# Scenario - Unresponsive



## RedZone (Jul 3, 2007)

A few months ago, I had quite an interesting call.  I still have questions about it, and unfortunately I haven't followed up... but maybe someone here can offer me their opinions.

I'd rather offer this case to the people here as a scenario.  Although some may feel it is rather trivial, there is quite a lot to learn.  I will change the presentation only slightly, and since I do not quite remember every detail, I will have to ad-lib some.  Upon conclusion, I will summarize the exact presentation (as I remember it), my treatment, the pt's response, and some personal opinions.

------
So.... it's about 8AM.  You just had your breakfast and coffee, and while heading to your assigned CSL (cross street location), the dispatcher calls your unit.  You acknowledge.

"Respond to XYZ Nursing Home for an unconscious on unit 3B."

You make a U-turn and arrive at XYZ Nursing Home in about 3 minutes.  You load up the stretcher with your equipment, and head for the elevator.  

On arriving at unit 3B, a nurse greets you, "Thanks for coming so fast!  He's in room 7.  We couldn't wake him up for breakfast."

Let's take it from there... What would YOU do next?


----------



## emtwannabe (Jul 3, 2007)

check airway
check a pulse

How does the pt look?


----------



## Ridryder911 (Jul 3, 2007)

Ask if they are a DNR... just to be sure that nature is not supposed to take it's own course. 

R/r 911


----------



## Chimpie (Jul 3, 2007)

RedZone said:


> On arriving at unit 3B, a nurse greets you, "Thanks for coming so fast! He's in room 7. We couldn't wake him up for breakfast."
> 
> Let's take it from there... What would YOU do next?


 
Go to room seven. :unsure:


----------



## Chimpie (Jul 3, 2007)

Okay, but seriously....

You say Unit 3B, and then Room 7.  Is Unit 3B like a section of the nursing home? And Room 7 is an actual room?

Am I looking into this too deep?  Did you end up going to the wrong room?

(too much to speculate on here)


----------



## bstone (Jul 3, 2007)

Before ANYTHING....Scene safety and check BSI.


----------



## KEVD18 (Jul 3, 2007)

go to room
asses responsivness, abc
follow local protocol based on finding

usually when a scenario is presented for review here, more info is provided. like all the way up through what you found in your assesment and then we would speculate on our treatment.


----------



## RedZone (Jul 4, 2007)

Wow, I wasn't expecting such a huge response!

Ok, everyone had great suggestions!  And *KevD:* I'm trying to build a little anticipation here!  Also, I wanted to see what the first responses were.  But I promise not to drag this out!

*Chimpie:* Yes, 3B is my hypothetical "nursing unit", and the patient is in room 7 on that unit. You do bring up a good point here though.  Always verify that you have the right patient!  Many nursing home residents aren't normally oriented.  It is a good idea to check the patient's id bracelet.  If the bracelet is missing, and the patient isn't oriented, demand that the staff place an appropriate identification on the patient before transporting.

*bstone:* EXCELLENT!  Just because you're in a facility doesn't mean you let your guard down.  Rarely will I ever be informed of necessary isolation precautions unless I ask about them.  Also, being alert for "isolation" signs is a good idea!  Personally, I like the question, "Is there anything I should know about before I go in the room?"

*ridryder911:* Great point! Always ask about advanced directives at a nursing home.

Of course, the nurse is not done with the paperwork. She tells you that the patient could not be aroused this morning (about 15 minutes ago). He is in his late 40's and has a history of IDDM, liver cirhossis, and an internal pacemaker.  He is normally alert and oriented.  He does have a DNR order and is on contact isolation for hepatitis C.  There are no known allergies.  Besides the insulin, medications are unknown at this time since the administrator took the chart to photocopy the MAR (medication administration record).  

The nurse informs you that a "finger-stick" was done and the patient's glucose level was 24 mg/dl.  Somehow, she managed to squeeze a tube of oral glucose down this patient's throat, and a post-glucose "finger-stick" read 18 mg/dl.

*emtwannabe / KevD18:* You enter the room to find a moderately overweight man, snoring in bed with head raised to a semi-fowler's position.  

