# What would you have done?



## HappyParamedicRN (Dec 19, 2010)

Had a call today, just wondering what other paramedics would have done...

69 year old male PMH of Chronic renal failure (last dialyis the day before), CHF, Heart transplant (15 years ago), HTN, and Non insulin dependent diabetes. 

Got called for the altered mental status.  Upon arrival the wife states patient was just discharged yesterday from a major hospital after being transferred there. He was at a community hopsital for a complaint of shortness of breath and they could not figure out why (r/o PE, pneumonia) sent to tertiary care for further testing adn they too could not find anything and assumed he was possible fluid overloaded secondary to his CRF. Discharged yesterday home. 


Wife reports last night patient became increasingly confused, was getting out of bed and just standing up without reason. Altered mental status became worse prompting a call to 911. On our arrival patient is alert and oriented x 3, sitting on the edge of a bed with slight increase in work of breathing and an isolated complaint of s.o.b. Eyes were noted to be deviated up.  He denied pain or discomfort and was pale, warm, and dry.  FD unable to get a saturation prior to putting him on a NRM.  Lung sounds were clear and equal bilaterally with good air movement slight crackles heard in the bases.  Radial pulses were weak, but patient had shunts in both arms (one working and an old one).   

VS in the house:  112/80 
                        HR high 80s
                         RR 24-26
                         Sat: unable to obtain, pt on a NRM


Paitent was extricated and on entering the truck patinet became more confused and has a significant increase in his work of breathing.  Lung sounds now absent bilaterally.  Paitent using accessory muscle and druing transport patient became restless and uncooperative.  He stated multiple times "I cannot breath, help me" and was pulling off the NRM. In my state we do not have RSI and cannot even sedate to facilitate intubation. 

Vitals:  90/p HR in the 90s sinus, no ectopy.  RR 32-36 . Lowest oxygen sat was 93% on NRM; however he would not keep the probe  on towards the end of transport. Unable to obtain 12 lead because of combativeness.  Patient now a bit mottled.  No longer following commands.   

Just as we were about to pull into the hospital driveway  patient became non-verbal and then becamse unresponsive with some non-purposeful flexion in his upper extremiteis with strong stimuli.  No seizure activity present, he moaned once wtih the painful stimuli as well.  Resps became more gasping so I opted to attempt oral intubation even though he was semi conscious.  

Bagged him with a BVM and then got the tube on the first attempt, he was an easy airway.  No gag reflex; however once we started bagging him he began fighting us alittle bit, but thankfully we were at the hospital so they could sedate him as soon as we hit the room, which they did.  

The doctor seemed a little confused as to why we tubed him, although I explained the whole senerio to him which he was half listening to.  I have no doubt that this guy needed a tube though. 

Would you have tubed this guy without being able to sedate him? Would you have tubed this guy at all?  

What do you think about his lung sounds and such a significant change over a 5 minute period?

 I hesitated on giving him albuterol because I was worried that he may have filled up with CHF when he put those legs up and may have had severe bronchospasm from that.  I hesitated to treat him for CHF thoughbecause of his BP and the fact that his lungs were so dim I couldn't here sh*t.   He had no hx of COPD or asthma that the wife stated.  No inhalers.   I was also wondering if there was a neuro component to this since the AMS started last night with no reports of s.o.b. and as stated previosly his eyes deviated upward which I have never seen before.  Or was he in a metabolic acidosis that was causing the tachypnea and AMS...  He was a mystery.

Post intubation ETCO2 was 69, which leads me to believe that this indeed may have been resp failure, but I am wondering if there was more to him.  He had no "shark fin" on his end tidal wave for though for someone with barely any air movement at all.  No frothy pink fluid up the tube either.  

Any ideas?

Happy


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## MrBrown (Dec 19, 2010)

Sounds neurological to Brown and Mrs Brown agrees.

Need to get him into the magic head lookeyat thingamadongle with much of the expediciousness.

Brown would not bother calling for an RSI qualified Intensive Care Paramedic or Doctor .... take him to the hospital


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## Mobey (Dec 19, 2010)

Sounds like some lung pathology for sure.

Are you sure the air entry sounds were indeed clear and not just absent? Not trying to judge you, just saying that sometimes airways get so tight you literally can't hear anything (often called Silent chest).
In a high stress situation, clear can be confused for quiet/absent.

If the EtC02 was that high, there is no way this is neuro, he was hypercapnic so there was indeed poor gas exchange.

PE is still a good differential.
but I would go with CHF causing some "cardiac asthma" presenting with a silent chest.

