# Unconscious 64 y/o



## LACoGurneyjockey (Dec 18, 2014)

Your ALS unit is dispatched priority 1 for an unconscious patient. You arrive to find a 64 year old female GCS of 3 in bed. Skins warm pale dry, agonal respirations at 4/min, family reports she was last seen normal 10-30 minutes ago. History of diabetes and A-Fib. Only meds are "some diabetes pills", and you do not have a reliable historian. You palpate a rapid, strong pulse.
For vitals: pulse is 170 and bounding, respirations are agonal at 4/min, skins pale warm dry, audible crackles, BP 196/120, pupils are fixed and non-reactive, BGL at 130.
12 lead attached (apologies in advance for the quality).

Your local community hospital is 10 minutes away and has thrombolytics but nothing more specialized. Your STEMI center is 70 minutes by either ground or air. Your trauma/STEMI/stroke center is 80-90 minutes by air.
What more info do you want, what going on with her, and where does she need to go?


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## Angel (Dec 18, 2014)

so much going on.
start with airway, intubate, get waveform ect.
does her mechanical pulse rate match the monitor? 
pupil reaction?
Falls, blood thinners?
her ECG is concerning but everything else screams clot leading to a stroke.
Has she gotten her meds today/as scheduled?
Is the STEMI center also a stroke center?


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## Aprz (Dec 18, 2014)

The highest on my differential would be an intracranial hemorrhage based on the sudden change in level of consciousness with a normal blood sugar, high blood pressure, fixed and non reactive pupils, irregular respirations / bradypnea, history of atrial fibrillation, and probably takes an anticoagulant like warfarin/coumadin.


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## Clare (Dec 18, 2014)

I really dislike shonky ECGs .... an ECG full of artefact or wander is useless and is poor practice.  Don't waste time acquiring one if it's not going to be of diagnostic quality with good capture.  Oh, and can people please stop acquiring a rhythm strip? If you think the patient has a problem that warrants a rhythm strip it's worth taking the extra 30 seconds to acquire a proper 12 lead ECG +/- R) sided +/- posterior.  A rhythm strip really is of no diagnostic value whatsoever.  It's almost saying like "oh I think the patient is hypoglycaemia, I don't know, I didn't do a blood sugar, I just looked at him and thought it might be hypoglycaemia". 

This lady is having a haemorrhagic stroke until proven otherwise.  A haemorrhagic stroke is much more likely to present with significant hypertension and altered level of consciousness as she has. 

She needs to go to a tertiary hospital by the fastest means possible as she has an immediately life threatening problem. 

If it is by helicopter then so be it, respond the helicopter. 

Airway is a priority in this patient, if she can be intubated without medicines so be it, but, if we can get an Officer skilled in RSI to her then even better.  

That's it really, I don't think she really needs much else to be honest.


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## Akulahawk (Dec 18, 2014)

I'm basically with Aprz here. This has the feel of an intracranial bleed, given that she's got a history of A-fib, she's probably on some kind of anticoagulant. She's going to need to get to a hospital that has neurosurgery and stroke care available. I don't think she's going to get any clot-busters... Absent something else going on, she's ultimately going to need a nicely decorated pine box... in the meantime she'll need to be intubated, one and perhaps two lines established, even if one's a saline lock, and get rolling. 

I'd say to take her to the local community hospital, get a head CT and put a helo on alert. Even if you fly the patient, there's going to be some transit time for the helo to come to you, so get her to a place where they can at least do some imaging, draw some labs and get her packaged for the flight to the tertiary center if necessary. This way the tertiary center has some idea what they'll be getting within 90 minutes... if she's salvable.


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## Clare (Dec 18, 2014)

Akulahawk said:


> I'd say to take her to the local community hospital, get a head CT and put a helo on alert. Even if you fly the patient, there's going to be some transit time for the helo to come to you, so get her to a place where they can at least do some imaging, draw some labs and get her packaged for the flight to the tertiary center if necessary. This way the tertiary center has some idea what they'll be getting within 90 minutes... if she's salvable.



Taking her to the local hospital will achieve nothing.  The patient should be taken to a place of definitive care first unless she has an immediately life threatening problem that cannot be fixed at the scene and deteriorating physiology such that she must have an intermediate stop for stabilsation.  For example, if nobody is available on scene who can intubate her then take her to the local hospital to be tubed, however, if the patient can be intubated on scene then there is no need to take her there.  Labs will not be helpful in the overall clinical picture as of right now. 

Helicopters take time, that is acknowledged.  However, how long are they going to take? 20 minutes? Let's say 20 minutes, that's not unreasonable.  It will be quicker to wait for the helicopter and take her straight to the tertiary hospital.  If the helicopter cannot land very close to the scene and the patient must be taken to the helicopter e.g. to the local park or something, you can go there while the helicopter is on the way.  It would be even better, and has been done locally, where you need the helicopter halfway or something like that if the patient is very sick. 

