# 45yo Male...Unconscious



## Fox800 (Oct 14, 2009)

Dispatched to a priority 1 unconscious party...MDC tells you that you have a 45 year old male, who was last seen awake yesterday.

Upon arrival, you are greeted at the door by an elderly woman who is the man's mother. She leads you to a back bedroom where you find a middle-aged man supine in bed, with his head slightly elevated on pillows. Respirations are snoring and you can see vomit around the mouth.

You and your partner are paramedics. You arrived on scene with four fire department first responders who are EMT-B's.

You direct fire to suction the vomitus, place an OPA (the patient accepts without difficulty) and begin BVM ventilation with 100% O2 at 15lpm.

The patient has a GCS of 3 and is unresponsive to any painful stimuli. You and your partner are unable to obtain peripheral IV access or EJ access after four attempts. The pt. has very poor veins and obvious signs of IV drug use/track marks. After 0.8mg naloxone IM, the pt. awakens to a GCS of 14 (E4, V4, M6). He is awake and will follow commands but is confused. Breath sounds are coarse, with rhonchi in all fields. You suspect aspiration of vomitus. SPO2 will not raise above 88% despite assisting the pt.'s respirations with a BVM.

BP: 140/90
HR: 140
RR: 10-14/min
SPO2: 88% w/BVM assist
BGL: 102
Temp: 98.6
ECG: Sinus tachycardia, no ectopy, normal PR and QRS width
SAMPLE: The pt. is confused and cannot/will not give you any information. His mother does not know anything about his medical history, either.

What's your next course of action?


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## firecoins (Oct 14, 2009)

load him on the stretcher and move to the hospital.


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## Fox800 (Oct 14, 2009)

Done. En route to the hospital, RR increases to 40-50 and SPO2 drops to between 65-75% with BVM ventilation. GCS remains the same. Fire is bagging for you. Now what?

I forgot to mention, you found an empty bottle of Amytriptylene on scene.


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## atropine (Oct 14, 2009)

keep bagging nothing else to do really, how far is the hospital?


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## MrBrown (Oct 14, 2009)

How's our transport time?

Drop an LMA and see if we can get an Advanced Paramedic skilled at rapid sequence intubation to locoate us significantly faster than we can arrive at the hospital


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## firecoins (Oct 14, 2009)

is the BVM attached to O2 by any chance?  

If he is still confused we might intubate.  Call for .3mg/kg of etomidate and tube.


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## Fox800 (Oct 14, 2009)

The hospital is about 10 minutes away code 3 (and yes, you are going code 3).

Your pt. will not accept an LMA. He is awake, responsive to verbal stimuli with a GCS of 14 (E4 M4 V6). He will not accept an OPA or NPA. When you "woke him up" with naloxone, he began to gag so (obviously) you pulled the OPA. Pt. vomits again a few minutes after that, while prepping for transport/getting him secured to the stretcher.

Yes, the BVM is attached to the O2  flowing at 15LPM off a giant tank.


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## atropine (Oct 14, 2009)

well then just bag and go easy enough.^_^


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## Fox800 (Oct 14, 2009)

Ok you're bagging and...the pt. isn't doing any better. Their SPO2 is in the 60's. Skin is pale/warm/moist so poor circulation shouldn't really be a factor.


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## atropine (Oct 14, 2009)

I got to be honest as long as he has a pulse and isn't turning blu and the hospital is within 10 minutes, I really wouln't do much more^_^


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## triemal04 (Oct 14, 2009)

Well because you screwed up from the get go and gave narcan instead of immediately intubating and transporting, now you get to RSI this pt.  Etomidate, sux and versed and most likely vecuronium as well.  Some suctioning post-intubation would be called for but probably won't have great results.

Oh...and that pesky TCA OD...probably want to go ahead and give 50mEq's of sodium bicarb.  You know...if you want to do this right.

As a sidenote, not everyone who OD's on opiates needs to be given narcan; it'll depend on how OD'd they are, and, more importantly, *HOW PATENT IS THEIR AIRWAY.*  If you check their lung sounds and hear rhonchi...especially with signs that they vomitted...maybe giving narcan is a bad idea.  Maybe it would be better to intubate them right then so that you can provide at least a little more effective form of ventilation.


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## Fox800 (Oct 14, 2009)

triemal04 said:


> Well because you screwed up from the get go and gave narcan instead of immediately intubating and transporting, now you get to RSI this pt.  Etomidate, sux and versed and most likely vecuronium as well.  Some suctioning post-intubation would be called for but probably won't have great results.
> 
> Oh...and that pesky TCA OD...probably want to go ahead and give 50mEq's of sodium bicarb.  You know...if you want to do this right.
> 
> As a sidenote, not everyone who OD's on opiates needs to be given narcan; it'll depend on how OD'd they are, and, more importantly, *HOW PATENT IS THEIR AIRWAY.*  If you check their lung sounds and hear rhonchi...especially with signs that they vomitted...maybe giving narcan is a bad idea.  Maybe it would be better to intubate them right then so that you can provide at least a little more effective form of ventilation.



Ouch. 