Neurological: He is unresponsive to both voice and painful stimuli.  Limp in all four extremities.
Airway: You hear spontaneous snoring respirations.  There is no indication of vomiting or foreign body obstruction.
Breathing: Respirations are steady and appear to be of adequate rate & volume.  The chest expands appropriately with each breath, lung sounds are equal bilaterally and there are no rales, rhonchi, or wheezing upon auscultation.  No accessory muscle use is noted.
Circulatory: Cyanosis is noted on the patient's lips.  Otherwise he is cool, pale, and diaphoretic (dripping wet).  Pupils are normal size and equally reactive to light.  Strong, bounding, equal radial pulses. There is no JVD and no pedal edema.
Abdominal exam: There is ascites.  Abdomen appears distended and rigid in all quadrants.
V/S: RR: 18/min and regular.  HR: 80/min & regular.  BP: 100/60.
ECG: Regular pacemaker rhythm.
12-Lead: Pacemaker rhythm.  No changes noted when compared to a previous 12-Lead on file.


----------



## Ridryder911 (Jul 4, 2007)

Get a baseline v.s., and of the routine oxygen, and I.V. of your choice, after repeating a finger stick. Dependent on the reading (which I would expect to be low < 80mg/dl) I would treat appropiately with D50W concentration, or if unable to establish IV, prepare Glucagon. Twelve lead should be establish simultaneously as any < LOC and as well IDDM type patients should have performed. Aware that cirrhosis may alter my D50w level.

If the D50W has + effects, and increased LOC then have the dietician prepare a high carbohydrate and protein plate. Notify local medical control or patients physician of situation and possibility of not transporting the patient. The NH can monitor the glucose and increase the FSBS and as well change the medication as needed. 

R/r 911


----------



## KEVD18 (Jul 4, 2007)

only change id make is we couldnt leave the pt unless they signed a refusal...


----------



## bstone (Jul 4, 2007)

I'd place the pt on high flow O2 via NRB, put on the cardiac monitor and start a 20 gauge IV of NS. Once established, push an amp of D5W and reassess PT's responsiveness, sugar and vitals.

Did you mention what his pulse ox is?


----------



## RedZone (Jul 4, 2007)

*KEVD18:* Generally, yes.  Regional standards differ.  Assuming this patient were to be A&O after treatment, most systems would probably consider the consent/refusal decision to reside with the patient.  At least in my system, an OLMC contact would be required since treatment was provided.

*bstone:* Pulse oximetry on room air is 89%.

*Ridryder911:* I'm impressed. For a second, I almost believed that you worked for an EMS service that was integrated appropriately into the local healthcare system.  Then I realized you had to be dreaming when you expected your ALS unit to be equipped with a glucometer.

Ok, enough sarcasm.  I hope Rid doesn't mind my picking on him as I really am impressed by his commitment to EMS.  I think that everyone's treatment is great.  Extra credit to bstone for not automatically assuming how the patient will respond.  

As for me, I was with rid and kev.

--------
I was taught to be cocky, and have learned that this attitude can be quite valuable.  This particular day, I was overly cocky.

"I'll wake him up for you," I told the nurse before even taking one look at the pt.

After my evaluation (as in the prev. post), I was even more confident that the presenting problem was AMS due to hypoglycemia.  The story, the presentation, the assessment all pointed to "insulin shock" as some lay people may call it.

There was ONE thing that stood out to me though.  The cyanosis / hypoxia.  I had yet to see a hypoglycemic patient present with this.  But, maybe it could be attributed to prolonged hypoglycemia.  Besides, my first treatment was placing the patient on a non-rebreather.  Both his cyanosis and pulse-ox improved as I continued with my care.  After all, he IS hypoglycemic, that's pretty much confirmed.

IV 0.9% NS at a KVO rate was established with an 18 guage in his left arm.
D50W 25 g IVP with a Thiamine 100 mg IVP chaser (we religiously follow up D50 with Thiamine here).

After 5 to 10 minutes... no change.

A repeat dose of D50W 25 g IVP was administered.

No change.

Reassessment: Besides the cyanosis improving and a 96%+ Pulse Ox, there are no other significant changes.  

