# apathetic



## vquintessence (Jan 3, 2011)

It's a beautiful Fall day, but you're stuck working on a rusty private ambulance. You're dispatched at 16:40 for the reported altered mental status. Upon arrival you're met by a middle aged man at the entrance to a well kept residence; the small patch of lawn out front is well cared for and the dwellings interior is immaculate. The man appears less than thrilled upon the arrival of yourselves and PD. He nonchalantly leads your group to the basement. When asked "What brings us here today?", the man simply responds "My son" and doesn't provide anything further; he is clearly agitated.

While descending into the finished basement, it becomes apparent it's the neglected quarters of the residence. The plaster has several holes at shoulder and foot level, the furniture is banged up, and a broken coffee table lays stacked haphazardly against the far wall. In the near vicinity of the staircase you note a 16 y/o male found R lateral recumbent on the hardwood floor. Initial attempts to rouse the pt w/ noxious verbal stimuli fail; a firm trapezius squeeze earns a barely audible groan and a weak, non-purposeful attempt to move an upper extremity.  There are no known witnesses and there's nothing additional within the immediate vicinity to provide any obvious clues to the pts condition. Vitals obtained on scene by your proficient partner: BP 144/72, HR 120, RR 8.

ASSESSMENT:
CONSTITUTIONAL: Age appropriate physical development w/ proper signs of nourishment. The child appears well kept and is fully dressed in athletic clothing.
NEURO: Profound somnolence noted, gcs 7 (1/2/4). No posturing.
HEENT: Symmetrical & atraumatic face/head. Ears unremarkable. Eyes have normal sclera and pupils are round & equal w/ notable mydriasis 8mm. Nose unremarkable. Oropharynx has no remarkable odors and presents w/ dry mucosa; (+)gag reflex.
CARDIO: Unremarkable heart sounds. (+)strong/regular peripheral pulses. Good distal cap refill.
THORAX/PULMONARY: Chest symmetrical & atraumatic. No retractions. Respirations bradypneic & slightly irregular w/ poor t/v. Auscultation cta bilat.
ABD/GEN: SNT all quadrants w/ decreased bowel sounds. Absent (L) testicle. (-)priapism. (-)incontinence.
SKIN: pink/warm/dry. Normal skin turgor. (-)petechia/purpura, (-)rash, (-)jaundice.
MUSCULOSKELETAL: Above average muscle development; generally athletic build. Extremities are largely unremarkable.

DIAGNOSTIC:
EKG reveals sinus tachycardia w/o ectopy. 12 lead ekg reveals a prolonged QRS of 110m/sec and prolonged QT intervals; normal PRI, (-)axis deviation, (-)BBB, etc
spO2 94% RA and ETCO2 60 mm/Hg with typical wave-form.
CBG 94 mg/dL
No thermometer is available


As alluded to earlier, the father is completely apathetic to his son and his present state. When asked about social and medical hx, the father is very guarded and reluctant to provide information. Your suave partner gets the PD on scene to assert some authority, yielding the father to state the childs only medical history is a testicular torsion within the past year "that my [his] son uses as an excuse for everything". There is also one medication prescribed "for the problem", but the father doesn't bother to know or find it.  There is nothing further to be gained from him.

The nearest hospital is level 3 and is 15 minutes away; it boasts a CT scanner, non-interventional cath lab and dialysis capabilities.  A level 2 trauma center is 35 minutes away with all the bells and whistles.  The local med flight is occupied.  What are you doing, where are you going, and why?


----------



## jjesusfreak01 (Jan 3, 2011)

If I had to guess, I might be thinking the problem is related to stress on the body due to use of supplemental steroids based on the physique and missing testicle. In particular, he might have an enlarged heart or a similar problem. That's all I feel comfortable guessing at...


----------



## NomadicMedic (Jan 3, 2011)

I'm thinking that I need to find that med that dad was talking about. I'm guessing tricyclic overdose. The widened QRS, sinus tach, depressed respirs and  altered mental status are leading me down that road. 

