# Straightforward...or is it?



## Fox800 (Dec 28, 2010)

You are dispatched to a sick patient. Dispatch information is that your patient is a 22 year old patient who "seems sick". You are working on an ALS ambulance, you and your partner are both paramedics of equal clinical authority.

On scene, the patient's mother and father guide you in to a well-kept house. They called you because the pt. seems very lethargic and is slow to respond. They tell you that the patient has chronic back pain and was having trouble sleeping last night so she took some pain medications to try to go to sleep. You find the patient sitting in a kitchen chair, she looks like she is asleep. Her head is down with her chin to her chest and you notice there is a reddish syrupy liquid spilled on her face and down the front of her shirt. The bottle on the table next to you is Tussionex, and by your powers of deduction you establish that that's what is also spilled on the patient. Here's your initial information:

28 year old female
PMH: Chronic back pain, depression. No diabetes, no seizure history, no cardiac or respiratory history.
Meds: Parents aren't sure what she takes, but they bring you what they can find...Norco, Tussionex, Prozac...and some OTC supplements and stuff, not important
NKDA per family

BP: 74/40 manual
HR: 140
RR: 40-50, pt. does not slow her breathing in response to coaching
SPO2: 85% on 15lpm NRB
ETCO2: Varying between 55-65
Lung Sounds: "Junky"
BGL: Normal, lets say 100
Temp: Normal, let's say 98.5.
Pupils: Constricted, 1-2mm and reactive
Pain scale: Unable to obtain due to mental status
ECG: Sinus tachycardia, 12-lead unremarkable
Mental status: Responsive to loud verbal stimuli, GCS=11 for incomprehensible verbal. Pt. barely opens her eyes when you yell and will obey commands somewhat.
Skin: Pink, cool, dry
Physical examination: Unremarkable except what's noted above. No incontinence. No signs of trauma observed. No MedicAlert tags.

Parents deny any history of drug/alcohol abuse and aren't aware of any life changes that may have made the patient more depressed/unstable than normal.

An IV has been established. What's your next move/questions?


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## firecoins (Dec 28, 2010)

put her on the monitor. whats her rhythm?

Is she pregnant?


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## Fox800 (Dec 28, 2010)

Sinus tachycardia on the monitor. 12-lead doesn't show anything interesting. Not pregnant. And oops, I put two different ages. The pt. is 28 years old, not 22.


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## Sassafras (Dec 28, 2010)

For the stupid people here, Tussionex is what?  Some for of Robitussin or guiafenessen (sp?)?  
It's kind of crappy she's only statting at 85% on a NR. I'm thinking first things first is establish a decent airway. But with junky lungs there's something pathological going on unless she aspirated something. Hmmm...thinking here with just my BLS cap on.


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## firecoins (Dec 28, 2010)

Fox800 said:


> Sinus tachycardia on the monitor. 12-lead doesn't show anything interesting. Not pregnant. And oops, I put two different ages. The pt. is 28 years old, not 22.



I figured it as a dispatching mistake.


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## Fox800 (Dec 28, 2010)

firecoins said:


> I figured it as a dispatching mistake.



Nicely done.

"Tussionex contains a combination of chlorpheniramine and hydrocodone. Chlorpheniramine is an antihistamine that reduces the natural chemical histamine in the body. Histamine can produce symptoms of sneezing, itching, watery eyes, and runny nose. Hydrocodone is a narcotic cough suppressant.

Tussionex is used to treat runny or stuffy nose, sneezing, and cough caused by the common cold or flu."

I'll also throw in that the Tussionex is an old prescription, from >6 months ago.

Her airway is patent.


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## Melclin (Dec 28, 2010)

Seems like she's overdosed and aspirated. Maybe not realizing the tussionex and norco both contain opiates (per my googling. Why do you Americans insist on using brand names in case studies?). But that seems too obvious given the title of the thread. 

The RR of 40-50..are they deep or shallow? How hard is she working?

If they're shallow, lets ventilate her with a closed circuit. I don't really know if you would do the same with a BVM. Like so, but without the straps.







If they're deep or she's working hard, we need MICA quick smart. A prehospital RSI might be in her future. That's not my decision, but I think its appropriate to call someone for whom it is. 