What next?

-------
And no, we really don't carry glucometers.  Let's assume the SNF's glucometer is not readily available.  Minutes ago I fired off a letter to my region asking about cardiac referrals.  Mandatory glucometry is further down on my list.


----------



## Bongy (Jul 4, 2007)

Ok... At first I would like to agree with Rid... Nursing Home is a great place for hypoglycemia...In advance I would like to check his medication and in any case I would gave him Naloxon 0.4 IV(possible some opiate pain killer toxicity)... Support ABC...If no change in LOC - intubate(even if pulse ox is ok)... Medical History please!


----------



## RedZone (Jul 4, 2007)

Bongy said:


> Ok... At first I would like to agree with Rid... Nursing Home is a great place for hypoglycemia...In advance I would like to check his medication and in any case I would gave him Naloxon 0.4 IV(possible some opiate pain killer toxicity)... Support ABC...If no change in LOC - intubate(even if pulse ox is ok)... Medical History please!



I agree with you Bongy.  Ideally, I would have liked to see this gentleman's medication list.  Unfortunately, that information was not yet available to me.

As for support ABC: Nobody mentioned it (and I must admit, I didn't bother myself), but a head-tilt chin-lift or an OPA may definitely be called for here.  Even considering placing the patient in a laterally recumbent position is indicated.

Medical history: mentioned in previous post: IDDM, Liver Cirrhosis, Hepatitis C, Surgically Implanted Pacemaker

Intubation:  What's your indication?


----------



## bstone (Jul 4, 2007)

After placing the NRB @ 100% 15lpm, what does the pulse ox and blue lips look like? What's he resping at?


----------



## RedZone (Jul 4, 2007)

bstone said:


> After placing the NRB @ 100% 15lpm, what does the pulse ox and blue lips look like? What's he resping at?



Cyanotic lips have now improved.  They're more of a pale color now.  No significant changes in vital signs.

For simplicity, your post-treatment vitals are:

Resps: 18/min & Regular
HR: 80 & Regular
BP: 100/60


----------



## Bongy (Jul 4, 2007)

RedZone said:


> Intubation:  What's your indication?


As I understand - pt still cianotic,in addition - pt CAN NOT protect his airway... I'm quite not sure about a gag reflext... I prefer to intubate instead of waiting for aspiration...
Is there any response for naloxone? If not - I start to suspect for Sub Arachnoid Hemmorage... BTW... Peripheral cianosis and 100 % Sat? Or ONLY blue lips? Because it more and more start to look like isolated cerebral hypoperfusion.... Massive intra cranial hemmorage...But without Cushing triada...


----------



## Ridryder911 (Jul 4, 2007)

I would review his med.'s as well. Hopefully, all EMS units carry a glucometer, especially ALS rigs, if not there is serious problem, with your EMS system. At the very least chemstrips...(which I have not seen on EMS units in decades) Repeat the glucose level and see what that is.

Coma cocktails (Narcan, D50w, Thiamine) are no longer emphasized by such organizations such as NAEMSP, ACEP, NAEMSE, AHA, etc..  Unless the respiratory rate and I see an obvious opioid, I doubt I would administer Narcan. His respiratory rate and saturation rate is adequate, I might check his EtCo2 to make sure his MRO2 is adequate. Personally, I would place in a NP and maybe an oral. Dependent upon his reflexes, I doubt I would intubate him at this time. It might not be needed. 

The Thiamine is of course administered for Wernicke's encephalopathy, with D50w; which can mimic ICP and neuro problems. It is not going to hurt, but doubt it will help. I would perform a more detail neuro assessment as well as checking for hepatic portal hypertension and "liver flap" in which can represent high levels of ammonia (which is predominant in cirrhosis and liver patients). Is there nystgmus, Trousseau sign, and Chvostek's sign which is related to calcium level (which liver patient's have problems maintaining).  

Distal cyanosis? There are a ton of potential reasons, mainly relating to peripheral vascular disease which is a risk, again for those of liver and cardiac history. What grade of pulses? +1-+4? Clubbing, edema, is there perfusion with the pacemaker such as proper capturing? 

