# Sick as ten men



## Melclin (Jul 25, 2011)

Went to this job today. It was an interesting one.

0745: 22YOM, Overdose - Unconscious/not alert. You are called to a supported accommodation facility for people with mental illnesses and intellectual disabilities. 

You find a bloke face down on his bed, the floor is covered in rubbish and some drug paraphernalia including syringes.  

Obviously you move him to a place and a position free of dangers and obstructions you your assessment.

A - Pt has jaw excessive jaw tone and you cannot open the mouth much more than 2-3cm. Pt gags with the placement of OPA and NPAs. Cannot visualise the upper airway past the tongue. I elected not to scope this bloke at this stage due to the presence of a gag reflex. There is some stridor.

B - Pt is breathing with long slow laboured breaths. Tidal volume is variably adequate. RR 10.

C- Pt has a week pulse of 40, slow and irregular. BP 140/80. Pt is pale and cold. 

D- GCS - 3, Pupils equal, sluggish (3mm), eyes deviated to the right. 

Other bits: Temp: 30.4 C (87F), SpO2: 78%, BSL: "Lo", 


Hx: unspecified mental illness, drug abuse of unknown kind and interlectual disability. 
Meds: Valproate, Prozac.
allegies: NKA.

PhysEx: Pt has urinated and opened his bowels. No puncture marks are evident.

After 5 minutes on 100% oxygen via a closed ventilation circuit 
- the pt begin coughing/periodically vigorously exhaling. 
- there is a more pronounced upper airway snore (now more of a gurgle).
- complete trismus is evident.
- bloody, frothy sputum is being blow from the mouth.   
- the pt is GCS 4 (e1v1m2), pt is exhibiting decerebrate posturing.
- pupils are equal and sluggish at 8mm, no deviation.


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## Smash (Jul 25, 2011)

I have to disagree with your assessment.  This patient does not sound as sick as ten men.

He sounds as sick as three hospitals.

Had he not become sicker my first thought would have been to treat him as you did, transport to hospital.  I don't like playing with cold people, and they don't like playing with me.  They have a nasty tendency to do strange and unpredictable things when you start poking them with drugs and stuff.

Was there any evidence of drug overdose?  I know you stated no punctures visible, but were all his meds present and correct?  Any trauma evident?

What was his ECG like?

I presume you called for Intensive Care backup?  Did you do anything about the blood sugar?

My first impression would be brain injury secondary to probably prolonged hypoxia, maybe as a result of drug overdose.  Of course the list of differentials is long and illustrious; this is just my first gut feeling.

I personally would have used a recoil bag to give 100%, as you aren't flushing out nitrogen with the circuit.  Did his SpO2 come up?

Ok, so oxygenation has occurred and now every thing has gone down the :censored::censored::censored::censored:ter.  I would have very much preferred to manage this chap conservatively given how badly wrong things can go, but now that he has some (presumably neurogenic) pulmonary oedema with an increasingly compromised airway, he has kind of forced our hand.

Man, nothing good can come from this... How far are you from hospital?  Can you just load and go and make it someone else's problem?

We would normally want to give him a bit of fluid before we give him any vasoactive drugs to stave off the inevitable fall in BP, however all that will do is flush cold blood from the peripheries into central circulation with predictably bad effect.  His BP is actually quite high given the rest of his vital signs, so maybe we will let that go by...

So do we need to carry out an RSI?   Only problem is, the only paralytic I have is sux, and that is not a drug I want to use in this chap - the potential bradycardic effects are going to be heightened by the hypothermia and hypoxia, the duration will be prolonged (not that much of a problem) not to mention the fact that he has possibly been face down for some time, potentially with resultant hyperkalemia.  Rocuronium would be better, but not an option for me.  Crap.

Well, a decision has to be made.  If we are close to hospital, continue basic care and make him someone else's problem.  If that is not an option, we need to control his airway and ventilation so RSI it is.  Very small dose of sedation/analgesia, succinylcholine 1.5mg/kg, pass the tube and probably start CPR.

After that, manage whatever crops up and wait for the :censored::censored::censored::censored: storm that is to come.


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## Melclin (Jul 25, 2011)

Ah I really could have set this up better. Thats what you get for trying program your DVR at the same time. 

Firstly, this bloke was last seen late last pm. No indication of suicidal ideation. Carers were not aware he was shooting up in his room. Was found this morning when a carer checked on him when he didn't come to breakfast. No further hx.

My partner was jockeying and had a good look, I never had time to check once I took his airway on. There was evidence of IV drug _use_, presumably heroin. Medications are handed out by carers and there were no empty packets that we found.

