The Unresponsive Male

[Nattens]

Hi All,

Before beginning I will say that we are in this situation extremely limited with that diagnostic and clinical tools we have available.

Wishing to share my first "big" job that I did on New Years Day. I was working at a large music festival in my home state (Australians may be familar with it) in an overnight shift when a call comes from the event security that we are required to an unconscious, unresponsive male pt. The responsive team went to the pt and loaded him to our medical centre.

Pt was brought in in the recovery position with 8lpm oxygen via hudson mask applied. Response team advises that the pt was completely unresponsive, OP airway attempt failed due to trismus. On arrival pt beings coughing up and develops stridor. Airway is suctioned however pt is still showing stridor.

Vitals as follows

-Skin is warm, pink and dry
-Unknown hx, unknown MOI, unknown allergies Phx or medications, no medialerts
-GCS 3
-ECG shows sinus rhythm of 75
-SpO2 is 99% on O2, drops with the removal of O2 via hudson
-Temperature is 34.6 celsius
-BGL is 6.3mmoL
-Blood Pressure is 114/74
-Chest ausculatation shows entry to all parts of the lung however stridor is present
-Respiratory Rate is 25
-Pt appears to be using accessory muscles on inspiration
-Secondary survey is uneventful
-Pupils are equal at 5mm but unreactive to light.

(All I can think about at the moment)

I know what happened to him, however I am interested as a newbie to hear what you guys would do in this situation with this pt.

-Local hospital with basic ED is 30 minutes via road
-Tertiary hospital with large ED facility is 120 minutes via road
-Major city hospital with trauma, respiratory, cardiac etc specialties is 30 minutes via helicopter.

 

[Anjel]

Choking?

Drunk and aspirated his own vomit?

What is the blood glucose in american units lol

 

[d0nk3yk0n9]

What is the blood glucose in american units lol

According to a quick search, 6.3 mmol/L is about 114 mg/dL.

 

[Anjel]

According to a quick search, 6.3 mmol/L is about 114 mg/dL.

Sweet. So thats fine.

 

[exodus]

CVA? Sounds nearly identical to all the other unresponsive scenarios in the past few days. I got a feeling the ALOC is due to the trisumus though. Drop an NPA and see how that goes. Trismus is secondary due to seizure, anti-psychotics, stimulants, etc. Very possible case at a major music festival.

 

[gw812]

Gimme an appx. age based on appearance. Teen? Young adult? Geriatric?
I'm thinking 'Hudson' to you is 'NRB' to me. When you say his sat drops if you take off the NRB how far? Is the airway patent or are you having to bag him?
Also, is there any discoloration around the mouth? Signs he was snorting or huffing something from a bag? Any paint, glue, or cement in his pockets?

 

[Handsome Robb]

A Hudson mask is just a simple mask, not a NRB.

Was there any bystanders that saw what happened? Any friends to ask if he's taken anything? What kind of music festival ie rave, rock, reggae ect? Any signs of trauma?

How's his temp.

First thought could be malignant hyperthermia secondary to ecstasy but I didn't do a great job of reading the whole scenario since I'm on my phone.

 

[AlphaButch]

Any little containers around? Whippets are pretty popular at festival type events down here. Don't know if you have simliar issues over there.

 

[Nattens]

Anjel 1030: I'd say the choking on the vomit had occured with this one, apologies for the Australianisms, not sure on what the American versions are.

exodus: Not confident on a CVA with this one, however amphetamine use would be highly likely considering the environment.

gw812 and NVRob: Apologies, pt was approx 20 yo M, no discolouration around the mouth, no drugs or alcohol or paint or anything found with him and pockets are completely empty, no friends at the festival, no bystanders saw him drop, no signs or trauma. Temp 34.6 celsius (don't know about fahreinheit but by our protocols that is a mild hypothermia). Festival is a 3 day campout with a variety of rock, dance and other styles.

The O2 sat drops to 92% on room air, 100% was applied once we got down to 92% from 99% since it was clear that he couldn't get enough on room air.

 

[HMartinho]

Any seizure?

 

[Handsome Robb]

Anjel 1030:
exodus: Not confident on a CVA with this one, however amphetamine use would be highly likely considering the environment.

I'd expect to see hyperthermia with amphetamine or stimulant use, not hypothermia. This could very well be dependent on down time and ambient temperature. Also I'd expect him to have some HTN and tachycardia but if he's speed balling that could hide it pretty well and could most definitely explain this situation.

Any track marks on his arms, feet or in between his toes?

Where did the team find him? Did they just scoop and run or did they take the time to take a quick gander around to look for clues?

92% isn't bad. I'd go for a NPA if I was confident there was no head trauma. RSI for definitive airway control is an option, worst comes to worst I'd be ready to get a surgical cric in him. "Jump to the bottom of the algorithm".

Work on some access so you have it. TKO, doesn't seem like he needs any help with volume, he's not compensating. Some might argue trialing narcan as a rule out but I'm not game. If he is speed balling the opiates might be the only thing keeping him from going ballistic.

I'm heading down the drug pathway but this very well could be some sort of CVA. Seizure is possible too but again I'd expect to see him start to improve and would also think he'd be hot and sweaty from a seizure that's going to make him so postictal that he has a GCS of 3 for an extended period of time.

This guy sounds like he needs a hospital with neuro capabilities. So my flavor would be air to the big house. How far out is the air unit though? I'd consider transfer to the local ED then transferring him out or start driving towards the city and meet them enroute.

 

[EMT PR]

To my personal opnion, in that scenario in a music festival- O.D of drug or alcohol is the most likely, however- in pt. with 3 G.C.S you can't take the chans... and like NVRob says:

This guy sounds like he needs a hospital with neuro capabilities. So my flavor would be air to the big house. How far out is the air unit though? I'd consider transfer to the local ED then transferring him out or start driving towards the city and meet them enroute.

 

[Nattens]

To my personal opnion, in that scenario in a music festival- O.D of drug or alcohol is the most likely, however- in pt. with 3 G.C.S you can't take the chans... and like NVRob says:

Pretty much, fortunately we had a doctor nearby who was paged, on his arrival the pt was intubated, two 18g IVs were placed, naso gastric tube was placed and urinary catheter was placed. Not sure about any of the other details as I had to leave the scene to not clutter the procedure room (very enclosed space). I was told rum and coke came out of the naso-gastric tube and the pt filled 3 emesis bags from the urinary catheter.

Pt was then airlifted via helicopter. Chopper took 20 minutes to arrive from the city and he was airlifted to one of our state's biggest hospitals.

Heard today the pt is currently in the ICU in a critical condition.