monitoring/suctioning would be my first priority for this patient.

 

[fma08]

Could have tried a bit of narcan, especially given the lack of spontaneous respirations and pinpoint pupils.

Anyone check a BGL? Doesn't seem to be the problem, but never bad to check.

They did, 15.3 mmol/l, a bit on the higher side.

 

[Juxel]

They did, 15.3 mmol/l, a bit on the higher side.

That's about 276mg/dl for those of us who are familiar with that format.

 

[triemal04]

Has to be drugs! A-Fib for 19 year old? You sure? That's strange. MAT makes more sense to me if he took weird drugs to deplete his K, Mg. I woulda intubated with an ETT (sounds like it coulda be done w/o RSI drugs, too). Woulda given naloxone (while avoiding romazicon). If the QRS was wide, I would have given sodium bicarbonate (TCAs?). Woulda checked a blood sugar.

Second the trycyclic OD with likely several others as well. And even without a "history" of drug use also might consider this being a speedball OD. It be more likely to see the rapid change in pt's status after the narcan but probably could also happen after the respiratory issue was fixed. But intubation (by RSI or otherwise) would be a good choice for him and a small dose of narcan would have been good initially.

 

[Melclin]

Not sure exactly what 'partially effective' means. It was in the first responders notes. But obviously is wasn't working. Sp02: of 100 must have been taken with the NP. I would imagine that the OP didn't work well or they had alot of trouble getting it in and 'partially effective' was the closest option to select on the Electronic Patient Care Record.

No TCA present in the house.

I meant triple airway maneuver. To clear and view the airway. I dont quite understand how it could be affective, but then have such problems with an OPA that you then had to use an NP.

UA snore. Yeah upper airway. Sorry that should be UA: snore .

Has anyone considered aspiration associated conditions. Do any of the symptoms point that way? Shallow, fast (with some assitance) breathing?

I'd be interested in suggestions as to why the pt. wasn't tubed. RSI seems a bit extreme considering a good colour returned, with more basic ventilations and given the posibility of opiate and particularly benzo overdose.

 

[BruceD]

Tricyclic overdose typically results in anticholinergic effects, which would include mydriasis, not miosis. (Of course wouldn't want to diagnose based on that), so i'm leaning away from TCA overdose.

Xanax overdose produces CNS depression (miosis & respiratory depression), arrhythmias, oddly...tachycardia, seizures, muscle rigidity, syncope

Effexor has the potential to cause neuroleptic malignant syndrome, characterized by autonomic instability, delirium, agitation, coma, and.. muscle rigidity. (did he have a fever?)

So, polypharmacy can't be ruled out, but I'm not going to make a guess as to the actual cause. If it was one of the above, narcan would be ineffective (flumazenil would be the d.o.c.)

 

[boingo]

pinpoint, unresponive, with respiratory rate of less than 6 would get narcan here.

 

[vquintessence]

Polypharmacy c Dystonic reaction anybody?

Well I was toying with polypharmacy OD c dystonic reaction? I realize he wasn't displaying any cholinergic imbalance however there seems a possible suspicion based on: trismus, pts age, access to psych meds, how pt described as spontaneously (yet momentarily) jerked up to only collapse back down.

I agree with Bruce with xanax and/or effexor OD and their symptom profiles fitting the bill, however the chances of either one being the culprit for the trismus are very uncommon (and I cheated about xanax to learn trismus isn't listed among any adverse reactions.) Muscle fatigue yes, muscle rigidity less so, but trismus is beyone uncommon.

Eh some worthless $0.02. I just like the dystonic reaction theory B)
But yeah, start with some Narcan simply based on presentation, but would definately try some Benadryl h34r:

 

[MSDeltaFlt]

Hey guys,
I'm interested to see how everyone would treat the following case at all the different levels of qualifications we have here and what you think the problem might be.

Called out at 3:53am, CODE 1:Severe SOB. Arrive on scene to find 19yo male unconscious. Found by parents on the floor in the living room.
No response.
Trismus present, but breathing.
Palpable pulse.
No haemorrage.

I'm told triple airway was affective and OPA was "partially affective". Ventilated with closed circuit 100% O2.
Pulse: 130
ResRa:<6
3 lead ECG: Atrial Fibrillation (uncontrolled)
BP: 140/90
GCS: 3

Temp: 35.5 (tympanic)
Skin: Cool, dry cyanotic
Pupils: equal and reactive, but pinpoint.

Chest: L and R sounds clear + shallow, decreased effort, equal expansion, UA snore.

MICA (Intensive care paramedics) arrived four mins later.

etCO2: 75 mmHG, normal resp waveform.
SP02: 100 (with oxysaver).
RBG: 15.3 mmol/l

OPA swapped for NPA after, it appears, it was decided that vents were inadequate. Not sure if that was done before or after the SPO2 of 100. After affective vents, ResRa increases to 20.

IV access: 18g AC, 500ml sodium lactate TKVO

According to parents, pt has a history of depression and self harm. A veritable pharmacy of medications exists in the house. Pt. has Xanax and Effexor prescribed, but many others are available.

No known allergies.

No evidence of narcotics, no track marks, parents adamant no illegal drugs (aren't they always).

