# 43 female/unconscious



## NomadicMedic (Jan 5, 2014)

1630, on a Thursday. Dispatched for a sick person/unknown. Two medics on the a fly car, 2 EMTs in a BLS ambulance <5 minutes behind you. 

Arrive at a well kept, single story ranch style home. You walk in to find a 43 year old woman, supine on the floor. She is pale, shallow resps and is wearing jeans and a t shirt. No shoes or socks. 

The husband says he just came home and found her like this. He talked to her 20 minutes ago on the phone and she asked him to get a pizza for dinner, and indeed there is a Little Cesear's pizza on the table. He says she hasn't been sick, doesn't take any medication that he knows of and was fine 20 minutes ago! WTF!

Vitals are:
Skin is pale and cool. Pupils are 4mm and sluggish. HR is 54, sinus. No ectopy. Pressure is 104/54. Resp rate is 10 and shallow. Glucose is 92. Lactate is 1.1 mmol/L. 

You are 25 minutes from a hospital. 
And you can have a helicopter if you really want one. 

And go...


----------



## VFlutter (Jan 5, 2014)

Responsive to any stimuli? Any obvious signs of trauma? 

Lung Sounds?

I am assuming no acute ST changes...

Outside Temp? Hypothermic? 


I am guessing there is a clot or an empty bottle of pills somewhere....


----------



## STXmedic (Jan 5, 2014)

Lupus. Next.


----------



## teedubbyaw (Jan 5, 2014)

What Chase said plus o2 sats, start bagging her, check for any indications of substance abuse, rapid head to toe and get her on the ambulance. 12 lead and IV en route.


----------



## exodus (Jan 5, 2014)

Any oral trauma?  Sounds neuro.


----------



## STXmedic (Jan 5, 2014)

My initial thought is neuro, too. 

What Chase said, plus any family history of CVA/hyperlipid/MI? Recent traveling? Recent doctors appointments? Birth control?


----------



## Handsome Robb (Jan 6, 2014)

Why bagging her? Lets get a room air SpO2 and find out how well she's ventilating and oxygenating herself on room air then titrate her SpO2 to an appropriate level. 

Definitely sounds neurological. Any history of drug/ETOH abuse? Smoker? Recent pregnancy? Incontinence? STX asked the next few questions I was going to put here. Recent traumatic injury? Any signs of a traumatic injury? What's her GCS? Any signs of funniness? I don't know why but it seems like the pizza has some relevance here otherwise why would you tell us it's right there on the table? ...

DDx:
CVA/Neuro
Fall -> CHI/TBI
DV -> CHI/TBI
Lupus.


----------



## Handsome Robb (Jan 6, 2014)

I want to add OD to my list...maybe TCAs? Early on, but she's not that hypotensive although her diastolic is a touch on the low side and her MAP is only ~70. Still perfusing but at a metabolic acidosis and that'll change things. No signs respiratory alkalosis though... Right season, starting to get to that right age bracket. Any recent fights or trouble at home? Added stressors? Trouble at work? history of suicidality?

There's no sign of increased ICP with this young lady's vital signs either so that points away from my trauma theory. 

I need to reinstate my premium+ membership, I finally got onto a computer and realized it was gone. I was wonder why I couldn't edit posts.


----------



## Razorbackgirl (Jan 6, 2014)

Robb said:


> I don't know why but it seems like the pizza has some relevance here otherwise why would you tell us it's right there on the table? ...



Is the pizza there as possible corroboration of the husband's story? 

Is the patient a smoker?  Any evidence of trauma (lac, disturbed surroundings, etc.)?

I'm just a student, so I may be off-base here - forgive me, if so. I was originally thinking CVA, DV, PE, OD (accidental or suicide attempt), ruptured ectopic pregnancy, unless evidence of trauma exists.  But that lactic acid reading is making me think trauma, PE, and ectopic pregnancy rupture are less likely.  

So, CVA, DV, OD?


----------



## TheLocalMedic (Jan 6, 2014)

I'm thinking an OD.  Benzos?


----------



## Handsome Robb (Jan 6, 2014)

TheLocalMedic said:


> I'm thinking an OD.  Benzos?



Definitely crossed my mind. Not horribly respiratory depressed yet but the timeline would fit. Pops the pills, aren't working fast enough, calls hubby and sends him for pizza to stall him... h34r:


----------



## NomadicMedic (Jan 6, 2014)

Okay. Here's more stuff, since you asked.

The house is warm, 70 degrees. Her room air sat is 82. Lungs are clear in all fields. She is Unresponsive to anything but painful stimuli. When you give her a sternal rub, she lets out a bit of a groan and brings up her arms in a decorticate posture. 

Husband says no drugs. No cigarettes. No birth control pills, she had her tubes tied after the 2nd kid. He doesn't know what's going on, he just came home from work and WHY AREN'T YOU HELPING MY WIFE!!!

Ahem.