A little judgmental, eh?

We don't have RSI in our system. We do have nasotracheal intubation.

FYI just because an empty bottle of Amytriptylene was found doesnt = TCA OD. So...giving naloxone to a pt. with respiratory depression means we screwed up? Changed a pt. with snoring respirations and GCS 3 to an awake pt. with GCS 14 and an good intrinsic respiratory drive.

So let me follow your logic. Unconscious pt. + track marks + vomit + snoring respirations + GCS 3 = intubation before naloxone? We chose less invasive before more invasive.

Bicarb? Good thinking for a TCA OD and this was considered on scene. Do you think this pt. has signs of a TCA OD? He responded to naloxone. GCS improved 3 --> 14. Respirations 6 --> 14. The QRS is of a normal width. He is tachycardic but is not hypotensive. He was not treated for a TCA OD at the ER.

And I agree not every narcotic OD needs naloxone. If a pt. is altered or unconscious with a good respiratory effort and stable vitals, I am less inclined to administer naloxone. It is administered for respiratory depression, not specifically for mental status changes.

So you would intubate a suspected narcotic OD prior to administering naloxone? Congratulations, now you've probably changed the game from a pt. that would receive naloxone in the ED to one that will require an ICU stay.

This call was crappy, no way around it. RSI would have been ideal...but are you going to immediately RSI a patient with a GCS of 14 who follows commands, with an SPO2 of 88-90%? With a 10 minute transport time? The patient had aspirated, possibly hours prior, and that was the reason for his crappy sats and breathing.


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## triemal04 (Oct 14, 2009)

Fox800 said:


> Ouch.
> 
> A little judgmental, eh?
> 
> ...


Sorry, caught me on a bad day.

I missed the part about no change in the QRS width, but even with that...with a heartrate that high...I'd be leaning towards a TCA OD with the pill bottle present (be nice to know how many were missing for more info).  The tachycardia could be due to hypoxia, so it could potentially be worth briefly waiting after intubating (if you were able to increase his SpO2) to see if there was a change.  Withholding it or giving it could be seen as right or wrong I suppose, but I'd be leaning towards giving it.

As for being wrong to give narcan...well...you were.  You gave narcan to someone who has obvious signs of possible aspiration (low SpO2 with bagging, vomit at the mouth); did you check his lung sounds before or after the narcan?  If you couldn't raise his SpO2 with a BVM, what do you think would happen when he started breathing on his own?  He accepted an OPA so initially intubating should have presented little to no problem and would have allowed you much better treatement options.

Like I said, not everyone who OD's needs narcan, even if they have a decreased respiratory drive.  Look at the whole picture.


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## triemal04 (Oct 14, 2009)

Missed you edit.  So...what did happen in the ER?  How long before he was intubated?

And yes, *in the given situation* I would have intubated the pt and withheld narcan.  Why?  Because he aspirated!  If his lungs are full of vomit and you can't raise his sat's with a BVM, what do you think will happen post narcan?


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## Fox800 (Oct 14, 2009)

triemal04 said:


> Missed you edit.  So...what did happen in the ER?  How long before he was intubated?
> 
> And yes, *in the given situation* I would have intubated the pt and withheld narcan.  Why?  Because he aspirated!  If his lungs are full of vomit and you can't raise his sat's with a BVM, what do you think will happen post narcan?



Interestingly enough, he was started on CPAP in the ER. I didn't catch the whole story as this was at the end of the shift...so I don't know what happened next. He was treated for opiate OD + aspiration. And I agree with you, I would have given sodium bicarbonate 1mEq/kg if we could have established IV access. We were considering IO, but at that point our pt. had a GCS of 14, was awake and responsive to verbal stimuli, and had an SPO2 of 88-90% with BVM. I'm very hesitant to intubate a pt. prior to administering naloxone in an opiate OD, unless there are extraordinary circumstances. If we can save a pt. from being intubated --> ICU stay, shouldn't we try that? It seems to me that if it's a problem you can reasonably fix with naloxone, I'm going to try that.


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## triemal04 (Oct 14, 2009)

Fox800 said:


> Interestingly enough, he was started on CPAP in the ER. I didn't catch the whole story as this was at the end of the shift...so I don't know what happened next. He was treated for opiate OD + aspiration. And I agree with you, I would have given sodium bicarbonate 1mEq/kg if we could have established IV access. We were considering IO, but at that point our pt. had a GCS of 14, was awake and responsive to verbal stimuli, and had an SPO2 of 88-90% with BVM. I'm very hesitant to intubate a pt. prior to administering naloxone in an opiate OD, unless there are extraordinary circumstances. It seems to me that if it's a problem you can reasonably fix with naloxone, I'm going to try that.


I don't disagree with any of that.  Once he was awake if you had CPAP that wouldn't have been a bad idea either.  But if his sat's were dropping and respiratory rate was increasing...a trial run of CPAP while getting everything ready (assuming you can RSI) wouldn't be bad, but unless there was a big turn around...  Plus you lose the ability to do any suctioning.