I'd get access, intubate, NG tube with 100 grams of activated charcoal and two amps of Bicarb. I'd get him to the closest facility and let them manage the kid.


----------



## vquintessence (Jan 7, 2011)

n7lxi said:


> I'm thinking that I need to find that med that dad was talking about. I'm guessing tricyclic overdose. *The widened QRS, sinus tach, depressed respirs and  altered mental status* are leading me down that road.
> 
> I'd get access, intubate, NG tube with 100 grams of activated charcoal and two amps of Bicarb. I'd get him to the closest facility and let them manage the kid.



Bullseye on the second post.  Good shooting partner.

Was hoping there might be additional opinions for my own curiosity, but nobody seemed to give a crap about the scenario. h34r:


----------



## Veneficus (Jan 7, 2011)

vquintessence said:


> Bullseye on the second post.  Good shooting partner.
> 
> Was hoping there might be additional opinions for my own curiosity, but nobody seemed to give a crap about the scenario. h34r:



I try to let others have a chance and if the scenario is being discussed in a good way by the participants I stay out of the way.

My only opinion is that the proper dose of bicarb is not an AMP. it is a milliequivalent/KG.


----------



## NomadicMedic (Jan 7, 2011)

Veneficus said:


> I try to let others have a chance and if the scenario is being discussed in a good way by the participants I stay out of the way.
> 
> My only opinion is that the proper dose of bicarb is not an AMP. it is a milliequivalent/KG.



Good point. The dose for TCA overdose is 1 to 2 mEq/kg. Seeing that the pt is a healthy, well nourished American male, 100mEq is a reasonable dose. (that is, 2 amps of bicarb, 50mEq per amp)

Sorry if I wasn't explicit enough. 

Thanks for the scenario.


----------



## Melclin (Jan 10, 2011)

Yeah, seems like a pretty textbook TCA overdose. I've never seen one get past sinus tach and ~GCS 10, but I understand from the book learnin' that the case you present is the textbook scenario.

The other thing that came to mind initially was that quetiapine is now very common as a first line in bipolar maintenance (as a +/- with lithium or valproate, and more recently monotherapy) and monotherapy for psychosis. It interacts with a few things like anti fungals and of course other antipsychotics/sedatives/EtOH to increase AMS. It also causes tachycardia, QT prolongation, dry muscous membranes and reduced conscious state. 

Not so much the wide QRS though as far as I know, plus hypotension is a pretty prominent symptom I understand. Also, I re-read the description and saw he was 16, so I suppose its a bit young for a fully fledged psychosis or bipolar diagnosis (although not impossible). Still, good to keep the brain ticking I suppose.


----------



## Jay (Jan 10, 2011)

I would have to go with the following evidence-based analysis along with some speculation:

The father is agitated and does not desire to have PD on scene because there may be some additional drug or alcohol use in addition to the mystery prescribed medication which there is a more than fair chance is either a steroid, TCA of some sort or narcotic analgesic that can be deduced by the remainder of the post. With the enormous muscle growth it is possible that the lad was abusing steroid prior to the torsion or mixing thereafter. This would also explain the rage and holes in the walls. 

The kid is responsive to pain but is not posturing and the head otherwise appears unremarkable which suggests some kind of overdose. 

HR is up and RR is down which probably points to TCA OD and not a narcotic OD but in-case there is some compensation here would it really hurt to try 0.4 nalaxone? The low T/V backs this up as well.

Initially I was thinking that there was some kind of violence that the father was covering up and was thinking that I would have tried to find some kind of evidence of surgery near the testicle. The torsion seems to fit but does it?

The cardiac ectopy could be caused by an electrolyte imbalance but since a possible TCA OD can also be treated with bicarb (in part to correct the disrhythmia) than why not start a line of NS and introduce some bicarb.

The father claiming that the boy uses "excuses for everything" could indicate depression or even drug or alcohol abuse which could explain the ectopic condition as well, this could also be congenital but I wouldn't bargain on it. 