Your partner goes on a hunt through the medicine cabinet in the bathroom. He finds a bottle of 10mg Buspirone, empty. But the script is several month old. Nothing else, aside from OTC vitamins and allergy meds.


----------



## unleashedfury (Jan 6, 2014)

DEmedic said:


> Okay. Here's more stuff, since you asked.
> 
> The house is warm, 70 degrees. Her room air sat is 82. Lungs are clear in all fields. She is Unresponsive to anything but painful stimuli. When you give her a sternal rub, she lets out a bit of a groan and brings up her arms in a decorticate posture.
> 
> ...



why have an empty script that's several months old in the cabinet? whos script is it? Buspar is a antianxiety medication any history of mental health issues. 

with the painful stimuli perceiving a decorticate posture I am suspecting a possible overdose of benzo's or the said Buspar. 

Neurological would be my second suggestion, but the patient complained of no illness, any recent falls, complaints of severe headaches?


----------



## VFlutter (Jan 6, 2014)

IRRC Buspar is relatively safe and requires high dosages for OD. How many pills in the bottle? Unless it was a 60 or 90 day script, which is rare with psych meds, I am not sure the dosage would be significant enough. The symptoms somewhat fit but not quite. 

I am leaning towards a Neuro event. Spontaneous bleed r/t undiagnosed aneurysm? 

Either way she needs a head CT and Tox screen ASAP.


----------



## unleashedfury (Jan 6, 2014)

Chase said:


> IRRC Buspar is relatively safe and requires high dosages for OD. How many pills in the bottle? Unless it was a 60 or 90 day script, which is rare with psych meds, I am not sure the dosage would be significant enough. The symptoms somewhat fit but not quite.
> 
> I am leaning towards a Neuro event. Spontaneous bleed r/t undiagnosed aneurysm?
> 
> Either way she needs a head CT and Tox screen ASAP.



I stand corrected then,, I just researched that and a study showed that healthy male volunteers showed minimal drowsiness symptoms while being dosed 375 mg of Buspar, I know Zoloft requires extremely high dosages for effects Buspar was a new one to me.


----------



## NomadicMedic (Jan 6, 2014)

The Buspar had her name on it.  I have no idea why she kept an empty bottle. 

What else do you want to know? What would you do? 

(You're all doing an excellent job with this...)


----------



## Rialaigh (Jan 6, 2014)

Edit


----------



## Akulahawk (Jan 6, 2014)

Is the patient taking any herbal supplements?


----------



## unleashedfury (Jan 6, 2014)

DEmedic said:


> The Buspar had her name on it.  I have no idea why she kept an empty bottle.
> 
> What else do you want to know? What would you do?
> 
> (You're all doing an excellent job with this...)



Well based on the information you have posted to include vital signs and a primary assessment, I would start by oxygenating the patient securing the airway with a BLS airway. and prep for transport.

I am suspecting a Neuro injury so I would go to the appropriate center, In my area ground 30 minutes if I don't already have aeromedical in the air you said 25 minutes If that's a stroke center that's my destination by ground. (give or take 25 minutes for aeromedical to get up in the air and arrive if not incoming already) 

As far as treatment Monitor BLS airway, hi concentration 02 to supplement the depressed respiratory rate, establish IV access, and a diesel bolus.


----------



## abckidsmom (Jan 6, 2014)

DEmedic said:


> Okay. Here's more stuff, since you asked.
> 
> The house is warm, 70 degrees. Her room air sat is 82. Lungs are clear in all fields. She is Unresponsive to anything but painful stimuli. When you give her a sternal rub, she lets out a bit of a groan and brings up her arms in a decorticate posture.
> 
> ...



Are we managing her airway?  Let's do that.  What's her EtCO2?  What does that waveform look like?  What's her 12 lead show?

Meanwhile, I'll start an IV and drive her to the closest tertiary care center.


----------



## NomadicMedic (Jan 6, 2014)

ETCO2 is 66, non obstructive waveform.


----------



## abckidsmom (Jan 6, 2014)

DEmedic said:


> ETCO2 is 66, non obstructive waveform.



Further evidence of the impact of her non-effective ventilatory status.  Does she accept an oral airway?


----------



## Angel (Jan 7, 2014)

I agree with everyone else as far as ddx, im suspecting OD on the benzos or neuro event including possible seizure.

any incontinence? oral trauma? 

tx would include BLS airway, OPA if not then NPA and bag, if she accepts the OPA id also like to intubate, titrating to an appropriate ETCO2, get a line and transport to the nearest facility. they can stabilize and transfer if needed. 

I would keep her as an ALS pt (since you mentioned BLS is nearby)


----------



## NomadicMedic (Jan 7, 2014)

As you attempt to insert an oral airway, she gags and begins to vomit.

No oral trauma. No incontinence. 

Ambulance is now on scene. You've been there for 5 minutes.