I agree, most OD's, even the ones that need initial assistance breathing don't get intubated.  This would count as extraordinary circumstances though.  You can't just look at what's happening right then, but what will happen after you do something; in this case, with an OPA and BVM (and assuming good technique) you can't raise the pt's sats, due to the vomit in his lungs.  If he starts to breath on his own, the vomit is still there, and likely won't have any change in SpO2, and now you've got someone who's in respiratory distress and awake.  Tube him.  Especially if you are lacking RSI; what happens when his sat's start to drop like that?


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## triemal04 (Oct 14, 2009)

And for your edit:  He's aspirated...a pretty large amount it would seem.  Where do you think he's going once you get to the ER?


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## Fox800 (Oct 14, 2009)

triemal04 said:


> I don't disagree with any of that.  Once he was awake if you had CPAP that wouldn't have been a bad idea either.  But if his sat's were dropping and respiratory rate was increasing...a trial run of CPAP while getting everything ready (assuming you can RSI) wouldn't be bad, but unless there was a big turn around...  Plus you lose the ability to do any suctioning.
> 
> I agree, most OD's, even the ones that need initial assistance breathing don't get intubated.  This would count as extraordinary circumstances though.  You can't just look at what's happening right then, but what will happen after you do something; in this case, with an OPA and BVM (and assuming good technique) you can't raise the pt's sats, due to the vomit in his lungs.  If he starts to breath on his own, the vomit is still there, and likely won't have any change in SpO2, and now you've got someone who's in respiratory distress and awake.  Tube him.  Especially if you are lacking RSI; what happens when his sat's start to drop like that?



You're on the same track as me. Unfortunately CPAP per our protocols is not authorized for overdose/aspiration. We were not able to get a hold of an MD prior to arriving at the hospital. And yes I agree...aspiration equals ICU stay.


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## triemal04 (Oct 14, 2009)

Fox800 said:


> You're on the same track as me. Unfortunately CPAP per our protocols is not authorized for overdose/aspiration. We were not able to get a hold of an MD prior to arriving at the hospital. And yes I agree...aspiration equals ICU stay.


Well...uh...then why did you give him narcan?


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## Fox800 (Oct 14, 2009)

triemal04 said:


> Well...uh...then why did you give him narcan?



Because by reverse logic...prehospital endotracheal intubation isn't indicated just because we suspect the pt. may be going to the ICU...


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## Fox800 (Oct 14, 2009)

OK how about this.

Does suspected aspiration from OD overdose + questionable respiratory effort and SP02 = endotracheal intubation (not facilitated by medications) before administering naloxone?


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## triemal04 (Oct 14, 2009)

Fox800 said:


> Because by reverse logic...prehospital endotracheal intubation isn't indicated just because we suspect the pt. may be going to the ICU...


Ok, that's funny.  It is indicated in this situation due to the high likelihood of the airway still being compromised post-narcan though, has nothing to do with going to the ICU.  

Cheers.  :beerchug:


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## triemal04 (Oct 14, 2009)

Fox800 said:


> OK how about this.
> 
> Does suspected aspiration from OD overdose + questionable respiratory effort and SP02 = endotracheal intubation (not facilitated by medications) before administering naloxone?


Yes.  That's what I'm saying should have been done initially.  The pt has vomit around his mouth plus coarse rhonchi in his lungs, low SpO2 with the use of a BVM and OPA, and has OD'd on a narcotic; the "suspected aspiration" should be VERY strongly suspected.  He accepted an OPA; intubation shouldn't be very difficult, and, as I keep saying, if you can't raise his SpO2 while bagging him, do you really think it'll change when he breathes on his own?  In the given situation you don't need RSI; just tube him.


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## Fox800 (Oct 14, 2009)

triemal04 said:


> Ok, that's funny.  It is indicated in this situation due to the high likelihood of the airway still being compromised post-narcan though, has nothing to do with going to the ICU.
> 
> Cheers.  :beerchug:



Haha OK I MAY have been giving you a hard time.


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## Fox800 (Oct 14, 2009)

triemal04 said:


> Yes.  That's what I'm saying should have been done initially.  The pt has vomit around his mouth plus coarse rhonchi in his lungs, low SpO2 with the use of a BVM and OPA, and has OD'd on a narcotic; the "suspected aspiration" should be VERY strongly suspected.  He accepted an OPA; intubation shouldn't be very difficult, and, as I keep saying, if you can't raise his SpO2 while bagging him, do you really think it'll change when he breathes on his own?  In the given situation you don't need RSI; just tube him.



I understand this. However things were complicated by the fact that SPO2 initially rose after initiating BVM ventilations to around 90%. They did not decline until transporting...about 5 minutes out from the ER. Tough spot to be in.


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## triemal04 (Oct 14, 2009)

Fox800 said:


> I understand this. However things were complicated by the fact that SPO2 initially rose after initiating BVM ventilations to around 90%. They did not decline until transporting...about 5 minutes out from the ER. Tough spot to be in.