Original ECG: Sinus brady with occasional escape beats. 

*Hospitals and backup*
As it turns out this was literally across the road from a major hospital. Had the ambulance broken down, I reckon we would have just walked to ED. My partner got some intensive care backup as more of an arse covering exercise more than anything I think. He wasn't even remotely interested. 

*Some more*
After 15 minutes of O2 and 25 grams of dextrose, he presents largely the same as the 5 minute mark in addition to:
*- A BSL of 4.5
- Pupils are equal and sluggish at 3mm.
- BP: 180/100
- Sp02 100%
- HR: 110 Sinus Tach*


*Stuff we did*
In regards to the O2, early on I flush the circuit regularly. I know its still not a perfect 100%, but I like having the ability to clearly monitor RR and Vt. I'm aware that I might get better results with a BVM and I'd switch if the sats hadn't come good. 

To be honest we didn't clue into the hypothermia early one. My partner went straight for the dextrose when the bsl came back. I think there was a certain amount of we're right next to hospital, lets do his sugar and boogie type thinking. To be honest I didn't think of it, I was buried in his airway. 

Good thing to keep in mind for next time.


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## MrBrown (Jul 25, 2011)

This is what we would call a status one patient (critical problem) and Brown has a feeling the EM and ICU Consultants are going to be saying bad things about us dragging them out from watching telly to do some work on this chap.

He needs to go to a major hospital with much fastness and early notification.

It sounds like he has had some massive neurogenic problem, probably nunngered his hypothalmus and brain stem.  

If we can't put some form of adjunct in then we need to be ringing up for Intensive Care to come RSI him or if major hospital is closer than considering this bloke is already pretty buggered lets just get him on the scoop and out of there as if we are escaping the taping of a Richard Simmons commercial *Shudder

Re suxamethonium in hypothermia - Smash can you elaborate please?

Now, do pass Brown the Masterfoods jar, Brown does like some seasoning on Brown's vegetables.


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## Martyn (Jul 25, 2011)

> Re suxamethonium in hypothermia - Smash can you elaborate please?




Suxamethonium chloride

Side effects include malignant hyperthermia, muscle pains, acute rhabdomyolysis with hyperkalemia, transient ocular hypertension, constipation[1] and changes in cardiac rhythm including bradycardia, cardiac arrest, and ventricular dysrhythmias


Malignant hyperthermia (MH) or malignant hyperpyrexia[1] is a rare life-threatening condition that is usually triggered by exposure to certain drugs used for general anesthesia; specifically, the volatile anesthetic agents and the neuromuscular blocking agent, succinylcholine. In susceptible individuals, these drugs can induce a drastic and uncontrolled increase in skeletal muscle oxidative metabolism, which overwhelms the body's capacity to supply oxygen, remove carbon dioxide, and regulate body temperature, eventually leading to circulatory collapse and death if not treated quickly


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## usalsfyre (Jul 25, 2011)

Martyn said:


> Suxamethonium chloride
> 
> Side effects include malignant hyperthermia, muscle pains, acute rhabdomyolysis with hyperkalemia, transient ocular hypertension, constipation[1] and changes in cardiac rhythm including bradycardia, cardiac arrest, and ventricular dysrhythmias
> 
> ...



MH is a severe side effect of succinylcholine, but my guess is that Smash is referring to sux's tendency to cause bradycardia (esp in a patient that potentially has elevated K+) potentiating the bradycardia already present from the hypothermia.


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## usalsfyre (Jul 25, 2011)

Across the street from a tertiary facility I'd simply place O2, fix the BGL, throw some blankets on and boogey. 

In the middle of nowhere like I usually work? Pretty much the same, except replace "O2" with "preoxygentation and RSI as appropriate". We use rocc so I'm not worried about bradycardia as much. However, given that the trismus is likely neurogenic he's likely going to need muscle relaxers. I'm not using one of the crap "DAI" protocols out there as I'm likely to end up with a patient who has trismus, and is difficult to ventilate due to loss of muscle tone elsewhere. 

Also I'd start an infusion of warmed fluid, probably giving at least the standard 20ml/kg bolus as the kid's probably septic. Watch for signs of severe hyperkalemia and treat as appropriate, maybe a foley to see what his urine looked like, if it's rhabdo'ish I might consult med control about adding some bicarb to the fluid infusion.


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## Simusid (Jul 25, 2011)

I'm trying to follow along with everything going on in this case.  So my EMT-B question is, what's the possible etiology of the bloody frothy sputum?