Bottom line is the kid needs airway management, 12-15LPM NRB to bring up the SpO2, line of NS, Bicarb would treat both possibility of the TCA and Ectopic condition side, 0.4 of Narcan to err on the side of caution, if we can confirm that the kid went down not too long ago some charcoal via ng is not a bad idea but probably wont be too helpful either because recent studies are swaying away from it for TCA OD as it shows minimal benefit. Finally, contact the Level 3 as there is no suspected brain injury and go Code 3 however TCA OD is only a matter of time and hauling a$$ there probably wont make a difference anyhow but he should get the full, royal treatment upon arrival to rule anything else out. 

Any other thoughts?


----------



## NomadicMedic (Jan 11, 2011)

Jay said:


> Bottom line is the kid needs airway management, 12-15LPM NRB to bring up the SpO2, line of NS, Bicarb would treat both possibility of the TCA and Ectopic condition side, 0.4 of Narcan to err on the side of caution, if we can confirm that the kid went down not too long ago some charcoal via ng is not a bad idea but probably wont be too helpful either because recent studies are swaying away from it for TCA OD as it shows minimal benefit. Finally, contact the Level 3 as there is no suspected brain injury and go Code 3 however TCA OD is only a matter of time and hauling a$$ there probably wont make a difference anyhow but he should get the full, royal treatment upon arrival to rule anything else out.
> 
> Any other thoughts?



Yes, I have a few thoughts. The kid needs to be intubated, not an NRB. TCA overdoses can decompensate rapidly, it's a smart idea not to be behind the curve on this. There is a 50% mortality rate in patients that present with trivial signs, and these signs _aren't_ trivial. The Narcan isn't indicated, as this doesn't simply present as an opiate OD.  _*Eyes have normal sclera and pupils are round & equal w/ notable mydriasis 8mm.*_ However, I feel the Activated Charcoal is indicated, as 100g of charcoal may bind upto 4g of TCA.


----------



## Jay (Jan 11, 2011)

n7lxi said:


> Yes, I have a few thoughts. The kid needs to be intubated, not an NRB. TCA overdoses can decompensate rapidly, it's a smart idea not to be behind the curve on this. There is a 50% mortality rate in patients that present with trivial signs, and these signs _aren't_ trivial. The Narcan isn't indicated, as this doesn't simply present as an opiate OD.  _*Eyes have normal sclera and pupils are round & equal w/ notable mydriasis 8mm.*_ However, I feel the Activated Charcoal is indicated, as 100g of charcoal may bind upto 4g of TCA.


I never said not to intubate but did simply put it as "airway management", at my level I could only drop an OPA and use the NRB which is appropriate. As you stated the signs aren't trivial which is why I stated the obvious for TCA OD protocol and what I could do assisting ALS in the case. As for the eyes, they are the only thing missing from the opiate triad and considering that the father wasn't being cooperative is it really worth not trying a coma of unknown origin protocol in conjunction with the above, you don't know if there are any pre-existing ocular conditions so why chance it? As you said, the patient could decompensate quickly. Just a thought.


----------



## emtech419 (Jan 29, 2011)

Jay said:


> I never said not to intubate but did simply put it as "airway management", at my level I could only drop an OPA and use the NRB which is appropriate.



An NRB is not appropriate.  Resp rate of 8 plus desaturation and hypercapnea indicates this patient is not breathing effectively.  From a BLS level, place your OPA/NPA depending on whether gag reflex is present or not, and start bagging.

My command facility's ALS protocols won't let me drop an NG to administer the charcoal, and my service doesn't even carry charcoal, but I agree with the previous comments about start your normal saline and introduce the bicarb for the TCA overdose, as well as .4 narcan.  Nowhere does it say your patient can only have one thing wrong with them at a time, and .4 narcan will not harm your patient in any way if there are no opiates on board.

AMS of unknown cause with resp/airway compromise absolutely indicates narcan, and no matter what signs you find, you cannot prove 100% that this is a TCA overdose without a blood test, so why not give a little narcan?


----------