It is.  Again, you just need to be aware of not only what's happening, but what will happen in 5,10,15,20 minutes, and what will happen in 5,10,15,20 minutes if you do what you are about to do.  If the SpO2 only had that small an increase after several minutes of bagging (guessing, but if you tried 4 IV's...) it's a good sign something is wrong.  If there is rhonchi and signs of vomit it's an even better sign.

Take it as a learning experience; bet the same thing won't ever happen again, will it.


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## Fox800 (Oct 15, 2009)

I'm interested to hear what others may suggest as well. We have one vote for bag them to the hospital, and one for intubate prior to trying naloxone.


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## Aidey (Oct 15, 2009)

If the pt responds to narcan, and has a good respiratory drive and can protect his airway, what is intubation after the fact going to help in the short run? The pt has already aspirated, the ship has sailed. Agressive bagging or CPAP runs the risk of pushing the particulate even further into his lungs. If the pt is stable, or stable enough to get to the hospital I would not be that aggressive with them because there is a good chance I'm going to make the pt worse in the long run by being that aggressive. 

If I brought an opiate OD RSIed into the ED without first attempting narcan my MD would have my head on a plate. Heck, if I bring in any stable but unresponsive pt RSIed without first trying narcan I would be toast. It's one thing if the pt is crashing and you have to intubate right off to stabilize. It's another to RSI a fairly stable pt first and ask questions later. 

This guy had lower O2 sats, and was tachy, but he wasn't crashing. There aren't repeat vitals, but I wouldn't be surprised if his pulse dropped at least some when his O2 sats came up. 

Aspiration doesn't mean he is going to end up on a tube and vent either. Yeah, he bought himself an ICU stay, but that doesn't mean he is going to need to be intubated.


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## MrBrown (Oct 15, 2009)

Now that I have thought about it some more; I wouldn't use naloxone.

I would argue it's better to keep this guy down and drop in an LMA, breathe for him and take him to the hospital.

To wake him up with naloxone and have to drop him again to reintubate him seems a bit foolish.


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## Aidey (Oct 15, 2009)

Why is it better for him to be out?


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## Smash (Oct 16, 2009)

Polypharmacy overdose, poor SpO2 despite 100% O2, aspirated, tolerating OPA. 

This patient needs to have a number of problems dealt with, and narcan is not going to fix them all. It may not fix any of them given that there is strong suspicion of the pt having had other drugs. 

It is unlikely that the patient will need RSI, however I would certainly be prepared for it before I attempted to intubate. 

Narcan being given for any unconscious patient irrespective of what is wrong with them just makes we want to cry. Given the history and presentation of the patient it seems reasonably apparent that even if he wakes up we are not going to fix all the problems, and having narcan on board can potentially complicate the course of treatment.


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## Aidey (Oct 16, 2009)

Where is the polypharmacy? There is no evidence that he actually took the Amnitriptyline and the pt responded well to Narcan. It is one thing to intubate after trying narcan and not having any reaction. It is another to just automatically intubate (I'm talking in a stable, or mostly stable patient here). 

I'm not advocating narcan first in every unconscious patient. I'm saying that in stable patients, it is better to try narcan first, rather than intubate, which has a lot more complications than narcan administration. 

From the information given the pt has 3 problems. 1. A mental illness (amnitriptyline RX) 2. Chronic IV drug use. 3. Acute aspiration second to ALOC. What problem is the narcan going to aggravate? The aspiration isn't going to change whether the pt is breathing on his own or we are breathing for him. The only complication I see is that he may not be as cooperative as he was while knocked out. 

What benefit is intubation going to have for this patient?


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## Akulahawk (Oct 16, 2009)

Hmm. Patient accepts an OPA, has vomited, likely aspirated... and isn't getting all that good of an increase in SpO2 with bagging? While normally giving naloxone to an OD patient might be a good idea, to me, I'd rather intubate him and forego the naloxone to better protect his airway. If he's vomited and aspirated once, what's to say he won't vomit and aspirate more? If he hadn't vomited and aspirated, I'd consider sticking with BLS airway management until the naloxone took effect.


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## Fox800 (Oct 16, 2009)

Let me clarify the pt.'s response to treatments.

Initial SPO2 on arrival was around 85%. With a BVM, it rose to 95+%. This rise from 85% to 95% happened in a normal/respectable time interval, maybe 2-2.5 minutes. 

Naloxone administered IM. Pt. awakens to GCS 14. By this time, about ten minutes had elapsed between initial airway management, IV attempts, blood glucose measurement, 12-lead acquisition, naloxone administration, positioning the stretcher, etc. Pt. moved to stretcher, SPO2 drops to ~90%. 

Transport code 3. En route, SPO2 declines to 65-75% despite assisting ventilations. Pt. remains awake and responsive to verbal stimuli, he is able to follow commands.

I'm on the same page as Aidey. If I intubate a suspected/possible opiate overdose with signs of respiratory depression without trying naloxone, the ER physician and my medical director are going to have my a@$.


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## Fox800 (Oct 16, 2009)

Smash said:


> Polypharmacy overdose, poor SpO2 despite 100% O2, aspirated, tolerating OPA.
> 
> This patient needs to have a number of problems dealt with, and narcan is not going to fix them all. It may not fix any of them given that there is strong suspicion of the pt having had other drugs.
> 
> ...