Grey Turner's of Cullen sign? 
Any abdominal distension or rigidity?
I know her back pain is chronic but there's no harm in checking.
How's here peripheral circulation and temp? 

Possibility of pregnancy would be high on my list (but you answered that).

Regarding that iatrogenic hole in her arm, I don't much care for the idea of putting naloxone in it, but I do think it would look pretty nice with 20mls/kg of NS trotting through. If the doctors wanna narc her, that's their decisions, they've got more options for sedation, induction and pain relief. But I sure wouldn't wanna do that until MICA were quite they weren't going to intubate her.


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## Fox800 (Dec 28, 2010)

Respirations are very rapid (40-60) and shallow.

Negative Grey Turner's or Cullen's signs.
No abdominal distention/rigidity.
Weak radial pulses, normal temp, skin is cool but dry and has good color.
Negative pregnancy.

IV is ran wide open. We got 1000mL NS in and her BP is up to...let's say 88/56. Nothing else changed from the fluids, though.

Transported emergent to a comprehensive receiving facility.

More questions/ideas? This one threw us and the ED physician for a loop (at least initially).


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## DrParasite (Dec 28, 2010)

I'm thinking drug overdose as well, probably opiate based.

chronic back pain, constricted pupils, decreased LOC, and the reddish liquid (possible the result of an aspiration) makes me think monitor/maintain the airway, and since apparently people on this board don't like to give narcan in the field, so M+T to an ER for further tests and evaluation.


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## Melclin (Dec 28, 2010)

Fox800 said:


> Respirations are very rapid (40-60) and shallow.
> 
> Negative Grey Turner's or Cullen's signs.
> No abdominal distention/rigidity.
> ...



Did you ventilate her? If so what was her response?

OD/Aspiration doesn't quite fit (unless it was intentional and she did something else as well), but I can't imagine what else this would be. 



DrParasite said:


> I'm thinking drug overdose as well, probably opiate based.
> 
> chronic back pain, constricted pupils, decreased LOC, and the reddish liquid (possible the result of an aspiration) makes me think monitor/maintain the airway, and since apparently people on this board don't like to give narcan in the field, so M+T to an ER for further tests and evaluation.



I'm not totally against naloxone, but its not a great idea to narc a person who is hypoxic and who will wake up into a world of probably severe respiratory distress. This doesn't totally fit the bill for a straight opiate OD either, so what I'm doing in not giving naloxone is saying, I don't _know_ whats going on, and I'm not going to simultaneously remove the possibility of an important prehospital treatment (RSI), and cause my pt possibly significant distress (withdrawal, hypoxia, resp distress) by giving a drug that only fixes problems that can be fixed in other ways that don't involve the above.


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## Veneficus (Dec 28, 2010)

Fox800 said:


> Meds: Parents aren't sure what she takes, but they bring you what they can find...Norco, Tussionex, Prozac...and some OTC supplements and stuff, not important



OTC supplements and stuff are always important.

But it looks like she is quite the mad scientist. She has a double dose of opioids, a SSRI, which thogh less than a TCA still antagonizes muscarinic, histaminergic, and a1 adrenergic. 

So she is probably breathing really rapidly to offset her rather profound metabolic acidosis. 

Better still, she has probably also lost control of her peripheral vascular control. 

If she took some OTC pain meds to help (like acetominophen) before during or after the competition for activation/inactivation in the liver there is probably a reduced metabolism prolonging and or potentiating the effects of any or all.

Better still if she took some ibuprofin or its derivitives like naproxin, her kidneys are probably paying the price for that too with some acute renal insufficency or failure. 

Perhaps she really hit the jackpot and mixed it up with some aspirin and has not only metabolic acidosis but respiratory alkalosis as well.

We can also probably rule in some self medication with the ETOH for pain.

Kidneys are probably going down anyway from insufficent BP, and since the receptors are antagonized already by the prozac, it will probably take a lot of vasoactive support along with fluids to help the BP.

Cardiac output compromised by decreased venous return.

I think she qualifies for some narcan in order to help redce some vasodialation a bit. we hope. 

She is going to get a couple litres of saline and might as well toss in some pressor too, dopamine couldn't hurt, though with the antagonism it is probably going to take a fair amount. 

Then she gets an NG and a charcoal.   