----------



## Handsome Robb (Jan 7, 2014)

Did we get a FSBG off this lady? With the way her mental status is described I'd like to give her a touch of narcan just to cover my bases and if no effect I'd like to intubate her. I don't have RSI capabilities so here I'm stuck with BLS airways or a nasotracheal intubation. 

She's hypoxic, hypercapneic and hypoventilating, I'd say an intubation is indicated. Not to mention now she's vomiting cause we were playing with her gag with our BLS airway. 

If we do have RSI lets do 2-3 mcg/kg of fentanyl, 0.3/kg of etomidate then your paralytic of choice. I'd be tempted to do a defasiculating dose in her if we're going to use a DPNMB since we have the potential for elevated ICP with an acute neurological insult on our DDx list.


----------



## Angel (Jan 7, 2014)

suction and NPA, id transport code 3 to nearest facility. 

speaking as a student: Im on the fence about narcan, #1 being pupils aren't constricted and don't point me down narc OD (esp since the buspar is a benzo). On the other hand treating down AEIOU-TIPS this is something we should consider and it wont necessarily "hurt" anything

My decision is TO give narcan 2mg IV once in the back.


----------



## NomadicMedic (Jan 7, 2014)

Have we all reached the same conclusion? She's altered to the point where she can't protect her own airway.

Okay. My first guess was a bleed, second was an OD. 

So, here's what happened. I realized nothing going was going to come of just sitting around, so I started a line, drew bloods and she then was intubated with our standard RSI cocktail; Etomidate, Succinylcholine, Versed and Fentanyl. (I did not use additional paralytics). No issues. 7.5 tube placed on first attempt. 

Transported to the hospital, with effective ventilation and stable vital signs. 

CT was unremarkable. PT remained on the vent and transferred to ICU.

On follow up ... Benzo OD. The PT had anxiety and depression issues and had begged/borrowed/stolen Ativan from a friend. Took "a bunch" (at least 10 2mg tabs). She was discharged a couple of days later.

Nice job all.


----------



## Angel (Jan 7, 2014)

Off topic but you can draw labs AND RSI?! I'm pretty jealous as we can do neither here. what state do you work in?  

Good scenario!


----------



## FLdoc2011 (Jan 7, 2014)

Why the etomidate and versed? 

Just questioning why give more benzo to a benzo OD?


----------



## Rialaigh (Jan 7, 2014)

Maybe an all or nothing protocol for him. I would have just used a paralytic and intubated without further sedation of any kind.


----------



## chaz90 (Jan 7, 2014)

Angel said:


> Off topic but you can draw labs AND RSI?! I'm pretty jealous as we can do neither here. what state do you work in?
> 
> Good scenario!



If I knew nothing more, I'd still be able to make a pretty decent guess based on his username...

Drawing labs doesn't mean we can run any tests though. We routinely draw a set of blood tubes at IV initiation just to facilitate the process of running them at the hospital.


----------



## Carlos Danger (Jan 7, 2014)

FLdoc2011 said:


> Why the etomidate and versed?
> 
> Just questioning why give more benzo to a benzo OD?



They didn't know it was a benzo OD.


----------



## DesertMedic66 (Jan 7, 2014)

Angel said:


> Off topic but you can draw labs AND RSI?! I'm pretty jealous as we can do neither here. what state do you work in?
> 
> Good scenario!



Welcome to EMS outside of CA. We can draw labs in my area of SoCal but RSI is unheard of around here.


----------



## Handsome Robb (Jan 7, 2014)

Rialaigh said:


> Maybe an all or nothing protocol for him. I would have just used a paralytic and intubated without further sedation of any kind.



While I see why, I don't agree with this. She still is responding to painful stimuli thus needs to be treated for pain (tube/blade in her throat) and needs to be sedated for the simple fact that I refuse to intubate someone I don't know isn't totally out. If her vitals support it why wouldn't you sedate this patient along with paralytics?


----------



## Angel (Jan 7, 2014)

chaz90 said:


> If I knew nothing more, I'd still be able to make a pretty decent guess based on his username...



haha duh. 

and yea CA is pretty restricted as far as protocols go, I know of one ER that lets medics draw blood as part of some pilot type program for catching [sepsis? cant remember] earlier...not my county so I cant do it but thought it was interesting.


----------



## Tigger (Jan 7, 2014)

Robb said:


> While I see why, I don't agree with this. She still is responding to painful stimuli thus needs to be treated for pain (tube/blade in her throat) and needs to be sedated for the simple fact that I refuse to intubate someone I don't know isn't totally out. If her vitals support it why wouldn't you sedate this patient along with paralytics?



Not to mention that given the initial presentation, a head bleed is not out of the question and RSIing without sedation is certainly capable of increasing ICP, as other potentially detrimental physiological responses.


----------



## Rialaigh (Jan 7, 2014)

Robb said:


> While I see why, I don't agree with this. She still is responding to painful stimuli thus needs to be treated for pain (tube/blade in her throat) and needs to be sedated for the simple fact that I refuse to intubate someone I don't know isn't totally out. If her vitals support it why wouldn't you sedate this patient along with paralytics?