Naloxone was certainly indicated and reasonable in this circumstance. You have a pt. with a history of IV drug use (probably heroin/opiates), who is unconscious with profound respiratory depression. I don't believe in "coma cocktails" and don't give naloxone to unconscious patients with adequate respiratory drives.

I don't think anyone here expects naloxone to fix "all of the patient's problems" but it would reasonably help to resolve immediate life threats of 1. Bradypnea, 2. Poor tidal volume, 3. Airway compromise secondary to unconsciousness


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## Aidey (Oct 16, 2009)

One question, why were ventilations still being assisted? 

If a patient reacts well to narcan, and has a GCS of 14, how is intubation going to protect their airway any better than they can? That is what I'm not getting here. 

Sure the pt can still vomit, but people vomit all the time. I don't RSI all of them just for that.

This topic is a hot button for my MD. His feelings on it are that on one hand you are treating the problem and reducing or eliminating the risk of complications while on the other you are performing a dangerous procedure that can cause multiple complications and isn't actually fixing anything, just providing marginal protection. 

That being said, he also hates people who slam all 2mg of Narcan at once. On the flip side he also says if your pt is crashing, tube them now before it gets harder later. I've RSIed two OD patients while under his direction. In both cases we somehow managed to administer narcan before intubation without delaying the intubation. We used an MAD while getting everything ready.


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## Fox800 (Oct 16, 2009)

MrBrown said:


> Now that I have thought about it some more; I wouldn't use naloxone.
> 
> I would argue it's better to keep this guy down and drop in an LMA, breathe for him and take him to the hospital.
> 
> To wake him up with naloxone and have to drop him again to reintubate him seems a bit foolish.





Aidey said:


> Why is it better for him to be out?



I'd also like to hear the reasoning for this. I'm not a big fan of placing a rescue airway device (Combi-Tube, King LTS-D, LMA) to compensate for a pt.'s unmaintained airway when we can administer a medication to potentially reverse that.


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## Fox800 (Oct 16, 2009)

Aidey said:


> One question, why were ventilations still being assisted?
> 
> If a patient reacts well to narcan, and has a GCS of 14, how is intubation going to protect their airway any better than they can? That is what I'm not getting here.
> 
> Sure the pt can still vomit, but people vomit all the time. I don't RSI all of them just for that.



Ventilations were assisted due to the fact that the pt. was still exhibiting altered mental status, had poor lung sounds, was responding to verbal stimuli (not "alert") and had  poor pulse oximetry and capnography values (SPO2 65-75% and ETCO2 55-65mmHg).


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## Aidey (Oct 16, 2009)

How well was he tolerating that? A GCS of 14 is awfully high to tolerate override bagging.


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## Fox800 (Oct 16, 2009)

Aidey said:


> How well was he tolerating that? A GCS of 14 is awfully high to tolerate override bagging.



He was able to be coached through it. Always a joy trying to bag conscious patients.


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## boingo (Oct 16, 2009)

Playing Monday morning quarterback, I would probably have intubated the patient as you presented him, unresponsive, coarse breath sounds w/copious emesis, hypoxic and hypercarbic.  The fact that you were able to oxygenate him to the mid 90's w/assisted ventilation is great, it will provide me with a bit more time to intubate.  I see opiate OD's on a daily basis and very rarely intubate them, however this patient seems like a good candidate.  Waking up someone with lungs full of crap is very likely going to turn to shyte quick.  Fighting a hypoxic patient all the way to the hospital is no fun, and is not helping the patient.  Secure the airway, deliver some PEEP and improve his oxygenation is what my probable course of action would be on this patient.  My $0.02.


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## MrBrown (Oct 16, 2009)

If your medical director has a problem with you not giving this patient naloxone then he needs to be taken out back and shot.

I think we are confusing the concepts of oxygenation and ventilation; this guy is obviously well ventilated but poorly oxygenated.  It's not about adequacy of the airway and how well we are providing ventilatory assistance but that his puke has made its way down in to the bronchioles and alveoli which is imparing gas exchange.

That is something we cannot fix alone in the back of a moving ambulance with very limited tools.  Having said that obviously we do have a role in providing a patent airway as best we can.

If we wake this guy up to a near normal GCS and he starts to crash again we're gonna have to do something; he is now going to be a hell of a lot more resistant to us placing an LMA or trying to bag him than if we didn't wake him up.  The only way for us to overcome that is to knock him out again which is really not something I want to have to contend with doing as it puts us deeper in a pile of shyte.

Agreed that if we don't wake him up his autonomic drive to protect his airway from any aspirated secretions is going to be slim to non existant but is that worth the problems we're going to encounter if we wake him up and then have to deal with an awake guy who is crashing and going to try and resist whatever we do to help him?

Ever tried to bag a conscious status asthmaticus patient who is crashing? They already feel like they can't get enough air in (as I bet this guy would too) so us placing a bag mask over thier face doesn't help .... I know, lets try and get this guy to comply with us shoving a laryngeal mask down his throat and inflating it; I can see that going over well.