One has to worry esophageal varicies, and other medical problems as well. Determination of not to introduce anything into the esophagus and remembering clotting time will be reduced greatly causing potential problems such spontaneous or mild induced inner cranial bleeds as Bongy described. 

Personally, with lowering of glucose, I would look towards the emphasis of ammonia. 

R/r 911


----------



## emtwannabe (Jul 4, 2007)

what does a 12 lead show?


----------



## KEVD18 (Jul 5, 2007)

tough to say what i would do next cause i was at the H ten minutes ago. benefits of working a metro system. throw a rock in anydirection and hit an er


----------



## RedZone (Jul 5, 2007)

*The conclusion*

Not much else can be offered here, time to conclude.

*RidRyder911:* Ok.  I never doubted that there will always be something else that I can learn.  As to your opinion: I too have LONG held the opinion that my EMS system has some serious problems.  Recent participation in EMS forums have reinforced this opinion but also let me see that some other EMS systems have other serious problems of their own.  We just learn to make the best with what we got.  A lot of our training is based on personal experience and learning from the experience of others. Much of my learning is also due to exploring my curiosity. I do hope my EMS system improves, but now I am straying way off topic.  

Yes I can rant all day about problems with my EMS system. Thanks for the opportunity Rid!

*Bongy:* Ok, I agree that there is a concern with protecting the airway.  I am used to extremely short transport times, so I'd be comfortable with an OPA and left lateral recumbant positioning.  The demographics of your system may indicate otherwise.

*KevD18:* Oh, at some parts of the city, I could throw a rock and skip it across the roof of three hospitals!  But here there is emphasis on treating medical patients at the scene before preparing to transport.

To clear some things up:

BEFORE Treatment: Lips were cyanotic.  Otherwise, the rest of the skin was cold, pale, and diaphoretic.  I do not recall peripheral cyanosis, but my memory may not be 100% accurate.  

After several minutes of oxygen administration by non-rebreather, there was no cyanosis.

The AMS cocktail (D50W, Thiamine, Narcan): We still use it here... sort of.  Most of us no longer push one right after the other (or draw up the thiamine and narcan with the D50W Bristol).  Generally we will give narcan, if needed, or D50W and Thiamine, if needed.  But if there is no significant response, we are expected to complete the cocktail.  Personally, I try to avoid narcan.

Here's how it goes (really)...
-----------------
Confused about the failure to respond to D50, I begin packing up the equipment and prepare to move the patient from his bed to our stretcher.  I considered a possible CVA.  To fulfill my obligations, I pulled out two bristol(sp?) jets of Naloxone 2 mg.  My partner was new, but very eager to learn, and I was explaining my rationale to him step by step.

"The Narcan's not going to do anything, but I have to give it to him.  His pupils aren't pinpoint, his respirations aren't depressed... there's no indication of opiate overdose."

Not 30 seconds later, an aide walks into the room.

"Oh, he's going out this time?"

"Excuse me?  This happened before?"

"Yeah.  Last week, he was just like this.  I thought for sure he was going to be sent out.  But the doctor said it was because of his Duragesic Patch, and he just removed it and kept an eye on him."

"I didn't see a Duragesic Patch on him, is he wearing one now?"

"Oh no, they gave him a tylenol with codeine last night.  They really didn't want to give it to him though because of what happened last week."

Now, I actually hesitated to give him the Narcan.  (Again, see my opinion in the link).  But despite his apparently "adequate" ventilatory status, he was still unstable.  Also, I figured he wouldn't have that bad a withdrawal since he wasn't on pain meds for a prolonged period of time.  

You know what, Bongy, I should have just intubated him and tossed out the Narcan.

I gave him 2 mg IVP.  He woke up almost immediately.  I explained the situation to him and warned him about some symptoms he may feel.  He was quite understanding.

But on the way to the hospital, this patient went through the worst withdrawal I had ever seen.  Worse than any junkie I picked up off the street. He had diarrhea non-stop, he was nauseous, he shivered to the point that he could barely speak and the ED nurse even asked me if he was seizing.

