# Heres one for you guys!



## Remeber343 (Nov 17, 2011)

You are D/T a SNF for a 76 Y/O female, C/C unconscious unresponsive is breathing.  Additional from dispatch is that the pt has HX of diabetes, pt's BGL is "Low" and the RN is currently giving Oral Glucose.  When arriving, Nurse states the PT was fine early today, when she came to check on her 30 mins ago, the pt would not answer her or respond. Rn states due to the low sugar, she started administering oral glucose to try and bump it up a bit. Pt has HX of low sugar, but has never been unresponsive during her stay and this wonderful SNF.  RN states pt is at this facility for failure to thrive.    

You arrive to find your PT Seated in the hospital bed, RN administering Oral Glucose.  Pts ABCs are intact, besides the fact their are globs of Glucose in her mouth that she is unable to clear due to the fact she is altered, AOx0/4, pt groans to painful stimuli. Skin: Pink Warm Dry HEENT: Pupils pinpoint, nonreactive to light.  Chest = Rise & Fall, Lung clear = Bilat.  All Extremities are intact, no signs of pedal edema.

Vitals:  140/68, HR 110, BGL "Lo", Temp 98.2, 96% spo2 on RA

Pt has meds for HTN, Chronic Px, and a few others for cholesterol and such.  Tell me how you'd go through this and your thoughts!


----------



## Nervegas (Nov 17, 2011)

Clear the Oral glucose from her airway and start a line, D50 titrated to pt arousal, if no response, look for other s/s and possible causes for the AMS. Transport to the ED for evaluation of possible new onset DM/Unk. AMS.


----------



## emt_irl (Nov 17, 2011)

get rid of the oral glucose and look in a disapproving fashion at the rn, 1g/1ml glucogon i.m(its all i could give for this), re asses bgl after 3-5 mins and transport. consider a basic airway if still not a&ox4. re check bgl on transport to hospital. 

i'd begin to think the low bgl isnt the main issue here. ecg show anything interesting?


----------



## Epi-do (Nov 17, 2011)

Let's do our own dex to find out if it really is "low", and then address the blood sugar issue accordingly.  (IV, D-50)  

What is her RR?  Depth?  Pattern?  Anything unusual about it?

Just, exactly, what meds is she on for her chronic pain?  

What is her typical demeanor?  Any history of hiding/hoarding pills?  What about depression?  Has she had any recent labs drawn?  If so, what were the results?


----------



## NomadicMedic (Nov 17, 2011)

IV. D50. Narcan. 

What are we missing here?


----------



## Handsome Robb (Nov 17, 2011)

I'm not sure how quick I'd be to give narcan on this one. There's no note of irregularities or inadequacy in her respiration. 96% on RA + good skin signs tell me she is perfusing well and *probably* isn't hypoxic which leads me away from an OD although we could have ended up catching it very early on. Even then I'd expect her to be bradycardic and hypotensive not the opposite. She has an Hx of HTN though so I can see that counteracting it the usual HypoTN you would expect. What's her normal BP? Also what med is she taking for it? There are many different meds used to treat HTN and they all act on different receptors....

Another thought, we all jumped straight to narcs for the chronic pain maybe the meds prescribed aren't opiod based? To the OP: Better med list please. If you didn't get one that's a problem, you picked her up from a medical facility that has a chart on her.

Obviously you treat the BGL first with D50 or Glucagon if you can't get a line


----------



## fast65 (Nov 17, 2011)

IV then some D50, if that solve things then we can look into other options.


Sent from my iPhone using Tapatalk


----------



## NomadicMedic (Nov 17, 2011)

Altered, pinpoint pupils? 0.4 of Narcan.


----------



## Handsome Robb (Nov 17, 2011)

Let's see a med list. Chronic pain doesn't mean narcotic medications. I'm not disagreeing but I want more info first. Also, like I said, tachycardic and hypertensive vs bradycardic and hypotensive but she does have an hx of HTN.