This guy needs treatment we can't provide, so let's put away our flash toys and use good clinical judgement by taking him to the hospital.


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## denverfiremedic (Oct 16, 2009)

Maybe I'm missing something, but why are you using a BVM on this Pt. ? His RR is not really requiring that and as far as his spo2 level 88% is not great but it is not low enough to be a major concern at this point ? I'm I wrong?


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## denverfiremedic (Oct 16, 2009)

denverfiremedic said:


> Maybe I'm missing something, but why are you using a BVM on this Pt. ? His RR is not really requiring that and as far as his spo2 level 88% is not great but it is not low enough to be a major concern at this point ? I'm I wrong?


  Also if you are using a BVM his RR should be 12


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## taporsnap44 (Oct 16, 2009)

denverfiremedic said:


> Maybe I'm missing something, but why are you using a BVM on this Pt. ? His RR is not really requiring that and as far as his spo2 level 88% is not great but it is not low enough to be a major concern at this point ? I'm I wrong?



Respirations shoot up into the 40-50 range with oxygen sats dropping when moved to the stretcher.

Also looking at this as already knowing what happened, it seems there were two choices. Narcan and wake him up, have him vomit again and have respriations shoot way up and O2 sats drop. Now you have, im sure a very scared and paniced patient fighting to get more oxygen. Which this stress on top of what has already occured cannot be good on the patient.

Or you can intubate the patient and have his sats remain in the 80's which is much better than the 60's. Also with the tube in his airway is protected from anymore aspiration.


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## MrBrown (Oct 16, 2009)

denverfiremedic said:


> Maybe I'm missing something, but why are you using a BVM on this Pt. ? His RR is not really requiring that and as far as his spo2 level 88% is not great but it is not low enough to be a major concern at this point ? I'm I wrong?



Dude ... did you get your license out the crackerjacks?

Of course like anything we should not consider diagnostic indicators in silos and the larger clinical picture should be evaluated however in this case 88% SPO2 is rather hypoxic and would fit the clinical indicators that this patient is very poorly oxygenated.


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## denverfiremedic (Oct 16, 2009)

No I didn’t crazy enough!  .. but I have worked in areas that were 10,000 ft. + and 88% sop2 is actually quiet normal for someone not having the best day! and they were just fine. You clearly have not had a wide variety of experience if you call that severely hypoxic.. Further more I was asking a question " hints the ? marks.. take er easy big guy


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## Akulahawk (Oct 16, 2009)

denverfiremedic said:


> Maybe I'm missing something, but why are you using a BVM on this Pt. ? His RR is not really requiring that and as far as his spo2 level 88% is not great but it is not low enough to be a major concern at this point ? I'm I wrong?


Unless this patient normally has a lower SpO2, I get VERY concerned with a SpO2 of 88%... _especially_ if the patient is on O2! 


denverfiremedic said:


> Also if you are using a BVM his RR should be 12


When you're tracking a patient's breathing, you want to bring them down to a normal rate. That's between 12-20/min. Go any slower and the patient will likely start breathing on his own because you're going too slow...

I'm just guessing here, but once that patient was awake and able to protect their own airway, he probably would have done as well coaching him without the BVM... Oh, and he probably would have been RSI'd in the ED or in ICU... while they try to keep aspiration pneumonia from killing him. 

This is just one of those times that you can or should "buck" the normal OD protocol and intubate without giving naloxone. The guy was a GCS 3, no gag-reflex with indications of having aspirated some unknown quantity (but likely significant) of vomitus. I'd rather intubate, scoop & run with this guy. Can't get an IV? If you have IO available...

An 88% SpO2 at say 10,000+ feet would be good... at lower altitudes... not so much. Given the OP is in Texas, and residential area, I'm guessing, MUCH closer to sea level... I'd expect the SpO2 to max out somewhere in the mid 90's, if not >97/98% or better on >90% O2 concentration...


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## denverfiremedic (Oct 16, 2009)

I agree , 88% is not a good thing but I see 80's sop2 all day out here at 5,280ft and its not a huge thing, thats all I intended. Its normal for Colorado natives haha.. his RR was 10 - 14 right? that seems normal enough.


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## MrBrown (Oct 17, 2009)

denverfiremedic said:


> I agree , 88% is not a good thing but I see 80's sop2 all day out here at 5,280ft and its not a huge thing, thats all I intended. Its normal for Colorado natives haha.. his RR was 10 - 14 right? that seems normal enough.



Well you should be considering the larger clinical picture of this *specific* patient then and not relying on one-size-fits-all cookbook approach.

Interestingly enough I thought Denver Fire was a first response agency and that Denver Health provided ALS? I know Aurora (where I was) and some of the suburban Fire Departments around Denver have Paramedics.


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## denverfiremedic (Oct 17, 2009)

yea thats right , I actually work for both. I did consider the whole picture, I was just looking at the ABC's first and didnt really see why it was alarming.  %88 is hangin in there in my book.. thats all.. The rest is pretty strait forword,  LMA , Narcan and maintain VS and airway exc..