I wouldn't use more Benzo's in a suspected benzo overdose. If Benzo overdose is #1 on my suspect list then I am probably just assisting with ventilations via BVM and not intubating either. Once you intubate you kind of tie the ER doc's hands about using flumazenil and the patient might end up taking up an ICU bed for several days on multiple drips when it all could have been avoided with a bit of reversal medication in the ER. 

If I suspect neuro event more (which based on patient findings and vitals I really don't at all) then I think RSI with a paralytic and a narcotic are understandable but I will wouldn't use a benzo if benzo overdose is remotely likely. That said there are plenty of systems where it is an all or nothing procedure so I can't fault people who have to. 

Unless her RR is really really shallow I think it would be perfectly safe to transport this patient in on a cardiac monitor with a non rebreather for 25 minutes. If I am having to make a longer transport to a neuro capable facility or a chopper is needed for longer transport then I think a tube is perfectly good for a suspected neuro event.


----------



## Rialaigh (Jan 7, 2014)

Tigger said:


> Not to mention that given the initial presentation, a head bleed is not out of the question and RSIing without sedation is certainly capable of increasing ICP, as other potentially detrimental physiological responses.



Not to say it has never happened, but in years working within a hospital system I have never heard of or seen a head bleed with a BP that low unless they are an imminent cardiac arrest. I don't really see any information or vitals or patient presentation in this case that point be towards a bleed at all.


----------



## FLdoc2011 (Jan 7, 2014)

Wasn't questioning need to intubate really.   From what it sounds like, intubation was indicated here.   If you're truly going to RSI then goal is to not use BVM and achieve rapid induction/paralysis. 

In this case if she's basically unresponsive for an unknown reason I still agree with RSI,   You don't need etomidate AND versed.


----------



## NomadicMedic (Jan 7, 2014)

In all honesty, my first guess was some sort of catastrophic cerebral insult. It didn't seem to add up to me. He had been on the phone with her 20 minutes before, there was a hot pizza sitting on the table. The house didn't seem to scream "overdose" to me either. I know it's a bad idea to diagnose by ZIP Code… But sometimes you get tunnel vision. The lack of medications and any medical history also didn't scream that she was a psych patient or might have been overdosing on benzo's. 

As far as the RSI drugs, she did have a gag reflex, and I was unsure as to the depth of her sedation. I drew labs before I gave any RSI meds, so they would have a clean sample to determine the amount of benzo's in her system before I started piling meds on top of her. 

As for the ventilatory status, an end-tidal in the high 60s would immediately indicate that she was not adequately ventilated. Could I have managed her with a nasal trumpet and bag valve mask? Sure. Remember, it was 20 minutes to the ED. Did I feel as though intubation was the right method of airway control for this patient? I absolutely did

We don't carry Romazicon, and even if we did, I certainly wouldn't have used it in this case. There was absolutely no indication that she had taken any benzo's nor were there any empty bottles in the house. Her husband related several times that she didn't take any medications currently and didn't have any medical conditions that she saw a physician for regularly.

So… Was it the right call for me? I believe so. I protected her airway, transported her to the hospital. She got a CT and eventually discharged.


----------



## unleashedfury (Jan 7, 2014)

DEmedic said:


> Have we all reached the same conclusion? She's altered to the point where she can't protect her own airway.
> 
> Okay. My first guess was a bleed, second was an OD.
> 
> ...



The hospitals in your area will use the blood you drew?? We used to do that around here until the ED's would trash them and get their own labs. So it turned into a wasted expense for us


----------



## NomadicMedic (Jan 7, 2014)

unleashedfury said:


> The hospitals in your area will use the blood you drew?? We used to do that around here until the ED's would trash them and get their own labs. So it turned into a wasted expense for us



Two of the three hospitals that we frequent use our bloods. One doesn't...and we don't draw if we're going there. In most cases, I won't start an IV either, because they routinely pull our lines.


----------



## FLdoc2011 (Jan 7, 2014)

Just FYI,  even if a suspected benzo OD and certainly for benzo ODs that come in that I manage we don't give flumazenil.    In fact I have never given it, and ONLY seen it given for a hospital patient inadvertently given too much benzos.  

Benzo ODs get supported until it's out of their system,  if that means they're intubated in the ICU for a day then fine, but we're not reversing those people acutely.


----------



## Carlos Danger (Jan 7, 2014)

Rialaigh said:


> I wouldn't use more Benzo's in a suspected benzo overdose. If Benzo overdose is #1 on my suspect list then I am probably just assisting with ventilations via BVM and not intubating either.



Before I'd forgo sedation for intubation, I'd have to be quite confident that a sedative OD was the cause of the unresponsiveness. Confident as in there there are empty bottles of Klonopin or Ativan lying around that were filled just yesterday. But if a benzo OD was just one possibility on my list of differentials and I really had no idea what was causing the unresponsiveness, then I would definitely sedate prior to paralyzing for intubation. A dose of etomidate or ketamine or fentanyl - or even a benzo - will add almost no risk to the situation, but omitting it could potentially be harmful, if you are wrong about a sedative OD being the cause of the unresponsiveness. 