Also has she been sick? Bed sores? Failure to thrive could mean non ambulatory and that could cause bed sores which could cause sepsis. If she's non-ambulatory she very well could have a foley, UTI leading to Urosepsis maybe? She's not hypotensive (has hx of HTN) or febrile but being older she may not have the immune response capabilities.


----------



## Joe (Nov 17, 2011)

the great thing about narcan is it wont (not suposed) to hurt if your not od. so based on what i have been told and my scope...  Remove the gobs of oral gulcose and give the "nurse" the look... consider npa/opa but you didnt give us respiration rates... give 0.4 NARCAN.. transport. thats all thats in my scope though. i cant even check bgl.

IF ALL ELSE FAILS   PUT SNACK SIZE SNICKERS UP RECTUM TO CORRECT LOW BLOOD SUGAR


----------



## Handsome Robb (Nov 17, 2011)

Wait so you can give Naloxone but you can't check a BGL? Wow. Smash pointed out in another thread that it really could hurt if it doesn't work and the pt requires intubation and sedation/analgesia post-intubation.


----------



## fast65 (Nov 17, 2011)

NVRob said:


> Wait so you can give Naloxone but you can't check a BGL?



Really? That makes me lol



Sent from my iPhone using Tapatalk


----------



## Remeber343 (Nov 17, 2011)

Sorry for the delayed reply guys, its been a crazy day.  This call happened probably a month ago, but i'll give it ago.  Next time i'll try to include more info on the OP, first time putting one of these up. I also kindly educated the RN on proper usage of Glucose 

RR: 12, Resps were fairly normal for her. Pt is usually able to walk with assistance, pt normally Ao3/3 and is usually able to communicate w/o any problems.  Pt was on Oxycodone, which the pts PCP just bumped the dose up.  No hx of pill hoarding, no recent trips to the hospital or draws done.  

No HX of recent illness, but then again, the RN was just back from her 3 days off and did not get a report from the previous RN (whats new about that....seems like they never communicate)  Negative on the Foley or bed sores.

You are able to establish an IV line, give an AMP of D50.  The pts sugar now reads from "Lo" to 230.  Pt now is able to open eyes and is able to look towards you w/eye when verbal stimuli.  Pt is still "not back to normal" states RN.  You then give .4 Narcan, slowely titrating it up.  After a few minutes the pt is able to move spontaneously, turns head towards you when you speak to her, pt is able to speak, but is more of "word salad".  Pt is still A&Ox0/3.  

On a earlier note i should have mention... This particular SNF, or USNF, is known to have OD pt from time to time...


----------



## Remeber343 (Nov 17, 2011)

And Joe - Narcan isnt totally harmless, as they said, it can cause issues with intubations.  But also, if you give it to some druggy, it can cause them to go in to withdraws and cause sz.  Rare, but if it is a long time drug user, and that stuff is in their system, it can cause some serious issues later on.  Thats why you normally only give enough just to relieve resp. depression.


----------



## truetiger (Nov 17, 2011)

What issues with intubation does narcan cause, I'm curious, never heard of this happening?


----------



## usalsfyre (Nov 17, 2011)

truetiger said:


> What issues with intubation does narcan cause, I'm curious, never heard of this happening?



Mainly them awakening and yanking the tube, cuff inflated and all, out of their gob....


----------



## Remeber343 (Nov 17, 2011)

Some agency's that use narcs for intubation sedation and post intubation management.  It can cause the RSI mess to be less effective. Some agency's don't use narcs for sedation so for them it's not really a problem. There's a thread about it if you want to look it up. Each person has their own take on it.


----------



## truetiger (Nov 17, 2011)

Makes sense, we use versed/etomidate and succs/vec so it wouldn't be an issue for us, hence it not coming to mind.


----------



## abckidsmom (Nov 17, 2011)

usalsfyre said:


> Mainly them awakening and yanking the tube, cuff inflated and all, out of their gob....



LOL, this is a problem?