We must, absolutely must, wherever possible get out of the mindset of "a hospital is a hospital" and must start taking patients to the most appropriate hospital in the first instance, except in the small number of cases where the patient has an immediately life threatening problem that you cannot fix and they must be taken to an intermediate hospital to fix their A, B or C problem.  There are some clinicians who insist that patients are taken to their local hospital first, and sorry, but they are wrong.  The patient should be taken to the best place first and closest is not always best. 

I would not take this patient to a local hospital provided she can be intubated on the scene.


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## Aprz (Dec 18, 2014)

I don't think Akulahawk was saying take the patient to the local hospital because a hospital is a hospital.

If they have thrombolytics, they probably have a CT. It would kinda suck to transport the patient an hour or over just to find out that they weren't have a brain bleed. It would be even worse if the patient died during transport and it turned out they weren't having a brain bleed.

The local hospital can probably do RSI. With a 10 minute transport, I wouldn't attempt intubation unless I couldn't effectively bag-mask ventilate the patient using a BLS airway adjunct. After the patient is intubated, they'd probably use a ventilator to ventilate the patient rather than a bag valve mask, which would probably be better too.

The local hospital can probably treat the high blood pressure with something like cardene/nicardipine.

I think labs like getting the INR/PT would be useful to determine if the patient is actually on warfarin/coumadin. They might even have vitamin K and fresh frozen plasma to reverse it.

Since the hospital is so close to the patient, they might have the patient's records too, if the patient has gone there before.

I actually think it would be kinda cowboyish to transport the patient to the further facilities. I would personally transport to the local facility too. In the end, I do agree she does need to go to a facility with a neurosurgeon if she is having a brain bleed. Like Akulahawk said, they could prepare her for transport (start cardene and fresh frozen plasma infusion) while waiting for a helicopter. They'd transport the patient to the neurosurgeon having valuable information and somewhat treating her problem. The care she needs would be delayed, but not unreasonably. She would see a neurosurgeon sooner if you transport directly there without going to the local facility first, but you'd be taking a gamble, in my opinion.


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## EMT11KDL (Dec 18, 2014)

I am guessing with the flight time, the responding Helo is coming from that area, so response time for the crew to get to scene is going to be 60 minutes, that is just my guess, I do not know if the 70-90 minute time frame for air is the time from launch to scene, back to hospital or just flight time from scene to hospital, that will determine which option I go.  

I am also going down the road of ICP.

With the information that I have, Airway control-Intubate and sedation .  IV Access x 2, cleaner 12 lead if possible.  Wish we could get a better history on patient.  Depending on flight time to scene or hospital, I would probably go to the local hospital for CT Scan and Labs and fly from there.


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## EMT11KDL (Dec 18, 2014)

Clare said:


> Taking her to the local hospital will achieve nothing.  The patient should be taken to a place of definitive care first unless she has an immediately life threatening problem that cannot be fixed at the scene and deteriorating physiology such that she must have an intermediate stop for stabilsation.  For example, if nobody is available on scene who can intubate her then take her to the local hospital to be tubed, however, if the patient can be intubated on scene then there is no need to take her there.  Labs will not be helpful in the overall clinical picture as of right now.



I disagree with the Labs will not be helpful in the overall clinical picture as of right now.  I would love to know ABGs are on her, plus a full rainbow panel, I am going to need to know what the WHOLE clinical picture of this patient is, especially if I am going to be with this patient for 70-90 Minutes, and the Flight Crew also would like the information.  Certain Labs can change the treatment plan for this patient.  

She also does not meat criteria for thrombolytics at this time due to her blood pressure.  

Also not knowing the Flight Area, and what the elevation they will be flying at this can make things a little complicated for the Flight Crew due to pressure differences at altitude, plus the consideration of using Mannitol but contraindication is intracranial hemorrhage.  This is where a CT-Scan can be extremely helpful.


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## teedubbyaw (Dec 18, 2014)

Why is the 12 lead so craptastic if they're unconscious?


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## zzyzx (Dec 18, 2014)

If her pulse is in fact 170, then I would cardiovert. 
The AF may not convert, and it's obviously not the underlying cause of her unresponsiveness, but it's a problem that needs an attempt at correction.


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## teedubbyaw (Dec 18, 2014)

zzyzx said:


> If her pulse is in fact 170, then I would cardiovert.
> The AF may not convert, and it's obviously not the underlying cause of her unresponsiveness, but it's a problem that needs an attempt at correction.



I would work on correcting hypoxia first.