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## Dwindlin (Oct 17, 2009)

I actually disagree with those saying skip the Narcan.  Based on the inital assesment and management I think it was appropriate.  The trend is for the least invasive management posible.  99% of the time an ER is going to try everything else before intubation because all the data says mortality sky rockets (relatively) once they go on a vent.  My school uses a community model so on EM months I rotate through 6 different hospitals, and all of them likely would have tried CPAP/BiPAP with this guy first before RSI'ing him.  You jump the gun and tube him in the field that option is skipped and maybe thats all he would have needed.  

My only question, is did you try just a NRM after you woke him up?  Or did you simply keep bagging?  I find it odd he was oxygenating well with a GCS of 3 and BVM assistance, then suddenly drops once hes awake, and still being assisted.  Perhaps he wasn't as cooperative with the BVM as you thought?


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## Fox800 (Oct 17, 2009)

atkinsje said:


> I actually disagree with those saying skip the Narcan.  Based on the inital assesment and management I think it was appropriate.  The trend is for the least invasive management posible.  99% of the time an ER is going to try everything else before intubation because all the data says mortality sky rockets (relatively) once they go on a vent.  My school uses a community model so on EM months I rotate through 6 different hospitals, and all of them likely would have tried CPAP/BiPAP with this guy first before RSI'ing him.  You jump the gun and tube him in the field that option is skipped and maybe thats all he would have needed.
> 
> My only question, is did you try just a NRM after you woke him up?  Or did you simply keep bagging?  I find it odd he was oxygenating well with a GCS of 3 and BVM assistance, then suddenly drops once hes awake, and still being assisted.  Perhaps he wasn't as cooperative with the BVM as you thought?



CPAP was in our thoughts, unable to get ahold of medical control at the receiving hospital to get authorization (it's not authorized for overdoses). The physicians were busy with a critical patient are were in the middle of some procedure.

After the patient awakened to GCS 14, they were placed on a NRB at 15lpm as were moved to the stretcher and transported. The patient desaturated approximately half-way to the hospital and their ventilations were assisted once more with a BVM. Up until that point their SP02 was between 90-95% with a nonrebreather. The increase in RR and CO2 and decrease in SPO2 began while en route to the hospital. Vital signs at a low point were HR 40-50, SPO2 65%, ETCO2 55-60 mmHg.


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## Aidey (Oct 17, 2009)

Hmmm. So he was doing fine on the NRB. So what changed? A decline like that doesn't happen for no reason, there had to be something. Did the narcan wear off? O2 run out?


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## Crepitus (Oct 17, 2009)

Fox800 said:


> CPAP was in our thoughts, unable to get ahold of medical control at the receiving hospital to get authorization (it's not authorized for overdoses).



For everyone - Why would CPAP not be allowed in overdoses?  I thought it was indicated for any non-asthmatic case of inadequate ventilation?

After the pt was given Narcan then maybe they aren't an overdose anymore

Crepitus


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## Akulahawk (Oct 17, 2009)

Crepitus said:


> For everyone - Why would CPAP not be allowed in overdoses?  I thought it was indicated for any non-asthmatic case of inadequate ventilation?
> 
> After the pt was given Narcan then maybe they aren't an overdose anymore
> 
> Crepitus


CPAP is good and all... but it is of no help when the patient has an inadequate drive to breathe... like say... NO drive to breathe. 

Now if the patient just got woken up via naloxone... discovered there's crud in his lungs, and feels like he can't breathe, you think he's going to want to have the CPAP on?


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## Crepitus (Oct 18, 2009)

Akulahawk said:


> CPAP is good and all... but it is of no help when the patient has an inadequate drive to breathe... like say... NO drive to breathe.
> 
> Now if the patient just got woken up via naloxone... discovered there's crud in his lungs, and feels like he can't breathe, you think he's going to want to have the CPAP on?



Yep I get why CPAP won't work with a pt who's respiratory drive is absent.  I can see where CPAP could be a challenge with this particular pt.  (Of course I could see where bagging this particular pt could have been a treat as well).

I'm just trying to get more up to speed on CPAP as it was added to our scope while I was on hiatus.  I've seen/heard of protocols where CPAP is contraindicated in asthma's and COPD's.  (Seen some where it isn't as well for that matter).

What I'm curious about was the original comment that for drug overdoses across the board CPAP wasn't authorized.  Maybe it's not that CPAP wouldn't work, but rather than their medical director only specifically authorizes CPAP for a few conditions and those conditions alone.

Thanks for the response.   

For the OP, I can agree with the comments that waking the pt up isn't always the only option, but I also feel for how challenging the call can be.  I remember a pt almost 20 years ago that was similar, younger male (20-25 yo), OD'ed with aspiration, compromised airway, our guy was jaw clenched.  The charge medic 'forced' a supraglottic airway, (a PTL probably, I don't remember now), got bit in the process, then an attempt was made to wake the pt, who's LOC improved briefly and partially as his OD turned to be out both narcotic and non narcotic.  He thrashed like crazy, jerked out the airway, vomitted profusely, struck the charge paramedic and crumped all over again.  I believe he expired (the pt, not the charge medic) some months later after being discharged to a rehab unit.