I thought the eventual goal of all intubations was extubation?


----------



## usalsfyre (Nov 17, 2011)

abckidsmom said:


> LOL, this is a problem?
> 
> I thought the eventual goal of all intubations was extubation?



Traumatic extubation, not just for demented ICU patients anymore .


----------



## abckidsmom (Nov 17, 2011)

usalsfyre said:


> Traumatic extubation, not just for demented ICU patients anymore .



Back in the day, we had some guys go on a known narc OD, intubate the pt, and then put the narcan down the tube.  2 mg.

It was not pretty.  Not pretty at all.


----------



## Handsome Robb (Nov 17, 2011)

truetiger said:


> What issues with intubation does narcan cause, I'm curious, never heard of this happening?



Post intubation care ie sedation/analgesia.



			
				Rember343 said:
			
		

> Sorry for the delayed reply guys, its been a crazy day. This call happened probably a month ago, but i'll give it ago. Next time i'll try to include more info on the OP, first time putting one of these up. I also kindly educated the RN on proper usage of Glucose
> 
> RR: 12, Resps were fairly normal for her. Pt is usually able to walk with assistance, pt normally Ao3/3 and is usually able to communicate w/o any problems. Pt was on Oxycodone, which the pts PCP just bumped the dose up. No hx of pill hoarding, no recent trips to the hospital or draws done.
> 
> ...



See now I feel like an *** for semi-disagreeing with n7lxi since she had a positive response from the narcan...

Seems like your leading us towards an accidental opioid OD with the SNF's hx of ODs and the increased dose of Oxycodone along with a hypoglycemic episode. How much of a dose increase was it? are we talking a small change like 5/325s to 7.5/325s or doubling up the narcotic dose to a 10/325? 

But with the word salad after treatment I want a full neuro exam. I don't remember if you said it but I'd like a look at her rhythm on a 3/4 lead and possibly a 12-lead if I'm feeling frisky. I'll give the RN the benefit of the doubt with her being gone but if it's possible I'd like a gander at the chart from the past few days as well. After she woke is she complaining of anything? Weakness? Headache? When was this patient last seen normal? How are her pupils now? Hx of HTN and hyperlipidemia + "word salad" after waking makes me think a stroke is possible but I'm like 1 for 4 so far on this scenario so I wouldn't put a whole lot of money on my bet 

Sounds like this lady has more than one issue going on. Is she awake enough to give us a reliable Hx? Smoker? Hx of TIAs or CVAs? Has anything like this ever happened to her before? Is she med compliant? Is there a cause of the chronic pain such as surgeries? Is she obese or "nana sized"?

I like what you did with the UNSF statement :rofl:


----------



## Handsome Robb (Nov 17, 2011)

truetiger said:


> Makes sense, we use versed/etomidate and succs/vec so it wouldn't be an issue for us, hence it not coming to mind.



Where's the analgesia? I see a sedative(s) and a paralytic but no analgesic. I was under the impression analgesia was a standard of care when it comes to RSI/chemically assisted intubation/post intubation care. Our ground medics can't do RSI but flight here does versed or etomidate + fentanyl + succs or vec.

abckidsmom, someone really did that? I might be young and dumb, but not that dumb! :unsure: Some may disagree with the last statement h34r:


----------



## abckidsmom (Nov 17, 2011)

NVRob said:


> abckidsmom, someone really did that? I might be young and dumb, but not that dumb! :unsure: Some may disagree with the last statement h34r:



Not that dumb.

That happen back at the dawn of the new daylight after the dark ages of EMS.  It was really funny, in a "boy how stupid can you be" sorta way.


----------



## Dwindlin (Nov 17, 2011)

NVRob said:


> Where's the analgesia? I see a sedative(s) and a paralytic but no analgesic. I was under the impression analgesia was a standard of care when it comes to RSI/chemically assisted intubation/post intubation care. Our ground medics can't do RSI but flight here does versed or etomidate + fentanyl + succs or vec.