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## Akulahawk (Dec 18, 2014)

Clare said:


> Taking her to the local hospital will achieve nothing.  The patient should be taken to a place of definitive care first unless she has an immediately life threatening problem that cannot be fixed at the scene and deteriorating physiology such that she must have an intermediate stop for stabilsation.  For example, if nobody is available on scene who can intubate her then take her to the local hospital to be tubed, however, if the patient can be intubated on scene then there is no need to take her there.  Labs will not be helpful in the overall clinical picture as of right now.


You just said above that she's got a life threatening problem... and if it's a head bleed, you can't fix that on scene. Yes, airway management is a big priority, but imaging and labs will be more helpful to the helo crew and the tertiary facility. 


Clare said:


> Helicopters take time, that is acknowledged.  However, how long are they going to take? 20 minutes? Let's say 20 minutes, that's not unreasonable.  It will be quicker to wait for the helicopter and take her straight to the tertiary hospital.  If the helicopter cannot land very close to the scene and the patient must be taken to the helicopter e.g. to the local park or something, you can go there while the helicopter is on the way.  It would be even better, and has been done locally, where you need the helicopter halfway or something like that if the patient is very sick.


In this instance, you have a local facility that can do thrombotics, so they likely have a lab and a CT scanner on site. If the CT findings are negative for a head bleed, they should still be able to tell if she's herniating. If no bleed and increased ICP is the problem, that stop just for imaging could allow the flight crew to extend therapy from the tertiary facility to decrease ICP and get her to specialists quickly. This is a patient that easily could benefit from a pre-existing agreement with a tertiary center to basically be a helipad with imaging and labs...


Clare said:


> We must, absolutely must, wherever possible get out of the mindset of "a hospital is a hospital" and must start taking patients to the most appropriate hospital in the first instance, except in the small number of cases where the patient has an immediately life threatening problem that you cannot fix and they must be taken to an intermediate hospital to fix their A, B or C problem.  There are some clinicians who insist that patients are taken to their local hospital first, and sorry, but they are wrong.  The patient should be taken to the best place first and closest is not always best.
> 
> I would not take this patient to a local hospital provided she can be intubated on the scene.


You're right... hospitals are not equally good or capable. This patient doesn't need in-patient services. This one needs labs, CT scan, and possibly packaging for flight and a consult with the tertiary facility as to whether their services would be beneficial and the local facility may be able to initiate therapy based on tertiary facility recommendation. An emergent transfer where the patient stays < 30 min in the ED could be highly beneficial for a patient like this.


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## zzyzx (Dec 18, 2014)

teedubbyaw said:


> I would work on correcting hypoxia first.


Agreed.


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## Gurby (Dec 18, 2014)

Clare said:


> I would not take this patient to a local hospital provided she can be intubated on the scene.



I don't understand why this is your criteria?  If she can't be intubated, she can probably still be ventilated with LMA, or just good old fashioned BVM, no?  Are you that concerned about vomit/aspiration?


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## STXmedic (Dec 18, 2014)

Gurby said:


> I don't understand why this is your criteria?  If she can't be intubated, she can probably still be ventilated with LMA, or just good old fashioned BVM, no?  Are you that concerned about vomit/aspiration?


I wouldn't trust most providers to be able to effectively ventilate via BVM for a long transport.


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## DesertMedic66 (Dec 18, 2014)

Gurby said:


> I don't understand why this is your criteria?  If she can't be intubated, she can probably still be ventilated with LMA, or just good old fashioned BVM, no?  Are you that concerned about vomit/aspiration?


You really want to BVM (with a mask) for 70 minutes to the next closest facility? That's going to go south on you very fast


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## teedubbyaw (Dec 18, 2014)

DesertEMT66 said:


> You really want to BVM (with a mask) for 70 minutes to the next closest facility? That's going to go south on you very fast



it's all about dat c clamp grip strength, yo


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## Gurby (Dec 18, 2014)

Good point, I'll pass on BVM for 70 minutes.  What about an LMA or other BIAD though?  I guess we really don't want to have to depend on one of those for that long?


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## Carlos Danger (Dec 18, 2014)

LMA --> closest facility for sure.

Intubation, propofol gtt, art line, CT, INR, FFP, vitamin K, levetiracetam, and a long transport should be done on a real ventilator.


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## teedubbyaw (Dec 18, 2014)

Gurby said:


> Good point, I'll pass on BVM for 70 minutes.  What about an LMA or other BIAD though?  I guess we really don't want to have to depend on one of those for that long?



The two biggest factors are that they can't protect their airway, and that is an incredibly long transport time. Neither a king or LMA will truly protect the airway as well as an ET tube, and a hemorrhagic stroke pt will benefit from an advanced airway for a couple of reasons.


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## Carlos Danger (Dec 19, 2014)

Gurby said:


> Good point, I'll pass on BVM for 70 minutes.  What about an LMA or other BIAD though?  I guess we really don't want to have to depend on one of those for that long?



I would certainly avoid the use of an extraglottic airway for a long transport if at all possible, but for a short one I think they are highly appropriate.....probably even more appropriate than intubation in many cases. 