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## DrParasite (Jul 25, 2011)

usalsfyre said:


> Across the street from a tertiary facility I'd simply place O2, fix the BGL, throw some blankets on and boogey.
> 
> In the middle of nowhere like I usually work? Pretty much the same, except replace "O2" with "preoxygentation and RSI as appropriate".


that's pretty much what i was thinking


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## MrBrown (Jul 25, 2011)

Simusid said:


> I'm trying to follow along with everything going on in this case.  So my EMT-B question is, what's the possible etiology of the bloody frothy sputum?



In which other group of patients do we sometimes see bloody frothy sputum?

How is frothy sputum different than regular sputum and what does this tell us about where it is coming from?

If we know where the frothy sputum comes from what would make it tinged with blood?  Tip:  Think about the system in question's normal circulatory dynamics and the effect increased hydrostatic pressure would have on the clinical presentation we see here


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## abckidsmom (Jul 25, 2011)

usalsfyre said:


> Across the street from a tertiary facility I'd simply place O2, fix the BGL, throw some blankets on and boogey.
> 
> In the middle of nowhere like I usually work? Pretty much the same, except replace "O2" with "preoxygentation and RSI as appropriate". We use rocc so I'm not worried about bradycardia as much. However, given that the trismus is likely neurogenic he's likely going to need muscle relaxers. I'm not using one of the crap "DAI" protocols out there as I'm likely to end up with a patient who has trismus, and is difficult to ventilate due to loss of muscle tone elsewhere.
> 
> Also I'd start an infusion of warmed fluid, probably giving at least the standard 20ml/kg bolus as the kid's probably septic. Watch for signs of severe hyperkalemia and treat as appropriate, maybe a foley to see what his urine looked like, if it's rhabdo'ish I might consult med control about adding some bicarb to the fluid infusion.



An excellent summary.  What's a DAI protocol?


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## MrBrown (Jul 25, 2011)

DAI is gangsta old school butchershop massive afro style midazolam assisted intubation which was banned in Australia and New Zealand during the early 2000s because its super hella white bread styles bad news


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## Simusid (Jul 25, 2011)

MrBrown said:


> In which other group of patients do we sometimes see bloody frothy sputum?
> 
> How is frothy sputum different than regular sputum and what does this tell us about where it is coming from?
> 
> If we know where the frothy sputum comes from what would make it tinged with blood?  Tip:  Think about the system in question's normal circulatory dynamics and the effect increased hydrostatic pressure would have on the clinical presentation we see here



CHF or a pulmonary edema.   I was trying to tie those into his other symptoms.  For a PE I would expect tachycardia not brady, and I don't immediately think CHF for a 22 year old with a BP better than mine.


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## Martyn (Jul 26, 2011)

I am sort of but not quite but almost tempted to say he is a huffer...it sort of ties in with the medical problems he is experiencing plus you say he is an addict...!!!


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## bigbaldguy (Jul 26, 2011)

MrBrown said:


> DAI is gangsta old school butchershop massive afro style midazolam assisted intubation which was banned in Australia and New Zealand during the early 2000s because its super hella white bread styles bad news



Would someone please translate this from brownese to English. Lol


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## ClarkKent (Jul 26, 2011)

bigbaldguy said:


> Would someone please translate this from brownese to English. Lol



The only thing that I can translate is that this is something that Mr. Brown can't do any more.  Besides that, I have no F'en clue.


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## katgrl2003 (Jul 26, 2011)

bigbaldguy said:


> Would someone please translate this from brownese to English. Lol



I'm getting pretty good at translating brownese, but that one has me looking like a monkey doing a math problem. :rofl:


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## MrBrown (Jul 26, 2011)

bigbaldguy said:


> Would someone please translate this from brownese to English. Lol



Midazolam assisted intubation is bad


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## Smash (Jul 26, 2011)

What Brown is saying is that trying to get an endotracheal tube into a patient with trismus using a benzodiazepine alone is a very bad idea and causes more harm than good.  If RSI is to be done it needs to be done properly with a paralytic (or more properly with Roc rather than sux, but we all deal with what we have) as well as sedation and analgesia.

As for the sux and hypothermia, usalsfyre has nailed it.  Sux has a tendency to cause bradycardia.  It's not a problem in most people, and in fact we often don't notice it at all, however in someone who is this cold and who wants to be really bradycardic, I don't like to give them an excuse to go further down that route.  Especially as we can expect whatever drugs we give to hang around longer thanks to the hypothermia.  I'm also vary wary of sux in people who are exhibiting Cushing's Triad for the same reason (although by that stage it is probably a moot point anyway)

As for the pink frothy sputum, neurogenic pulmonary oedema (which is really a diagnosis of exclusion, but I think it's a safe bet in this patient) occurs when there is some kind of neurological insult and usually raised ICP.  The exact mechanism and pathophysiology is (like all interesting things) pretty unclear.