Tube was a good idea.... Hey the EtC02 was 69!

I probably would have RSI'd him once he went unCx. 

I realize your rationalle for not using Ventolin, I however am not quite sold on the B1 effects causing a huge CHF event if used in moderation. I probably would have tried a small dose just to see if the air entry sounds change. 

Sounds like you did a good job!


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## Sam Adams (Dec 19, 2010)

I've seen the Lung Sound problem a couple of times. You extricate the patient, jostle them around a bit, they're nervous, and they flash ....

You didn't mention it ... did you check his blood glucose level?


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## Hellsbells (Dec 20, 2010)

There is no doubt that this guy needed a tube. However, if it were me and i was nearly at the hosp, with no sedation, id have held off on tubing him, so long as I was able to ventiate with a BVM. My worry would be the risk of stimulating the gag reflex on a semi concsious pt and having him aspirate. Additionally, you say he was fighting the tube after you intubated him, the increased physical stress can't be good for his respiratory distress. BP, or Heart. 

However, its easy for me to second guess you, as I wasnt there and it sounds likea tough case. Its insane that you don't have RSI. Good job for getting the tube in a timely manner. 

Any idea how this case turned out. Did you ever get any follow up?


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## reaper (Dec 20, 2010)

You did fine with him. 

If you were pulling into hospital< i may have tried to ventilate him till he could be sedated. But, there was nothing wrong with tubing him.

I have to agree with Brown. I was thinking Neuro from the start. Possible slow bleed, with shifting pressures.


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## HappyParamedicRN (Dec 20, 2010)

Sam Adams said:


> I've seen the Lung Sound problem a couple of times. You extricate the patient, jostle them around a bit, they're nervous, and they flash ....
> 
> You didn't mention it ... did you check his blood glucose level?




oops sorry... cbs 198

I thought about just letting the er tube him, but i also thought about possibly filling his stomache with air resulting in an airway full of vomit from bagging him with a mask.. I slowly put the blade in to check for a gag reflex, which he had none, he didnt even gag as i was passing the tube.  He looked like he was about to code with his gasping breaths and with my above reasoning i decided to throw the tube down as we were pulling in the driveway.

around here the patient would have probably waited another 10minutes for a tube while we got him on the bed, on their monitor, drugs ready, doctor in the room... i didnt feel like he had that long.


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## CodyHolt83 (Dec 20, 2010)

I was going to say CPAP but then I read on....I'll bow out gracefully now.  lol


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## Sam Adams (Dec 20, 2010)

Sorry, a couple more ?'s

How did his last dialysis tx go? Any complications?
How much fluid did they take off? Was it the normal amount? More? Less?


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## Firemedic515 (Dec 22, 2010)

Sounds like he needed the tube. My gut says this was a metabolic issue.


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## HappyParamedicRN (Dec 22, 2010)

Thanks everyone for your input..

As far as i know his dialysis treatment the day before was fine.  I have no idea about how much they took off or whether itt was his norm.

I have written to the ER nurse manager requesting info, but with HIPPA not sure i will get it and this hospital isnt an EMS friendly place!  


Happy


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## HappyParamedicRN (Dec 29, 2010)

Well the only update was able to get was that the patient had a dx of CHF, non-STEMI, and pneumonia!  

Not sure how he ended up doing!

Thank you all for your input.

Happy


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## MediMike (Jan 1, 2011)

Hmmm...Anytime I see a combative/agitated dialysis pt. I always wonder about a metabolic acidosis.  I fully support you going for the tube, respiratory failure imminent if not already present and lookin' like he was headin towards the light haha


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## Outbac1 (Jan 1, 2011)

Well as I was reading the thread I was thinking a flash pulmonary edema. Sometimes when listening to lung sounds we hear equal air entry that may be clear but we don't listen close enough to the volume of air entry. The key here to me is that you heard some crackles in the bases. If there is enough fluid in the bases to cause crackles there is probably fluid throughout causing decreased air entry everywhere. The sudden loss of air entry,(post movement), I take as a big hint that there is an obstruction to ventilation in the lungs.
 It would be interesting to know what meds they were on. I'm guessing a beta blocker and a diuretic. Do you know if the pt still had some kidney function? Was there any extremity edema? The edema doesn't have to be huge and pitting. 
 I believe I would have gone down the CHF route. The pts recent and long term hx supports this. Nitro and CPAP and possibly lasix. For now I'll chalk up the altered status to hypoxia.
 In the situation you found yourself without CPAP, you didn't have much choice but to intubate. 
  I can't RSI here but at least I have Diazepam and Midazolm to keep them from fighting the tube.