But would not argue against the option of BLS airway management, either.




Rialaigh said:


> Once you intubate you kind of tie the ER doc's hands about using flumazenil and the patient might end up taking up an ICU bed for several days on multiple drips when it all could have been avoided with a bit of reversal medication in the ER.



Once the diagnosis of a benzo OD is made, why couldn't the ED just give flumazenil and pull the tube when the patient wakes up?


----------



## Carlos Danger (Jan 7, 2014)

FLdoc2011 said:


> Just FYI,  even if a suspected benzo OD and certainly for benzo ODs that come in that I manage we don't give flumazenil.    In fact I have never given it, and ONLY seen it given for a hospital patient inadvertently given too much benzos.
> 
> Benzo ODs get supported until it's out of their system,  if that means they're intubated in the ICU for a day then fine, but we're not reversing those people acutely.



Why would you not use flumazenil?


----------



## VFlutter (Jan 7, 2014)

Halothane said:


> Once the diagnosis of a benzo OD is made, why couldn't the ED just give flumazenil and pull the tube when the patient wakes up?



I am sure your experience with Flumazenil is far greater than mine but IMO it causes more problems than it solves. Especially in a patient with unknown history. If this patient was abusing Benzos for sometime it could cause seizures. As FLdoc mentioned I have only seen it used, rarely, for hospital benzo ODs.


----------



## unleashedfury (Jan 7, 2014)

Most systems and hospitals I frequent that have a benzo OD patient avoid flumazenil as the risks outweigh the benefits. 

Usually its just supportive measures. if they are tubed, vent and monitor, if they aren't tubed, allow them to sleep it off and monitor. as long as they are not a risk to themselves or others supportive measures are well played with a benzo OD. Then possibly a trip to a psychiatric unit


----------



## unleashedfury (Jan 7, 2014)

DEmedic said:


> Two of the three hospitals that we frequent use our bloods. One doesn't...and we don't draw if we're going there. In most cases, I won't start an IV either, because they routinely pull our lines.



Geez sounds like a pack of Nazi's. The hospitals we frequent don't want bloods. and are picky about lines. They get butt hurt if the patient dosen't have one, but then they get moody if you all you got was lets say a 20g, 

I have a theory of I'll get what I need, If the patient needs fluid resuc, yeah go big or go home, but the fragile old lady who needs maybe just a medication port for some zofran or something. a 20g will suit me fine.


----------



## Carlos Danger (Jan 7, 2014)

Chase said:


> I am sure your experience with Flumazenil is far greater than mine but IMO it causes more problems than it solves. *Especially in a patient with unknown history. If this patient was abusing Benzos for sometime it could cause seizures.* As FLdoc mentioned I have only seen it used, rarely, for hospital benzo ODs.



In an unknown history and possible long-term use you are right.


----------



## NomadicMedic (Jan 7, 2014)

unleashedfury said:


> Geez sounds like a pack of Nazi's. The hospitals we frequent don't want bloods. and are picky about lines. They get butt hurt if the patient dosen't have one, but then they get moody if you all you got was lets say a 20g,
> 
> 
> 
> I have a theory of I'll get what I need, If the patient needs fluid resuc, yeah go big or go home, but the fragile old lady who needs maybe just a medication port for some zofran or something. a 20g will suit me fine.




The hospital that doesn't accept blood is the one that pulls our lines. Nobody else does. I should have been more clear. 

And I very rarely start anything larger than a 20.


----------



## FLdoc2011 (Jan 7, 2014)

Halothane said:


> Why would you not use flumazenil?




I think it was already mentioned above,  but with unknown history, unknown ingestion, etc I'm not giving flumazenil at the risk of putting them into acute withdraw/seizure.

It's a little different if your sedating someone for a procedure and are using it as a reversal if they just got a little too sedated and there's really no risk of acute withdraw.  

But in this case we 're talking an unknown ingestion in someone who possibly abuses this stuff.

And no, the ER is not going to extubate anyone.   If they do start to wake then they're probably just going to be put on diprivan and re-sedated.


----------



## abckidsmom (Jan 7, 2014)

DEmedic said:


> In all honesty, my first guess was some sort of catastrophic cerebral insult. It didn't seem to add up to me. He had been on the phone with her 20 minutes before, there was a hot pizza sitting on the table. The house didn't seem to scream "overdose" to me either. I know it's a bad idea to diagnose by ZIP Code… But sometimes you get tunnel vision. The lack of medications and any medical history also didn't scream that she was a psych patient or might have been overdosing on benzo's.
> 
> As far as the RSI drugs, she did have a gag reflex, and I was unsure as to the depth of her sedation. I drew labs before I gave any RSI meds, so they would have a clean sample to determine the amount of benzo's in her system before I started piling meds on top of her.
> 
> ...