It seems that increased ICP causes inappropriate sympathetic activation amongst other things.  This causes increased peripheral and pulmonary vasoconstriction, decreased LV compliance and increased LVEDP, increased left atrial pressure, a shift of blood into pulmonary vasculature and increased pulmonary capillary pressure which along with increased pulmonary capillary permeability results in pulmonary oedema.


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## johnrsemt (Jul 26, 2011)

I want to see a video of the monkey doing math


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## Melclin (Jul 27, 2011)

We were too close to the hospital to ever take these obs ourselves but I'll give you some of the hospital's, prior to RSI, to further the scenario. 

If we assume no RSI,

- Pupils dilated again @8mm.
- BSL: "Lo" (unrecordably low)
- BP: 229/117
-I can't remember the exact HR, but it was SR (ie, not tachy/brady). 

Anyone pick it now?
I'd like to think given this third round of info, I would have got it, but who knows.


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## Handsome Rob (Jul 27, 2011)

I am really curious to hear the diagnosis if possible. Had a colleague suggest beta-blocker OD, but that does  not match the HTN, then tried out CVA resulting from cocaine OD, which does not account for the airway comromise. Stumped on this one, besides a diagnosis of "really jacked up".


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## firetender (Jul 27, 2011)

*happy to oblige!*



johnrsemt said:


> I want to see a video of the monkey doing math


 

http://www.youtube.com/watch?v=JMd3rU9FSc4


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## usalsfyre (Jul 27, 2011)

Bacterial meningitis and resultant increased ICP, septicemia and aspiration are my guess.


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## Handsome Rob (Jul 27, 2011)

*SWAG here...*

drug induced lupus erythematosus: may have acute onset, S/S include muscle rigidity, erratic HR, fluctuating BP, fever (hmm...), pericardial effusion, as well as joint stiffness. Dunno about the fever though, as this guy was hypothermic...


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## Melclin (Jul 28, 2011)

Some good guesses, but we're thinking zebras a little too much. Head back to towards the horses. 

Y'all have till the end of my night shift (and subsequent nap) to figure it out...the clock is ticking.


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## usalsfyre (Jul 28, 2011)

Melclin said:


> Some good guesses, but we're thinking zebras a little too much. Head back to towards the horses.
> 
> Y'all have till the end of my night shift (and subsequent nap) to figure it out...the clock is ticking.



Opiate OD with aspiration? Seizure thrown in there somewhere to complicate things?


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## Handsome Robb (Jul 28, 2011)

usalsfyre said:


> Opiate OD with aspiration? Seizure thrown in there somewhere to complicate things?



I was thinking something along these same lines, but I don't know if it can be that easy. Although he did say look for horses not zebras :huh:

The thing thats bugging me is the pupils not being pinpoint on reexamination and the patient being hypertensive and rising pretty quickly rather than hypotensive which I would expect to see. Did you give any naloxone? It's not 100% indicated but in this case I don't think it could hurt, especially with the paraphernalia present. 

As for the seizure. Wouldn't a patient be more likely to present with hyperthermia due to the extreme muscle exertion rather than hypothermia. If he was unresponsive for a lengthy period of time before being discovered could account for this I guess?

What about possible CVA, along the lines of a hemorrhagic stroke? He sort of is displaying Cushing's triad on the initial exam being bradycardic and a trend in widening pulse pressure, no irregular respirations though, but you did say tidal volume was variably adequate so this could be interpreted as irregular...

I give up.


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## mycrofft (Jul 28, 2011)

*Pituitary extension of a brain tumor?*

lumping the hypertension versus heartrate, the low temp and the low glucose...

And the most common cause of frothy blood tinged sputum in trysmus, after cheek gnawing, is attempts to mechanically open the airway.


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## Melclin (Jul 28, 2011)

NVRob said:


> Although he did say look for horses not zebras :huh:
> 
> The thing thats bugging me is the pupils not being pinpoint on reexamination and the patient being hypertensive and rising pretty quickly rather than hypotensive which I would expect to see. Did you give any naloxone? It's not 100% indicated but in this case I don't think it could hurt, especially with the paraphernalia present.