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## sihi (Mar 26, 2011)

Sat 93% is not so dramatic, it can by psychical probl.

Thanks hyperventilation his PaCO2 might became low - maybe this was a cause.
As I understand there wasnt episode of apnoe? Maybe unvisible convulsions?

I would intbate him if Sat would fall <90%


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## Farmer2DO (Mar 27, 2011)

I completely agree with your decision to intubate.  I would consider a metabolic disorder, including sepsis, high on my list, but neuro is still a possibility.  How about liver?  We know that he's had 2 major organs fail, who's to say he wasn't encephalopathic?  It could certainly contribute to the CHF.....

Nice job though.


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## HappyParamedicRN (Mar 27, 2011)

sihi said:


> Sat 93% is not so dramatic, it can by psychical probl.
> 
> Thanks hyperventilation his PaCO2 might became low - maybe this was a cause.
> As I understand there wasnt episode of apnoe? Maybe unvisible convulsions?
> ...




Have you ever heard the term treat teh PATIENT AND NOT THE MONITOR!  His sats were 93% ON A NON-REBREATHER and he became unresponsive with gasping respirations from respiratory failure. I am going to repeat myself TREAT THE PATIENT AND NOT THE OXYGEN SATURATION MACHINE!!! and his end tidal CO2 was in the 70s!!

Happy


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## sihi (Mar 28, 2011)

HappyParamedicRN said:


> Have you ever heard the term treat teh PATIENT AND NOT THE MONITOR!  His sats were 93% ON A NON-REBREATHER and he became unresponsive with gasping respirations from respiratory failure. I am going to repeat myself TREAT THE PATIENT AND NOT THE OXYGEN SATURATION MACHINE!!! and his end tidal CO2 was in the 70s!!
> 
> Happy



Sorry for my bad english (I understood that episode of hypoventilation appeared there).

 So high CO2 (in hyperventilation background) shows that it were metabolic problem.
Intubation end mechanical ventilation -- probably you would ventilate in "normal" frequency 10-12 breaths/min. -- I think it would increase cumulation of CO2. Hyperventilation tried to compensate metabolic acidosis. 

From humanity point this patiend should be sedated and intubated -- normooxemia and intravenous Na Bicarbonate must be ensured. 

Do you have capnometry in ambulance or it was EM department's indicator?

ps. machines help you understand what is happening inside patient.


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## usafmedic45 (Mar 28, 2011)

> If the EtC02 was that high, there is no way this is neuro, he was hypercapnic so there was indeed poor gas exchange.



You do realize that if you have an intracranial process affecting the respiratory centers, you can wind up with a high PCO2?  Not saying it was neuro....but just saying don't rule things out based on tests that don't rule them out.



> What do you think about his lung sounds and such a significant change over a 5 minute period?



Likely due to a change in position.  



> So high CO2 (in hyperventilation background)



Chances are good- given the CO2 and the clinical picture- that while he was breathing fast, he was moving only very low volumes with each breath so he was in fact, _hypoventilating_.   Most EMS providers think that simply having a fast rate = hyperventilation when it's the increase in minute ventilation that defines it.  You could be breathing 10 times a minute with a huge volume and be hyperventilating. 



> and his end tidal CO2 was in the 70s!!


Hey, don't get crappy.....Europeans don't use mmHg (torr) for their blood gas measurements normally.  He probably doesn't know what normal is in those units.  



> intravenous Na Bicarbonate must be ensured.


Depends on if there is really an indication for it.  His ETCO2/PaCO2 being elevated (and therefore his being acidotic) is not one.  In fact, giving bicarbonate in that situation would possibly be a bad idea.  The fix for acidosis due to respiratory failure is to ventilate the patient to "blow off" the CO2.


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## Farmer2DO (Mar 28, 2011)

HappyParamedicRN said:


> Have you ever heard the term treat teh PATIENT AND NOT THE MONITOR!  His sats were 93% ON A NON-REBREATHER and he became unresponsive with gasping respirations from respiratory failure. I am going to repeat myself TREAT THE PATIENT AND NOT THE OXYGEN SATURATION MACHINE!!! and his end tidal CO2 was in the 70s!!
> 
> Happy



Can I just say that your posts come off as really self-righteous and rather obnoxious?  Replying in all caps signifies yelling, and it appears that you are scolding a petulant 6 year old.  Again, if you don't want to reply in a polite, professional manner, why ask at all?