So, the final diagnosis: AMS secondary to narcotic overdose and hypoglycemia.
Report to ED staff: "He's a lightweight"

Now, my questions: How could he have overdosed off a single Tyl 3?  Could it be because of severe hepatic insufficiency?  Can someone be so extremely hypersensitive to opiates because of some other predisposition?


----------



## Bongy (Jul 5, 2007)

RedZone said:


> Now, my questions: How could he have overdosed off a single Tyl 3?  Could it be because of severe hepatic insufficiency?  Can someone be so extremely hypersensitive to opiates because of some other predisposition?



In my opinion,possible liver dysfunction AND misdiagnosed kidney insufficiency... If I remember well - opiates are metabolized by CYP45 and excreted via renal pathway...


----------



## Ridryder911 (Jul 5, 2007)

Redzone, I was not purposefully picking upon your service, but it is hard to believe an ALS service would provide XII lead ECG but not allow or provide simple device such as a glucometer? I know there are such systems, but it is a shame that a patient would have a device but the EMS unit would not. 

What I believe to occurred was the patient was already hypoglycemic prior to administering the Tylenol 3. The nausea and vomiting, shivering, diarrhea can be associated with both hypoglycemia and opioid withdraw symptoms. 

With diseased hepatic systems, who knows what all the consequences can be? These type patients are difficult to maintain even in a stable environment. Hopefully, a DNR was discussed with this patient, so in the event of an arrest prolong measures can be avoided. 

Good scenario!

R/r 911


----------



## RedZone (Jul 5, 2007)

Ridryder911 said:


> Redzone, I was not purposefully picking upon your service, but it is hard to believe an ALS service would provide XII lead ECG but not allow or provide simple device such as a glucometer? I know there are such systems, but it is a shame that a patient would have a device but the EMS unit would not.
> 
> What I believe to occurred was the patient was already hypoglycemic prior to administering the Tylenol 3. The nausea and vomiting, shivering, diarrhea can be associated with both hypoglycemia and opioid withdraw symptoms.
> 
> ...



Thanks.

Yeah, he was DNR.  And no I'm not offended by any "picking on my EMS system" at all, nor did I really think you were.

There have always been some things I never understood.  Most of the medics here, at least as far as I'm familiar with, never bother to read journals, attend national conferences, apply for national registry, or even follow up with changing ACLS trends that haven't been implemented into our protocols. As a result, we pretty much end up assuming that most other EMS systems work the same way ours does.  I have an opinion that many "NYers" end up taking this self-centered ignorant attitude about a lot of things.  Dare we admit that somewhere else on this planet exists a place where things are done better.  And if it is, "Bahh... that wouldn't work here."

And during the most recent years, with hospitals crying broke, several of them claiming bankruptcy, and a few closing their doors for good (not to mention the for profit services that are motivated mainly by $).... new changes aren't implemented until mandated by regulation.

The most serious offense of this: AED's are mandated by law to be placed in schools, ferries, and several other public places.  But, there has yet to be a state or regional mandate to place them on an ambulance.  Yes, all BLS 911 ambulances are required by city contract, but many non-911 BLS ambulances are not equipped with defibrillators.  My opinion... disgraceful.

Glucometers have only been allowed for the past few years.  I NEVER understood why they're not routinely implemented.  As I understand it, the doctors on the political side of our EMS maintain the opinion that blindly administering D50 to all AMS patients poses no threat.  The cerebral edema argument is answered with: "That's an opinion only held by some neurosurgeons and not the rest of the medical field.  There is minimal evidence that D50 in high doses can necrose brain tissue, but that's only if administered during the active event of ischemia, a relatively short window.  There are far more risks by failing to administer D50 when hypoglycemia is misdiagnosed," and the DKA argument, "administering D50 to a hyperglycemic patient is like spitting in the ocean, it poses no risk whatsoever."

That still provides no answer to why we shouldn't simply test blood sugar first; a quick, simple, and relatively cheap procedure. I've heard that it "poses a safety risk to the medic", and that the "testing strips, even when sealed, are sensitive to climate changes making field use innacurate."  My opinion, bull****.

Oh, and like I said, THANKS FOR THE OPPORTUNITY TO RANT RID!!


----------