Not standard of care, but may be in the future as there are some studies showing improved outcomes with analgesia.


----------



## truetiger (Nov 17, 2011)

Versed/Etomidate works well for us. Used the protocol a few times already and have had no issues.


----------



## usalsfyre (Nov 17, 2011)

truetiger said:


> Versed/Etomidate works well for us. Used the protocol a few times already and have had no issues.



Not a good answer. It may appear to work fine but Versed has ZERO analgesic properties meaning your patient is still getting the physiologic affects of pain from your laryngoscopy and having a tube stuck between their cords. Remember that pain affects the hind brain as surely as it affects the more perceptive lobes, causing things like catecholamine dump, ect. They may appear fine, but most sedated and especially paralyzed patients do.

Please don't tell me your routinely using long-term paralysis as well...


----------



## usalsfyre (Nov 17, 2011)

Dwindlin said:


> Not standard of care, but may be in the future as there are some studies showing improved outcomes with analgesia.


It IS the standard of care anywhere outside of ground EMS. You won't find CCT teams, HEMS, EDs, or anesthetist RSI'ing without analgesia on board.

Anyone who doesn't have opiates in their RSI protocol should be using the pain management protocol to treat them as well. And lobbying the hell out of their OMD.

I'll get off my soap box now.


----------



## Aidey (Nov 17, 2011)

Remeber343 said:


> if you give it to some druggy, it can cause them to go in to withdraws and cause sz.  Rare, but if it is a long time drug user, and that stuff is in their system, it can cause some serious issues later on.  Thats why you normally only give enough just to relieve resp. depression.



Cite your sources on the seizure bit.


----------



## usalsfyre (Nov 17, 2011)

A well acknowledged side affect of acute withdrawal is seizures, and naloxone has been known to cause acute withdraws.


----------



## Handsome Robb (Nov 18, 2011)

usalsfyre said:


> A well acknowledged side affect of acute withdrawal is seizures, and naloxone has been known to cause acute withdraws.



Seconded. I'll go looking for a reputable source since I know my paramedic text wont suffice here


----------



## Aidey (Nov 18, 2011)

Without completely diverting the thread my understanding (straight from a doc) is that the risk of seizures in opiate withdrawal decreases with age, assuming no underlying seizure disorder. So babies born addicted have a significant seizure risk, but adults do not. Even when heavy users are thrown into acute withdrawal by narcan. 

A search on pubmed for "opiate withdrawal seizures" comes back with 36 results, one of which is about seizures in adults, and the patient was a farking train wreck. A search for "narcan seizures" results in 395 results, and I'm yet to find one that is about narcan causing seizures. A bunch are actually about narcan helping stop seizures in patient's with tramadol induced seizures. 

I had a patient appear to develop seizures after narcan. We spoke with an ED doc about it, and he said in 20 years it was the second time he could remember hearing it happen. In the previous case the theory they developed was that the opiates were suppressing the seizure activity caused by severe hypoxia. That was the working theory in our case until we found out that our patient's tox screen came back negative, 4 times. After that it got chalked up to coincidence.


----------



## Remeber343 (Nov 18, 2011)

Aidey said:


> Cite your sources on the seizure bit.



as I said, it most commonly happens in chronic users/long term users.  I remember this tid bit out of our textbook, but here is one site i found within a min or two of searching the web:

http://www.opiates.com/opiate-withdrawal.html

And Rob, I'll get back to you in a bit, I have to run right now and didn't have time to type out the rest of the answers!


----------



## Aidey (Nov 18, 2011)

Sorry, but a page from a treatment center website is not an academic source.


----------



## Remeber343 (Nov 18, 2011)

I stated i did it very quickly, did i say it was academic?  It took me like a minute to even find that, and im sure finding an academic one wont be to terrible hard either, but im short on time right now and thats the best i can do for you at the moment.  Its going to have to work until im back at my computer and its easier to research things instead of on the phone.