Not going to tube her or add o2, until the hospital tells me she does not have ASA in the system as well.

While somebody make get the bright idea to push some bicarb because this is going to be a rather interesting (aka complex) tox management in the ICU, I think that can wait too.   

Next she gets to go to the hospital, where hopefully the ED will be turfing her post haste to the unit for more precise workup and correction. Maybe even some dialysis.



Fox800 said:


> What's your next move/questions?



Does she have insurance?


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## Fox800 (Dec 28, 2010)

Melclin said:


> Did you ventilate her? If so what was her response?
> 
> OD/Aspiration doesn't quite fit (unless it was intentional and she did something else as well), but I can't imagine what else this would be.
> 
> ...



She was alert enough to not tolerate a BVM.


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## Fox800 (Dec 28, 2010)

Let's assume that her only OTC item was a daily Wal-Mart brand multivitamin. For the purposes of this scenario it wasn't important.

I like the details about Prozac. Honestly I'm not sure what antidepressant she was on, this happened about six months back, I just remember she was on one. The Norco and Tussionex were the important parts that I remembered.

Aaaand...she has Medicaid B)

This is a case of two underlying problems happening at once. You guys are right with the OD but there's another element to this picture...


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## usalsfyre (Dec 28, 2010)

Seems awful septic, except for the temp. Any history of olguria that might indicate ARF? Coughing, flu like symptoms that made you think pneumonia?

The plan:
Lots and lots of fluid, preferably LR to prevent contributing to any preexisting acidosis.

RSI. Based on what's presented she needs it. We don't have any other indication she took an ASA overdose, so I'm ok with pulling the trigger on this one. 

NG with copious amounts of suction. Consider an inline neb with the mechnical ventilation. Maybe a pressor if she doesn't respond to fluid, based on the fact she doesn't look tight (pink skin) I'd probably go with norepi or phenylephrine.


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## Melclin (Dec 28, 2010)

I've just read the bit where it said slumped with chin on chest. How long after that was corrected did you get those vitals? I don't quite get the logistics of this. What time is it? What time last night did she take the pain meds? What time is it now? Has she just been sitting there all night drooling cough syrup? I wasn't ganna bother clearing this up because I figured the outcome would be above my head anyway, but now I'm interested.



Veneficus said:


> OTC supplements and stuff are always important.
> 
> But it looks like she is quite the mad scientist. She has a double dose of opioids, a SSRI, which thogh less than a TCA still antagonizes muscarinic, histaminergic, and a1 adrenergic.
> 
> ...



I suppose a severe aspirin OD as well as some opiates thrown in would fit  but (this is probably one of those area dependent things because ASA is fairly rare as a household analgesic here) why would you withhold O2 from a hypoxaemic, hypo-ventilating pt on the off chance (there is no evidence of ASA) she may have taken a six month supply of dad's cardiprin as well? What about the temp? An ASA OD severe enough to cause resp alkalosis but with no elevate temp?

If there is some ASA involved and she is progressing to mixed resp/metabolic acidosis with pulmonary odema (?junky lungs), then isn't intubation indicated?

Aside from the ASA: I suppose "shallow vents" is subjective, but I picture a person with severely reduced tidal volume, with an elevated end tidal, and reduced SpO2. Surely ventilating them is a good idea. Hypoventilation is bad regardless of whether or not its the primary problem, or on top of metabolic acidosis.  

Opiate induced hypoventilation Vs Metabolic acidosis induced hyperventilation. Is there going to be a winner? Or are you going to see an unpredictable merging of affects?

I'm still not sold on the naloxone. Her MAP is now 67 after only a litre of fluid. I wanted about 1400, and I'll say now she can have another 1400 (although we'd better keep an eye on these 'junky' lungs of hers). I don't see the benefits of waking up a hypoxic patient (and so probably non-compliant and mildly violent) in resp distress and pain in the hopes that her hypotension (which is now rising to more acceptable levels) is caused by the opiates, while taking away my MICA backup's ability to tube her if they feel she's indicated as it stands, or if she goes down hill. I think she can wait the 5-10 mins it will take for a rendezvous with MICA and then I'd be more open to narcing her if they decide not to tube. There have been a few jobs like this floating around where naloxone has been considered ill-advised on account of polypharmacy and aspiration.