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## usalsfyre (Mar 28, 2011)

My only thought is why wasn't NTG at least tried, esp given the hx of CHF and CRF, crackles in the bases, mottling and air hunger. When you had the status change after movement I would have been throwing NTG at this guy. High dose NTG can VERY often save a tube/bridge to BiPAP. Just by chance, was he dangling his legs off something on arrival?

I don't disagree with the tube when you did it, but I think suboptimal management earlier in the call led to that point.


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## Darrell (Mar 31, 2011)

I'm going to assume he's alive. Because of you.

You did your job to the best of your ability at that moment in time.


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## usafmedic45 (Mar 31, 2011)

Darrell said:


> I'm going to assume he's alive. Because of you.



That seems to be the gist of most of her posts.


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## firetender (Apr 1, 2011)

*Please file under...*



usafmedic45 said:


> That seems to be the gist of most of her posts.



...non-productive comment setting up future conflict.


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## usafmedic45 (Apr 1, 2011)

firetender said:


> ...non-productive comment setting up future conflict.


I really don't want to have conflict with her.   It's a lot like beating my head against a brick wall: nothing meaningful is accomplished and it leaves me with a headache.


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## AZnativeOne (Apr 1, 2011)

I would have sedated and intubated the pt.


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## sihi (Apr 14, 2011)

usafmedic45 said:


> Depends on if there is really an indication for it.  His ETCO2/PaCO2 being elevated (and therefore his being acidotic) is not one.  In fact, giving bicarbonate in that situation would possibly be a bad idea.  The fix for acidosis due to respiratory failure is to ventilate the patient to "blow off" the CO2.



I said normooxemia + bicarbonate.  Ofcourse NaBic without adequate ventilation would worse condition. Patiend must be intubated and mechanically ventilated.


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## Simusid (Apr 14, 2011)

usalsfyre said:


> Just by chance, was he dangling his legs off something on arrival?



I'm a stupid newbie basic.   Can you elaborate on this part for me?


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## Farmer2DO (Apr 15, 2011)

sihi said:


> Sat 93% is not so dramatic, it can by psychical probl.
> 
> Thanks hyperventilation his PaCO2 might became low - maybe this was a cause.
> As I understand there wasnt episode of apnoe? Maybe unvisible convulsions?
> ...





HappyParamedicRN said:


> Have you ever heard the term treat teh PATIENT AND NOT THE MONITOR!  His sats were 93% ON A NON-REBREATHER and he became unresponsive with gasping respirations from respiratory failure. I am going to repeat myself TREAT THE PATIENT AND NOT THE OXYGEN SATURATION MACHINE!!! and his end tidal CO2 was in the 70s!!
> 
> Happy





Farmer2DO said:


> Can I just say that your posts come off as really self-righteous and rather obnoxious?  Replying in all caps signifies yelling, and it appears that you are scolding a petulant 6 year old.  Again, if you don't want to reply in a polite, professional manner, why ask at all?





usafmedic45 said:


> That seems to be the gist of most of her posts.





firetender said:


> ...non-productive comment setting up future conflict.



Sorry, I have to agree with USAFMedic45 on this one. He's not the one who posted a scenario asking for input, then blasted someone (for who it appears English isn't even the first language, and probably uses different units than we do), responding to them like they were a child, and being the first one to actually start the non-productive comments. Perhaps an apology from her to Sihi would be appropriate? 

Just my thoughts. I don't think USAFMedic45 is the bad guy here.


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## firetender (Apr 15, 2011)

Farmer2DO said:


> Just my thoughts. I don't think USAFMedic45 is the bad guy here.



No such thing as "bad guy" here. It' simply a request for course correction.


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## MediMike (Apr 19, 2011)

usalsfyre said:


> my only thought is why wasn't ntg at least tried, esp given the hx of chf and crf, crackles in the bases, mottling and air hunger. When you had the status change after movement i would have been throwing ntg at this guy. High dose ntg can very often save a tube/bridge to bipap. Just by chance, was he dangling his legs off something on arrival?
> 
> I don't disagree with the tube when you did it, but i think suboptimal management earlier in the call led to that point.



(+1)


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## squrt29batt12 (May 30, 2011)

i think you did very well given the circumstances. tube was needed and if anything, the fact you tubed enabled you to give ppv and possibly push in some of that fluid from the bases


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## usalsfyre (May 30, 2011)

PPV does a very poor job of moving fluid out of the alveoli, without PEEP the minimal amount of fluid moved will simply flow back in when the positive pressure subsides. 

It's much better to reduce the hydrostatic pressure behind the fluid that's causing fluid to leak through the membranes in the first place.


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