In these mystical altered mental status cases, it's a challenge (especially in the nicer neighborhoods) to go to overdose, but I've found that people with normal skin, altered mental status, and depressed respiratory drive are usually not neuro issues.  

Warm, dry skin, AMS, I'm thinking toxicology every time.  There are lots of options.  We are seeing a really powerful batch of heroin in our small little rural area, and people continue to be abusing Benadryl, as well as benzos and oxycodones.  I try really hard to leave them asleep and manage their airways, because these people wake up in the most obnoxious manner.  

The other night I had a guy who was so anxious after I woke him up that I ended up sedating him (we don't RSI- all we have is Versed) because I thought he was going to jump out of the truck on the interstate.  I am not a big fan of the situation we're in, and I hate mixing known stuff with unknown stuff- his head flopped back and that was all she wrote, Jim.  

Time of year matters too.  I think that the likelihood that it's some sort of overdose is much higher this time of year.  Between the winter solstice and the vernal equinox, people are insane.  All of them.


----------



## Rialaigh (Jan 7, 2014)

Halothane said:


> Once the diagnosis of a benzo OD is made, why couldn't the ED just give flumazenil and pull the tube when the patient wakes up?



In my experience I have never seen a patient extubated in the ER even if it was probably the right thing to do. Once a tube is placed its automatically the ICU's problem...It's really a poor way to do things in some cases and results in extended intubation times for some patients that clearly don't need it but the ER doc doesn't want the liability involved and throws it on the ICU doc to wean from a vent and pull the tube.


----------



## Handsome Robb (Jan 8, 2014)

The ER isn't sitting there bagging a patient like this whole they do stay labs either, they're intubating and protecting the patients airway then searching for causes. The only time I've ever heard of romazicon used was in a situation like halothane described above. Our crew brought in an obvious benzo OD, along with all the empty bottles of Valium and Ativan they found next to the patient, and the ER have romazicon. Other than that I've never heard of it being used. 

Most definitely isn't used diagnostically.


----------



## Ironman (Jan 8, 2014)

*My 2 cents*

Oxygen.
Air evac.


----------



## chaz90 (Jan 8, 2014)

Ironman said:


> Oxygen.
> Air evac.



Nope


----------



## NomadicMedic (Jan 8, 2014)

chaz90 said:


> Nope




Quoted for truth.


----------



## Wheel (Jan 9, 2014)

Ironman said:


> Oxygen.
> Air evac.



Can you explain your choice here? It's probably not what I would do, but since you're a student, talking through your thought process could help you a bit.


----------



## Akulahawk (Jan 9, 2014)

Ironman said:


> Oxygen.
> Air evac.


Please explain your rationale behind these choices. None of us want to dog-pile on you, rather we want to know your thought process on this. 

Personally, I'm not going to fly this patient. 

We don't carry Romazicon out here, as far as I know, and even if we did, I'd be very reluctant to use it. I would want to start with BLS airway stuff and go from there, possibly rapidly up from there to other tools. She doesn't need to be there, she needs to be where she can be monitored and supported until she wakes up and we can't do that in the field.


----------



## NomadicMedic (Jan 9, 2014)

I believe it was a troll post.


----------



## Golden Eye (Jan 9, 2014)

Ventilate with a BVM, treat her for possible shock. Use an air evac because she's in shock and need immediate treatments. I would also suspect and ask if she's diabetic or possible stroke. Ask her my sample /opqrst.


----------



## Handsome Robb (Jan 9, 2014)

So not to be a prick...or awesome paramedic for that matter...but how do you plan on asking this woman about her SAMPLE history when she is unconscious?

I don't particularly think air is inappropriate for this patient, depending on your location and abilities to control her airway. If she's not protecting her airway, you're not doing well with BLS and don't have an RSI option if be on the radio calling for a flight crew just to RSI her if they're gonna be quicker than code 3 to the hospital.

About the only time I'll transport code 3 now is if there's an airway issue that I can't fix or uncontrollable life threatening hemorrhage.


----------



## chaz90 (Jan 9, 2014)

Golden Eye said:


> Ventilate with a BVM, treat her for possible shock. Use an air evac because she's in shock and need immediate treatments. I would also suspect and ask if she's diabetic or possible stroke. Ask her my sample /opqrst.



What kind of shock are you treating this patient for? If it's the generic first aid version, I don't think raising her legs in the air and tossing a blanket on is going to change a heck of a lot. Flight wise, remember this patient is 25 minutes by ground from the hospital and the helicopter hasn't even been alerted, let alone launched. 

Is this patient critical after she's had her airway controlled? I'd argue that she remains sick of course, but isn't necessarily time critical to the point that I'd fly her even if the aircraft was on the ground in front of me with a ground transport time this short. In fact, I'd transport this patient non emergently unless there was some kind of extreme traffic we were stuck behind. I don't think ~3 minutes of time saved would be worth it otherwise.