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## Melclin (Dec 28, 2010)

usalsfyre said:


> Seems awful septic, except for the temp. Any history of olguria that might indicate ARF? Coughing, flu like symptoms that made you think pneumonia?
> 
> The plan:
> Lots and lots of fluid, preferably LR to prevent contributing to any preexisting acidosis.
> ...



Sepsis that bad, that quick? We're only talking about 8 hours or so right?


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## Veneficus (Dec 28, 2010)

*the mystery component*

I would think that if she was given some industrial strength caugh medicine that she would have some underlying infection. Pneumonia, meningitis, PID, take your pick, but it won't matter, get some cultures start some vanc.

An alergic reaction to the medication, possibly, but with the double suppression of the histamine I wouldn't think it was a major factor. 

PCN if she took some could cause a type II hypersensitivity RXN, but I will look at the findings again when I get home.


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## Veneficus (Dec 28, 2010)

usalsfyre said:


> RSI. Based on what's presented she needs it. We don't have any other indication she took an ASA overdose, so I'm ok with pulling the trigger on this one.



she doesn't need to take an ASA OD, all she has to do is tie up her metabolic pathways with all the other crap.

What are you planning to RSI her with that is going to add to her witches brew?


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## usalsfyre (Dec 28, 2010)

Veneficus said:


> she doesn't need to take an ASA OD, all she has to do is tie up her metabolic pathways with all the other crap.
> 
> What are you planning to RSI her with that is going to add to her witches brew?



Definitely NOT etomidate (our agent of choice per clinical guideline), I'm thinking the associated adrenal supression is the last thing she needs. 

If I can get away with it (and where I'm currently at I could) I would probably nebulize some lido and do an awake intubation. Second choice would be a simple opiate induction with fentanyl to avoid hypotension and adding to the polypharm. Last choice would be propofol with a healthy slug of neo standing by to help with the inevitable hypotension. I'd like to stay away from benzos due to hypotension and length of action, etomidate for the above mentioned reasons, and ketamine to avoid adding to the "witches brew".

I'd like to avoid NMBs if I can, but if I have to use one any of the non-depolarizers will work (roc being my favorite). Sux has to many side effects for my liking in this case.


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## Veneficus (Dec 28, 2010)

Fox800 said:


> You are dispatched to a sick patient. Dispatch information is that your patient is a 22 year old patient who "seems sick".



Good, I like patients who at least seem sick than ones that are not making any effort to be.



Fox800 said:


> On scene, the patient's mother and father guide you in to a well-kept house.".



On medicade? A crack shack with a 60" plasma and the latest PS with 100 games I would expect, but certainly not a well kept house.



Fox800 said:


> They called you because the pt. seems very lethargic and is slow to respond. They tell you that the patient has chronic back pain and was having trouble sleeping last night so she took some pain medications to try to go to sleep.



Back pain. From what?

Ovarian mets?

Mittlesmirtz?

Prior trauma?

Renal problems?

Stones?

Good excuse to get opioids? (don't hate, some people do that)



Fox800 said:


> You find the patient sitting in a kitchen chair, she looks like she is asleep. Her head is down with her chin to her chest and you notice there is a reddish syrupy liquid spilled on her face and down the front of her shirt. The bottle on the table next to you is Tussionex, and by your powers of deduction you establish that that's what is also spilled on the patient.



Hopefully not caughing up blood from TB, malory weiss tears or bleeding peptic ulcer. Of course with the histamine block, probably not much acid.



 Here's your initial information:



Fox800 said:


> 28 year old female
> PMH: Chronic back pain, depression. No diabetes, no seizure history, no cardiac or respiratory history.



PGMA?

She is pregnant until proven otherwise by HCG.

Since she took some caugh syrup, there was probably some method to the madness. "say AHHHHH" or at least yell loud enough so we can evaluate the dental needs as a route of infection.

oooh, infective endocarditis...  Not lupus yet.  But if she is having renal manifestations of it...

But with her lungs and potential renal backpain lets add goodpastures and sarcoidosis to the list.



Fox800 said:


> Meds: Parents aren't sure what she takes, but they bring you what they can find...Norco, Tussionex, Prozac...and some OTC supplements and stuff, not important



Track marks, lots of perfume or drug paraphanelia?