Pt loaded into ambulance where airway is successfully suctioned. The kid then wakes up bolt upright and rips out his NP.
Pulse:128 BP:136/88 Skin: cool, pink, dry.
GCS: 8 (E-2, V-1, M-5) ResRa: 20 Pupils: pinpoint, reactive

10 mins later the pt drops back down to GCS 4 (eyes open to pain) and pupils were no longer pinpoint. Skin noticeably hot and and Resra:20 and uncontrolled A-Fib continue. BP:136/88, etCO2: 65, at handover.

I'm fairly tired right now but I think that's everything I can remember.

So, What do we all think happened, and more interestingly how would you have treated the situation. Would you do it differently? I might add that we were about 4 mins from a mid level hospital.

No 19yo is supposed to have A-Fib in any condition unless it is congenital. And then they are to have meds for it. With new onset A-Fib and ALOC, odds are you have just stroked out. Add to that pinpoint pupils, you might have a Pontene Hemorrhage. With a CVA at the base of the brain you will have temp problems. I realize you said tympanic temp, but core temps are more accurate. Rectal temps are unpractical in EMS, but noticeably hot skin is not supposed to happen.

You also need to control ICP's as best you can on the prehospital level. EtCO2's in the 60's and 70's is a bit high. High end tidals mean cerebral vasodilation which further increase ICP which take away from CPP which is what is going to drive this poor kid further down the drain. If you have RSI, put him down and get those EtCO2's in the upper 30's.

Don't waste time on scene trying to get a tube. Time is brain here. If you can't get it in a couple of tries, go to your backup airway.

Until proven otherwise (CT), assume the worse.

 

[Jon]

MSDelta... Wow. Wasn't thinking in that direction, but you make an awesome case.

Given all the drugs in the house... I'd likely max out my 2mg of Narcan by protocol, then try for a tube.

 

[fma08]

Diddo MSDelta, was not thinking CVA at all. Quite enlightening really.

 

[BruceD]

If it had been pontine hemorrhage, what are the chances he would be down a while at GCS 3, then sit up in the ambulance and pull out the tubes then 10 mins later fall back to GCS 4?

If his skin is hot to the touch as mentioned later in the post, I'm still very much leaning toward NMS possibly with other effects from polypharm.

but either way, I still believe load'n'go best treatment for this 'un.

kinda a neat case.

 

[MSDeltaFlt]

If it had been pontine hemorrhage, what are the chances he would be down a while at GCS 3, then sit up in the ambulance and pull out the tubes then 10 mins later fall back to GCS 4?

If his skin is hot to the touch as mentioned later in the post, I'm still very much leaning toward NMS possibly with other effects from polypharm.

but either way, I still believe load'n'go best treatment for this 'un.

kinda a neat case.

Actually pretty good for both. That can happen for either field diagnoses.

What I don't like is the A-Fib with ALOC. That tells me CVA until proven otherwise. Which is why I would be hesitant to push Narcan on this kid.

Narcan is contraindicated for resp depression not due to opioid ingestion. Side effects include tachycardia, hypertension, N/V, seizures, even cardiac arrest. Do you really want to cause these side effects on someone who could quite possibly be having a CVA?

 

[Melclin]

No 19yo is supposed to have A-Fib in any condition unless it is congenital. And then they are to have meds for it. With new onset A-Fib and ALOC, odds are you have just stroked out. Add to that pinpoint pupils, you might have a Pontene Hemorrhage. With a CVA at the base of the brain you will have temp problems. I realize you said tympanic temp, but core temps are more accurate. Rectal temps are unpractical in EMS, but noticeably hot skin is not supposed to happen.

You also need to control ICP's as best you can on the prehospital level. EtCO2's in the 60's and 70's is a bit high. High end tidals mean cerebral vasodilation which further increase ICP which take away from CPP which is what is going to drive this poor kid further down the drain. If you have RSI, put him down and get those EtCO2's in the upper 30's.

Don't waste time on scene trying to get a tube. Time is brain here. If you can't get it in a couple of tries, go to your backup airway.

Until proven otherwise (CT), assume the worse.

That is a Dx worthy of house. Fine work MSDeltaFlight. In this case though, I'm not sure that was what was wrong.

Here's some more info:
They took the kid to CT and he came back a few mins later and nobody seemed any the wiser, other than his lungs were 80% full of aspriated stomach matter. His liver was also full of acetaminophen. That's about all I know from the ED.

 

[MSDeltaFlt]

That is a Dx worthy of house. Fine work MSDeltaFlight. In this case though, I'm not sure that was what was wrong.

Here's some more info:
They took the kid to CT and he came back a few mins later and nobody seemed any the wiser, other than his lungs were 80% full of aspriated stomach matter. His liver was also full of acetaminophen. That's about all I know from the ED.

Just covering all bases until confirmation. Glad he got a CT to rule out anything.

However, Aspiration Pneumonia (50% mortality on top of whatever else is going on) + Liver Failure from Acetaminophen OD + possible Anoxic Brain Injury from however long his GCS was that low and hypoventilating vs possible Pontine Hemorrhage. Junior's screwed any way you look at it.