In regards to your questioning, remember this patient is unresponsive and not in a position to answer your questions. A SAMPLE history would be great, but it seems like you got as much as you can of that out of the husband. I don't see how the OPQRST mnemonic would be at all beneficial in this scenario. As far as your differentials go, hypoglycemia would be ruled out on scene with a glucometer, and the husband doesn't relate any kind of diabetic history anyway. Stroke is of course a possibility we can't rule out, and a head bleed would be high up on my list of differentials.


----------



## chaz90 (Jan 9, 2014)

Robb said:


> So not to be a prick...or awesome paramedic for that matter...but how do you plan on asking this woman about her SAMPLE history when she is unconscious?
> 
> I don't particularly think air is inappropriate for this patient, depending on your location and abilities to control her airway. If she's not protecting her airway, you're not doing well with BLS and don't have an RSI option if be on the radio calling for a flight crew just to RSI her if they're gonna be quicker than code 3 to the hospital.
> 
> About the only time I'll transport code 3 now is if there's an airway issue that I can't fix or uncontrollable life threatening hemorrhage.



Great minds think alike


----------



## Carlos Danger (Jan 9, 2014)

FLdoc2011 said:


> I think it was already mentioned above,  but with unknown history, unknown ingestion, etc I'm not giving flumazenil at the risk of putting them into acute withdraw/seizure.
> 
> It's a little different if your sedating someone for a procedure and are using it as a reversal if they just got a little too sedated and there's really no risk of acute withdraw.
> 
> ...



You guys are allowed to use Diprivan in the ED? That isn't right!

Just kidding, of course..... h34r:

Make sense. I haven't worked in the ED in a long time or in the streets for nearly as long, so I *occasionally* commit the sin of briefly forgetting that there are extra considerations that need to be taken into account when you are outside the OR or the endo suite.


----------



## Carlos Danger (Jan 9, 2014)

DEmedic said:


> I believe it was a troll post.



Hopefully that or just a really green guy who doesn't know any better because his EMT instructor unfortunately used to often something along the lines of "But don't worry about that.....in real life, if the patient is really sick just call for ALS or the helo".


----------



## Tigger (Jan 9, 2014)

DEmedic said:


> I believe it was a troll post.



Along with an epic humblebrag intro post.


----------



## Handsome Robb (Jan 9, 2014)

Halothane said:


> Hopefully that or just a really green guy who doesn't know any better because his EMT instructor unfortunately used to often something along the lines of "But don't worry about that.....in real life, if the patient is really sick just call for ALS or the helo".




I caught one of our PRN instructors telling an AEMT class this. She didn't teach that class again after I straightened out the miscommunication for the class.


----------



## abckidsmom (Jan 9, 2014)

Robb said:


> So not to be a prick...or awesome paramedic for that matter...but how do you plan on asking this woman about her SAMPLE history when she is unconscious?
> 
> I don't particularly think air is inappropriate for this patient, depending on your location and abilities to control her airway. If she's not protecting her airway, you're not doing well with BLS and don't have an RSI option if be on the radio calling for a flight crew just to RSI her if they're gonna be quicker than code 3 to the hospital.
> 
> About the only time I'll transport code 3 now is if there's an airway issue that I can't fix or uncontrollable life threatening hemorrhage.



If it's only 30 minutes to the hospital, it's important to have worked out well beforehand what the real-time dispatcher to dispatcher, dispatcher to pilot, pilot to weather check, crew to helo, helo to scene (approx.) time is.  Those times can really mean that it's a lot faster for the patient, safer, with less expense to just load up and drive to the hospital.  I need to see a clear difference (like airway is unmaintainable for the ride, or >10 minutes difference on time to definitive airway [no RSI here], etc.)

I have a sort of geographical line I like to keep in my head in our service area, and if we're west of that line (toward the hospitals to the west), or east of another line (toward the hospitals to the east), then I really have no intention of calling the helicopter unless I'm up against a transport delay for extrication or something.


----------



## VFlutter (Jan 9, 2014)

Halothane said:


> "But don't worry about that.....in real life, if the patient is really sick just call...the helo".



I think they taught the same thing to the ER docs in our community hospitals...


----------



## Handsome Robb (Jan 9, 2014)

abckidsmom said:


> If it's only 30 minutes to the hospital, it's important to have worked out well beforehand what the real-time dispatcher to dispatcher, dispatcher to pilot, pilot to weather check, crew to helo, helo to scene (approx.) time is.  Those times can really mean that it's a lot faster for the patient, safer, with less expense to just load up and drive to the hospital.  I need to see a clear difference (like airway is unmaintainable for the ride, or >10 minutes difference on time to definitive airway [no RSI here], etc.)
> 
> 
> 
> I have a sort of geographical line I like to keep in my head in our service area, and if we're west of that line (toward the hospitals to the west), or east of another line (toward the hospitals to the east), then I really have no intention of calling the helicopter unless I'm up against a transport delay for extrication or something.