----------



## Dwindlin (Nov 18, 2011)

I had the same results essentially as Aidey.  I was able to find one case report on PubMed but then in the discussion they remarked the etiology of the seizure was unclear.  

After a PubMed fail I checked out Tintinali's and Goldfranks, neither of which mention seizures in adult opioid withdrawal, naturally or narcan induced.


----------



## rmabrey (Nov 22, 2011)

Joe said:


> IF ALL ELSE FAILS   PUT SNACK SIZE SNICKERS UP RECTUM TO CORRECT LOW BLOOD SUGAR


Just move the globs or oral glucose to the rectum 



usalsfyre said:


> Not a good answer. It may appear to work fine but Versed has ZERO analgesic properties meaning your patient is still getting the physiologic affects of pain from your laryngoscopy and having a tube stuck between their cords. Remember that pain affects the hind brain as surely as it affects the more perceptive lobes, causing things like catecholamine dump, ect. They may appear fine, but most sedated and especially paralyzed patients do.
> 
> Please don't tell me your routinely using long-term paralysis as well...


Ours is the same as someone else state, versed, Etomidate, and Vec IF absolutely necessary. lack of Analgesia is why I cringe when medics brag about nasally tubing someone with our ET tubes..........yes we have a protocol for that:wacko:


----------



## Handsome Robb (Nov 22, 2011)

rmabrey said:


> Just move the globs or oral glucose to the rectum
> 
> 
> Ours is the same as someone else state, versed, Etomidate, and Vec IF absolutely necessary. lack of Analgesia is why I cringe when medics brag about nasally tubing someone with our ET tubes..........yes we have a protocol for that:wacko:



Our nasal intubation protocol does not include analgesia. However our post intubation sedation/analgesia protocol does include fent and midazolam. Retrograde amnesia is a wonderful thing


----------



## rmabrey (Nov 22, 2011)

NVRob said:


> Our nasal intubation protocol does not include analgesia.



DO you use ET tubes though?


----------



## jjesusfreak01 (Nov 26, 2011)

rmabrey said:


> DO you use ET tubes though?



Is there something else you can use? Serious question, enlighten me if there is. 

It is interesting to read about the physiological effects of pain. I would have thought Versed and a paralytic would be sufficient for RSI until reading that.


----------



## Handsome Robb (Nov 26, 2011)

rmabrey said:


> DO you use ET tubes though?



Yes. I'm with jjesusfreak01, what else is there to use?


----------



## medicsb (Nov 27, 2011)

usalsfyre said:


> It IS the standard of care anywhere outside of ground EMS. You won't find CCT teams, HEMS, EDs, or anesthetist RSI'ing without analgesia on board.
> 
> Anyone who doesn't have opiates in their RSI protocol should be using the pain management protocol to treat them as well. And lobbying the hell out of their OMD.
> 
> I'll get off my soap box now.



You have a lot of soap-boxing to do, because there are a lot of places, both EMS (ground- and aero-) and EM, not using opiates for RSI.    

This is probably something that is relatively local.  I've witnessed many RSIs in ORs and EDs, and, well, not too often are analgesics used as a pretreatment or for induction.  I went and checked an EM text (Rosen's) and an anesthesia text (Miller's) and though opiates are discussed, neither seems to mandate the use of an opiate for RSI.  In Miller's it is actually pretty clearly listed as "optional".  In Rosen's, it is recommended in certain instances (e.g. increased ICP or AMI).  So, I'm not too sure of the "standard of care" designation.


----------



## Dwindlin (Nov 27, 2011)

medicsb said:


> You have a lot of soap-boxing to do, because there are a lot of places, both EMS (ground- and aero-) and EM, not using opiates for RSI.
> 
> This is probably something that is relatively local.  I've witnessed many RSIs in ORs and EDs, and, well, not too often are analgesics used as a pretreatment or for induction.  I went and checked an EM text (Rosen's) and an anesthesia text (Miller's) and though opiates are discussed, neither seems to mandate the use of an opiate for RSI.  In Miller's it is actually pretty clearly listed as "optional".  In Rosen's, it is recommended in certain instances (e.g. increased ICP or AMI).  So, *I'm not too sure of the "standard of care" designation.*



The bolded is important.  "Standard of care" gets thrown around a lot.  Post induction analgesics are a good thing and likely improve outcomes (more good studies needed) but they are far from standard of care.