I said *more* towards the horses. But I wouldn't call this a horse in and of itself. 

I think you'll all kick yourself when you hear the answer.   

Also, pupils may not be pinpoint in opiate OD if the brain has been hypoxic for long enough. Or so I hear anyway. We didn't give it naloxone. The ED did, the result of which I will post when I give the answer.


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## Smash (Jul 28, 2011)

Fluctuating pupil size. Respiratory depression. Altered conscious state. Hypoxic. Hypoglycemic (did you do anything about that?)

I'll stand by my first assessment, but I suspect the culprit is GHB.


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## Handsome Robb (Jul 29, 2011)

I wanna know the final dx on this patient! haha


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## Melclin (Jul 29, 2011)

We pulled this bloke off his bed and into a corridor for space and safety. 

Given that I was not attending this job, I jumped on airway and struggled away there for a while. I wouldn't be surprised if the bloody sputum was my fault. I twice tried to pass an NP without any success (gagging and there was some obstruction too. I noticed small amount of old caked blood around his nose, so I wonder if the NP didn't revive and older epistaxis. His resps were so laboured along with stridor and tracheal tugging I was considering FBAO for a little while, but I didn't wanna scope him with a gag reflex and I couldn't after the trismus set it. 

In retrospect having had him gag on an OP was less than desirable given the possible ICP issues he was having. But I was told to do it by the attending paramedic and at the time saw no super strong reason to disagree. I also would have liked to have had a temperature earlier on. 

Other than oxygen and blankets, this guy got 25 grams of dextrose, brought his blood sugar up to about 5 (90). First BSL in hospital was again unreadibly low. He got 50 grams of dextrose, brought his BSL to 9.7. No luck with any narcan. A short while later his BSL was unreadibly low again. Initially they thought was that the culprit was a seizure. Before the tube drugs went in, his BP was 227/125. He was intubated and loaded with phenytoin. The docs were confused by the sugars but everything made sense when the facility we came from rang to say they had found several boxes of empty insulin pens (presumably stolen from one of the other residents, because he wasn't diabetic and insulin wasn't on his meds list) hidden in a draw.

*So, massive insulin overdose with associated neurological damage. *The doc told me later although there might have been some other drugs in the mix, he believed the main culprit was the insulin, with the long period of profound hypoglycaemia causing neuro damage, then aspiration and hypoxia as his GCS dropped to cause further damage. ICU took him but the registrar said it would be much better if he dies as there was almost no chance of any other outcome other than being admitted to the veggie patch. 

So. An interesting case and I wish I had the chance to attend it myself.

Thoughts?


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## Handsome Robb (Jul 29, 2011)

Didn't see that coming. Makes sense though. Would the trismus come from a relative state of hypokalemia? Seeing as insulin drives not only glucose but potassium into the cells as well?


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## mycrofft (Jul 29, 2011)

*Hm. I thought about it but disregarded*

Didn't think about aspect of the brain damage the hypoglycemia then attendant hypoxia (seizures, trysmus) woud have lain on. Must have included some longer acting stuff than Regular.

Thoughts about the "high BP versus low pulse rate and hypothermia" complex?


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## GoDucks (Jul 29, 2011)

Fascinating! What a great call. I never would have thought of a massive insulin OD, but you're right... I'm completely kicking myself for that now. Thanks for the post, this one sparked some great discussions between some of my coworkers and I.


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## MrBrown (Jul 29, 2011)

How interesting, better than sitting at the Branch watching telly eh?


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## mycrofft (Jul 29, 2011)

*The only massive insulin OD I saw was also full of methamphetamines*

She was the color of the frame around this text only a little darker, rapidly gasping, and had her back arched. She apparently lived with a bunch of crank cooks, was pregnant, and tried to abort with insulin. They tried to "wake her up" with meth. She lasted three more days, then died; she had so many ABG's and her clotting apparently was so diminished that her arm compartmentalized  and would have needed ampuation. Of course, the fetus was killed also.


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## Melclin (Jul 29, 2011)

NVRob said:


> Didn't see that coming. Makes sense though. Would the trismus come from a relative state of hypokalemia? Seeing as insulin drives not only glucose but potassium into the cells as well?





mycrofft said:


> Thoughts about the "high BP versus low pulse rate and hypothermia" complex?



Don't know. My current theory is that he was actually seizing on and off. 

Hypothermia just from exposure perhaps. It was a reasonably cold night, he was only wearing a tshirt and pants. Nanna on the floor all night type stuff.


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## zzyzx (Aug 1, 2011)

Crazy. That's one you'll never forget.


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