Vomiting and aspiration is a risk, of course, but is frankly a bit overblown in the prehospital world, IMHO. 

What frequently seems to be missing from discussions on the risk of aspiration when using an LMA or King is acknowledgement of the risks involved in prehospital intubation, which are not at all insignificant.


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## LACoGurneyjockey (Dec 19, 2014)

The patient was intubated and transported code 3 to the local hospital. CT showed a subarachnoid bleed, and later that night she was flown just under 200 miles to the nearest neurosurgery specialty facility. Could she have made it to the stroke center, probably. But they would have ultimately shipped her out to the same specialty center.


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## Angel (Dec 19, 2014)

darn, bleed from what?


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## LACoGurneyjockey (Dec 19, 2014)

Docs best guess was chronic untreated HTN...


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## NPO (Feb 25, 2015)

LACoGurneyjockey said:


> The patient was intubated and transported code 3 to the local hospital. CT showed a subarachnoid bleed, and later that night she was flown just under 200 miles to the nearest neurosurgery specialty facility. Could she have made it to the stroke center, probably. But they would have ultimately shipped her out to the same specialty center.


Knowing where you work/having familiarity with your protocols/area etc I would have called medivac for access to the higher level care facility and to get the CCT crew on scene. 

BUT.... That's easy for me to say now, after the fact.


EDIT: and I just realized this thread is old. Meh.


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## LACoGurneyjockey (Feb 25, 2015)

NPO said:


> Knowing where you work/having familiarity with your protocols/area etc I would have called medivac for access to the higher level care facility and to get the CCT crew on scene.
> 
> BUT.... That's easy for me to say now, after the fact.
> 
> ...



Only problem is medevac would have flown to the in county stroke center, who ultimately couldn't handle it and refused the transfer. That, and out where we are the airships flight time, scene time, and transport time is about the same if not slightly greater than our transport time to AV. Unless there's some reason we can't leave scene immediately (entrapment, off-road), we can go by ground quicker than by air.


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## Handsome Robb (Feb 27, 2015)

STXmedic said:


> I wouldn't trust most providers to be able to effectively ventilate via BVM for a long transport.


And that's why I love my ReVel. Originally we could only use it on CCT/SCT transfers but now vent cleared medics can use them for any patient. 

Screams bleed to me. Acute ALOC, hypertensive, risk factors...


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## BlueJayMedic (Feb 28, 2015)

In our area this patient would be managed with airway control and transport to local facility.  We do not have RSI. I would have started with our King LT and only intubated if airway was lost. I am not sure if I would waste time with cardioversion here, maybe a call to base hospital physician for consult on that. I feel as if the pulmonary edema is a rate problem and may benefit from the pressure and rate of proper vent illations. I am absolutely not driving by a building with a big H on it to go to another one with this patient. She is far too unstable for me to make the decision to risk her life to a tertiary care centre. This patient needed intervention, stabilization and transport by professional transport staff.  Personally I think you made the right decision here, interesting to see the different views on this one.


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## LACoGurneyjockey (Feb 28, 2015)

BlueJayMedic said:


> In our area this patient would be managed with airway control and transport to local facility.  We do not have RSI. I would have started with our King LT and only intubated if airway was lost. I am not sure if I would waste time with cardioversion here, maybe a call to base hospital physician for consult on that. I feel as if the pulmonary edema is a rate problem and may benefit from the pressure and rate of proper vent illations. I am absolutely not driving by a building with a big H on it to go to another one with this patient. She is far too unstable for me to make the decision to risk her life to a tertiary care centre. This patient needed intervention, stabilization and transport by professional transport staff.  Personally I think you made the right decision here, interesting to see the different views on this one.



I'm interested as to why the King tube? Here it's more of a last resort/rescue airway when ET fails, or if BLS arrives first by quite some time they can place one. But what advantage would you have in placing a king in this patient instead of an ET?


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## BlueJayMedic (Feb 28, 2015)

LACoGurneyjockey said:


> I'm interested as to why the King tube? Here it's more of a last resort/rescue airway when ET fails, or if BLS arrives first by quite some time they can place one. But what advantage would you have in placing a king in this patient instead of an ET?


10 minute transport time and less invasive, I think ETT has its place and I am glad its a skill I can use however if I can manage with a less invasive airway device I will. Personal preference really, I would just rather allow that to be done in the ED where they have more sterile equipment and more personnel to help with the procedure.  I guess this patient would have a higher chance to vomit now knowing about the increased ICP. keeping my scene time short would be my highest priority in this situation. In my area we have two on a truck and are lucky to get FD, and when we do often times it is volunteer around here who have low training as far as medicals go.  Tubing in the back even and needing cric pressure may not be an option. That being said we also cover a ton of ground and if the transport time was longer that may change my mind.


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