A train wreck of usals proportions.

[NYMedic828]

Wish I had CPAP to begin with.

We don't even have diltiazem anymore.

My only options are nitro, ECG 3/12 monitoring and cardioversion/amiodarone if it was warranted after nitro/nebulizer treatment.

 

[VFlutter]

That is a stampede and a half of zebras. Well not by themselves but all together is just crazy.

 

[usalsfyre]

I'm gonna forgo the APACHE II survival to determine how this guy does.

Dana, I want to know one thing to predict his future morbidity/mortality...what was his tooth to tattoo ratio?

 

[FLdoc2011]

Was it a confirmed PE by CT angio or some other study? An elevated d dimer in a guy like this isn't terribly specific.

 

[46Young]

@ OP, you mentioned that the pt had wheezing and also "shark-fin" waveform on the ETCO2. My understanding is when a pt has a total loss of alveolar plateau as above, CPAP will cause additional air trapping, since the pt cannot eliminate it due to the severe bronchoconstriction. Is it possible that the CPAP caused increased intra-thoracic pressure, and created a tamponade effect? If so, the earliest sign could be the ETCO2 trending downward, particularly south of 30-35, since ETCO2 values are dependent on venuous return. When the pt's pressure starting dropping, so did the ETCO2.

No in-line neb availability sucks, but then again there are systems, sometimes large systems, that don't even carry CPAP.

 

[Melclin]

At first glance, I'd think this to be an infective COPD exacerbation, pushed into some level of failure by said infection. What was this dude's temp?

Intensive care back after I first laid eyes on him.
Neb'd Albuterol, atrovent.
Aspirin
0.6mg GTN SL.

Pads on, two lines, hang a bag TKVO, draw up IV albuterol, dexamethasone, 1:1000 and 1:10,000 adrenaline, amiodarone. Fent and midaz ready for cardioversion or tube.

Depending on availability of Intensive care backup, I would be disinclined to move this guy before I got him a bit more stable. Going on the working dx above, I would really hate to take this guy out into the cold and have him peg out on me with no access and no drugs on board. I would be heavily criticised if I loaded this pt without doing anything for him first. Interesting comparison between the systems.

 

[Handsome Robb]

I would've CPAPd him with an inline neb since our units are designed to make inline nebs easy-peasy

I will usalsfyre, this guy is going to be in a hospital bed for a long time to come, possibly for the rest of his life.

 

[abckidsmom]

I'm gonna forgo the APACHE II survival to determine how this guy does.

Dana, I want to know one thing to predict his future morbidity/mortality...what was his tooth to tattoo ratio?

Tooth:tattoo=3:0

Make of that what you will.

 

[abckidsmom]

@ OP, you mentioned that the pt had wheezing and also "shark-fin" waveform on the ETCO2. My understanding is when a pt has a total loss of alveolar plateau as above, CPAP will cause additional air trapping, since the pt cannot eliminate it due to the severe bronchoconstriction. Is it possible that the CPAP caused increased intra-thoracic pressure, and created a tamponade effect? If so, the earliest sign could be the ETCO2 trending downward, particularly south of 30-35, since ETCO2 values are dependent on venuous return. When the pt's pressure starting dropping, so did the ETCO2.

No in-line neb availability sucks, but then again there are systems, sometimes large systems, that don't even carry CPAP.

I still regret missing that Bob Page class. Good info. I'll be learning more about it. Thanks!

 

[abckidsmom]

At first glance, I'd think this to be an infective COPD exacerbation, pushed into some level of failure by said infection. What was this dude's temp?

Intensive care back after I first laid eyes on him.
Neb'd Albuterol, atrovent.
Aspirin
0.6mg GTN SL.

Pads on, two lines, hang a bag TKVO, draw up IV albuterol, dexamethasone, 1:1000 and 1:10,000 adrenaline, amiodarone. Fent and midaz ready for cardioversion or tube.

Depending on availability of Intensive care backup, I would be disinclined to move this guy before I got him a bit more stable. Going on the working dx above, I would really hate to take this guy out into the cold and have him peg out on me with no access and no drugs on board. I would be heavily criticised if I loaded this pt without doing anything for him first. Interesting comparison between the systems.

There was no staying in this house. It bordered on hoarders-level clutter, and we barely had room to turn him around in the stair chair to get out.

I agree with drawing up meds before you need them, though. It's a good method to keep Murphy at bay.

 

[BandageBrigade]

I'm gonna forgo the APACHE II survival to determine how this guy does.

Dana, I want to know one thing to predict his future morbidity/mortality...what was his tooth to tattoo ratio?

I prefer the degree of stained his tank top(wifebeater if you prefer) is, with 0 being semi clean (dingy white) and 10 being call a hazmat truck x beer cans on floor and # of ash trays - trash cans actually in use.