----------



## usalsfyre (Nov 27, 2011)

medicsb said:


> You have a lot of soap-boxing to do, because there are a lot of places, both EMS (ground- and aero-) and EM, not using opiates for RSI.
> 
> This is probably something that is relatively local.  I've witnessed many RSIs in ORs and EDs, and, well, not too often are analgesics used as a pretreatment or for induction.  I went and checked an EM text (Rosen's) and an anesthesia text (Miller's) and though opiates are discussed, neither seems to mandate the use of an opiate for RSI.  In Miller's it is actually pretty clearly listed as "optional".  In Rosen's, it is recommended in certain instances (e.g. increased ICP or AMI).  So, I'm not too sure of the "standard of care" designation.



Every major medical center RSI I've been around has included opiates pre and post induction. The benefits are well documented. As far as HEMS, I've yet to run across an organization that didn't include opiates in their RSI guidelines. Examples? 

Waveform capnography is still considered "optional" for EMS in many text as well, good luck using that defense. I agree standard of care is a legal term. But should a bad outcome result you'll find any number of people willing to hang you out to dry on it. I don't think you'll find too many who will state opiates were a bad idea.


----------



## jjesusfreak01 (Nov 27, 2011)

usalsfyre said:


> Waveform capnography is still considered "optional" for EMS in many text as well, good luck using that defense.



New monitors are expensive, as are stand-alone ETCO2 waveform displays. I think everyone will probably start using them when they can justify upgrading the monitors. That said, none of the ERs in my area have bedside access to ETCO2, and I don't think the docs use it for intubations. They have it in the anesthesia dept though, where the docs know how well it works.


----------



## medicsb (Nov 27, 2011)

usalsfyre said:


> Every major medical center RSI I've been around has included opiates pre and post induction. The benefits are well documented. As far as HEMS, I've yet to run across an organization that didn't include opiates in their RSI guidelines. Examples?




Every major medical center RSI I've been around has not always or even commonly used opiates for pre-induction.      

Lets not overstate the "benefits" of opiates.  The benefits are founded on surrogate outcomes and mostly on patients undergoing planned procedures (i.e. in the OR under non-emergent circumstances).  

I know of a flight program associated with a "top 10" medical center that uses opiates as part of its protocol, but for post-ETI management (i.e. not for pre-Tx or induction).  

While I can't offer any other specific examples, I thought this may give a better idea than some anecdotes:
Resuscitation. 2009 Jun;80(6):650-7. 
Emergency airway management in critically injured patients: a survey of U.S. aero-medical transport programs.

This included 89 aeromedical programs, and only about half used an opiate as part of RSI (about 80% used etomidate and versed, so who knows what is actually used in the typical RSI) and half for post ETI management.  I'm doubtful that much has changed since the survey was performed.



> Waveform capnography is still considered "optional" for EMS in many text as well, good luck using that defense. I agree standard of care is a legal term. But should a bad outcome result you'll find any number of people willing to hang you out to dry on it. I don't think you'll find too many who will state opiates were a bad idea.



My point is that this topic isn't as cut-and-dry as you and others try to make it.  I don't think there is anything to indicate an opiate as part of RSI is a standard of care (except maybe in post-ETI management) and probably not nearly as common as you state.  It might be more of a standard of care to not use an opiate and just use a sedative. (Not saying this is right thing to do... but, not saying it is the wrong thing, either.)  

The only thing that is cut-and-dry is that you need to sedate and then paralyze for RSI; what drug combination is used is up for debate and will probably never be conclusively decided upon.


----------