In retrospect none of the choices on our scenario were well organized, but sometimes you are right on the wire and you make the choices that you make.


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## Akulahawk (Oct 18, 2009)

For sake of clarity, I'll respond in Red, inline. 


Crepitus said:


> Yep I get why CPAP won't work with a pt who's respiratory drive is absent.  I can see where CPAP could be a challenge with this particular pt.  (Of course I could see where bagging this particular pt could have been a treat as well).
> The problem with bagging this particular patient is that BVM use without any cricothyroid pressure is likely to cause gastric insufflation and he's going to vomit again... So, use the BVM while preparing to intubate, and leave him under. Most OD patients would probably do just fine with some BVM while you wait for the naloxone to work... This guy... probably better to just intubate, scoop and run.
> I'm just trying to get more up to speed on CPAP as it was added to our scope while I was on hiatus.  I've seen/heard of protocols where CPAP is contraindicated in asthma's and COPD's.  (Seen some where it isn't as well for that matter).
> The with the CPAP on those patients is that you just have to be aware of the patient's ventilatory status. COPD patients do a little "autoPEEP" on their own.
> ...


This is why Paramedics DO need the education to be able to think outside the box. My system has in the protocol that says that I have to give naloxone to OD patients... Now if I can articulate why I held the naloxone or provided careful titration of it, no trouble comes my way. 

I'm not exactly a garden variety cookbook medic...


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## emtfarva (Oct 18, 2009)

question? When his Sat's were in the 60's, he was warm and pink?

did you ever think that the SPO2 sensor was messed up? he had poor circulation, you said you tried 4 times to get an IV, and you still couldn't. I mean, you are bagging them, they are pink and warm, then maybe that the SPO2 was wrong.


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## MrBrown (Oct 18, 2009)

emtfarva said:


> question? When his Sat's were in the 60's, he was warm and pink?
> 
> did you ever think that the SPO2 sensor was messed up? he had poor circulation, you said you tried 4 times to get an IV, and you still couldn't. I mean, you are bagging them, they are pink and warm, then maybe that the SPO2 was wrong.



You consider SPO2 as part of the larger clinical picture, not in isolation however this clinical scenario fits with the SPO2 reading be as low as it was.

Some dude who is warm and pink with good ventilation and mentation who the SPO2 says 60% I'm going to go "yeah, right" but this guy I'd be inclinded to believe his SPO2 was in the 60s or 70s because it fists with his presentation.


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## Crepitus (Oct 19, 2009)

MrBrown said:


> fists with his presentation.



I hate it when the patient fists his presentation!


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## MrBrown (Oct 19, 2009)

Crepitus said:


> I hate it when the patient fists his presentation!



Oh yeah coz you know we don't do takedowns anything like they do on COPS ... quick blast of midazolam and whoops he's a slobbering mess on the floor is not anywhere near as exciting as some Sheriff Deputies fighting with some guy and tazering his ***


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## R.O.P. (Oct 20, 2009)

Just wanted to say this is a great thread.  Lots to think about- Thanks


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## RXMEDIC460 (Oct 20, 2009)

*bicarb*

you could give sodium bicarb as an antidote for the Amytriptylene and prepare to tube it the bicarb doesnt help.


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## MrBrown (Oct 21, 2009)

RXMEDIC460 said:


> you could give sodium bicarb as an antidote for the Amytriptylene and prepare to tube it the bicarb doesnt help.



Large doses of sodium can be used for TCA overdoses; I don't know about sodium bicarbonate as in sufficent doses it could cause alkalosis.

Personally I think the best thing would be to put away our drug bag and take this guy to the hospital.


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## Smash (Oct 21, 2009)

MrBrown said:


> Large doses of sodium can be used for TCA overdoses; I don't know about sodium bicarbonate as in sufficent doses it could cause alkalosis.
> 
> Personally I think the best thing would be to put away our drug bag and take this guy to the hospital.



Alkalosis is in fact exactly what we want to cause.  Tricyclic antidepresssants (TCAs) bind about 7 times more strongly to proteins in the myocardium than in plasma in a normal environment and the binding increases in acidic environments.  Alkalizing causes the binding to shift from the myocardium to plasma, whereby it can be metabolized and excreted.  If intubating a TCA OD I'll blow off CO2 to below normal levels to allow for the same thing.

There is a common idea that increasing the availability of sodium ions somehow overcomes the sodium channel blockade.  I'm not convinced of this: if the gate is shut, the gate is shut, in the same way that beta-blocker OD can't be overcome by administering beta-agonists but needs to have second messengers manipulated to cause inotropy and chronotropy from release of calcium from the sarcoplasmic reticulum.

However, despite the high likelihood of polypharm OD in this patient there are no obvious TCA specific signs, so I would question the use of NaHCO3.  I would still manage airway, oxygenation and ventilation with intubation as opposed to trying to wake him though.


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## Fox800 (Oct 23, 2009)

This thread has given me a lot to think about. Definitely learned a little.


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