Exactly how I do it as well ma'am  I've got specific geographic locations where I know they have to be co-dispatched to make any difference and locations where I know I can request them from the scene and they're still faster, or if I want to bypass the trauma center and fly them into California for the Burn Center in at UC Davis I can do that too as long as I'm outside a specific road that loops was the original city limits. 

Our HEMS is dispatched by our communication center so all it is is the dispatcher calling out to the ACS and saying "38 wants Cf on an airborne (standby, or ground standby or go)" and they dispatch the helo. Generally 8 minute request to launch time. Then 5-15 until overhead and 5 to on the ground.

Those Astar B350s are fast like a NASCAR


----------



## Akulahawk (Jan 9, 2014)

Golden Eye said:


> Ventilate with a BVM, treat her for possible shock. Use an air evac because she's in shock and need immediate treatments. I would also suspect and ask if she's diabetic or possible stroke. Ask her my sample /opqrst.


You have an unconscious, unresponsive patient. She can't answer your questions. The husband's probably about out of info at the moment, and probably freaked out so he's not going to be of much help at the moment.

The hospital's about 25 minutes away. The helo has to be launched, fly there, find an LZ that you have to set up, land, possibly be transported to the scene, do their own assessment of the patient and begin their own treatment of her, possibly be transported back to the helo, lift and fly 10 minutes to the hospital, where they then have to land, cool down the helo, unload it, and go to the ED. If you transport the patient instead, you'd have been there at the ED for about 20-30 minutes before the helo actually gets the patient to the ED.

A lot of us here have real-world experience with helos vs ground. Unless the helo is already in the air, if the ground transport time is about 40-60 min or more, you would be better served initiating transport instead of waiting for the helo to arrive. Were I to get shot or in a wreck where I'm at, I would hope that the ground EMS crew drives me to the Level 1 Trauma Center instead of waiting for a helo to pick me up. They may alert them  and get them flying this way, but if they can initiate transport before the helo is orbiting overhead, ground transport is the fastest way to get me to the ED. Not by much, but it is fastest. 

What _isn't_ the case any more is we used to have a helo base about 7 miles from here. From alert to being overhead was about 6-8 minutes. If they were simultaneously dispatched with ground EMS, they'd arrive at about the same time. I've seen that happen a couple of times. That base was moved quite a bit further away about a year ago so we no longer have that fast of a response if we need someone flown out. That happens maybe once a year. Maybe.


----------



## abckidsmom (Jan 10, 2014)

Robb said:


> Exactly how I do it as well ma'am  I've got specific geographic locations where I know they have to be co-dispatched to make any difference and locations where I know I can request them from the scene and they're still faster, or if I want to bypass the trauma center and fly them into California for the Burn Center in at UC Davis I can do that too as long as I'm outside a specific road that loops was the original city limits.
> 
> Our HEMS is dispatched by our communication center so all it is is the dispatcher calling out to the ACS and saying "38 wants Cf on an airborne (standby, or ground standby or go)" and they dispatch the helo. Generally 8 minute request to launch time. Then 5-15 until overhead and 5 to on the ground.
> 
> Those Astar B350s are fast like a NASCAR



The other thing is that our primary helicopter service is very, very, very conservative for weather.  So if it might storm this afternoon, and it's closing in on lunchtime, they're not coming.  

Or if there's a cloud in the sky between here and Singapore.  Or something.


----------



## NomadicMedic (Jan 10, 2014)

abckidsmom said:


> The other thing is that our primary helicopter service is very, very, very conservative for weather.  So if it might storm this afternoon, and it's closing in on lunchtime, they're not coming.
> 
> 
> 
> Or if there's a cloud in the sky between here and Singapore.  Or something.




That's the joke here. There's a cloud between here and Philly. Trooper 2 is down due to weather.  

It's not really that bad... Except when it is.


----------



## unleashedfury (Jan 13, 2014)

Robb said:


> I caught one of our PRN instructors telling an AEMT class this. She didn't teach that class again after I straightened out the miscommunication for the class.



I swear the new EMT-Basic curriculum goes as follows
Scene Safe/BSI
Apply High Concentration O2
Call for ALS

A lot of EMT's in my area are not taught how to appropriately manage a critical patient. diesel bolus is often the best treatment in most cases. our primary coverage area is within 10 minutes of the local band aid shop. So when new techs here they have to ride a call BLS they can often get a pucker factor and deer in headlights look YOU CAN'T DO THAT!! When my closest ALS is a hospital by all means I can and will.  



DEmedic said:


> That's the joke here. There's a cloud between here and Philly. Trooper 2 is down due to weather.
> 
> It's not really that bad... Except when it is.



The nice thing about here is we have about 3 different programs that are within reasonable time of our coverage area. One having hangars literally right across the runway from each other. Since each hospital network is trying to take over the world. They will fly except when its truly not possible.


----------