Fox800 said:


> NKDA per family



Not that it matters with all the antihistamine.



Fox800 said:


> BP: 74/40 manual



Cause she is in shock. Probably constipation from the opioids too now that I think about it.

HR: 140

"more shock, any abnormal heart tones?"

Pericardial effusion? (aka tamponade?) What is the amplitude of the QRS on the monitor? Normal or small?



Fox800 said:


> RR: 40-50, pt. does not slow her breathing in response to coaching



Toxicity described above, perhaps a PE from her contraceptives and smoking?
Anxiety from antidepressant?



Fox800 said:


> SPO2: 85% on 15lpm NRB



air not going in.

No o2 in or no gas exchange. Perhaps a pneumo from caughing? Not really thinking neoplasm, airway obstruction?



Fox800 said:


> ETCO2: Varying between 55-65



not surprising with the hypervent.



Fox800 said:


> Lung Sounds: "Junky"



very discriptive. TB, Pneumonia, aspiration, cardiogenic shock



Fox800 said:


> BGL: Normal, lets say 100



At least she is eating well or gluconeogenisis works.



Fox800 said:


> Temp: Normal, let's say 98.5.



too many factors for this to be reliable or really useful. At best it could be a sign of chronic infection.



Fox800 said:


> Pupils: Constricted, 1-2mm and reactive



opioids.



Fox800 said:


> ECG: Sinus tachycardia, 12-lead unremarkable



could show pericarditis or tamponade.



Fox800 said:


> Mental status: Responsive to loud verbal stimuli, GCS=11 for incomprehensible verbal. Pt. barely opens her eyes when you yell and will obey commands somewhat.



toxic, not surprising. Could be menengitis as well.



Fox800 said:


> Skin: Pink, cool, dry



Shock with vasodilation, but still pink at 85% spo2? Doesn't sound right. Sepsis. CO unlikely.



Fox800 said:


> Physical examination: Unremarkable except what's noted above. No incontinence. No signs of trauma observed. No MedicAlert tags.



I am sure there is something abnormal. perhaps unnoticed.



Fox800 said:


> Parents deny any history of drug/alcohol abuse and aren't aware of any life changes that may have made the patient more depressed/unstable than normal.



And she is a virgin too. I never believe parents, so all of this is still possible.

not describing toxic effects again


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## Fox800 (Dec 29, 2010)

Awesome discussion going on in here. I'm a bit short for time but I'll come back and address all of the questions a little later, the parents are coming to visit from out of town.

Initially we were concerned about a PE on top of an opiate OD. The main thing that didn't fit in my mind was the high ETCO2 reading.

The ER MD was also concerned about a PE, that was the main thing going through his mind as they started patient care.

Called the ER a few hours later, the patient was indeed septic with pneumonia, on top of the opiate OD.


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## Veneficus (Dec 29, 2010)

Melclin said:


> I suppose a severe aspirin OD as well as some opiates thrown in would fit  but (this is probably one of those area dependent things because ASA is fairly rare as a household analgesic here) why would you withhold O2 from a hypoxaemic, hypo-ventilating pt on the off chance (there is no evidence of ASA) she may have taken a six month supply of dad's cardiprin as well? What about the temp? An ASA OD severe enough to cause resp alkalosis but with no elevate temp?



Ventilate sure, if you can without fighting her. But it was already described as not tolerable. 

I would not intubate her because of the unreliable history and the already difficult toxicity issues. In my risk/benefit analysis, adding a RSI to a pt who is fairly maintaining the airway prehospital vs complicating the management later doesn't pay. If she wasn't breathing, I would be more inclined to the benefit side, but also consider the hypervent may be a compensatory mechanism to the metabolic acidosis and when you control the rate at 12-20 you are knocking that mechanism out. 

To use an experience on how well there can be respiratory compensation, I saw a GCS 3 renal failure patient who had dialysis removed as part of withdrawel of efforts, with textbook Kussmal's resps compensate for 9 days before expiring. My conclusion is that respiratory compensation can be considerable and sometimes beneficial.

I think I was more worried about a combined alkalosis/acidosis from potential mixes when I wrote that up and it just came out focsed on ASA.

Respiratory alkalosis can be caused by more than ASA. But I figure if she was taking the OTC stuff, potentially some alcohol, and the prescription meds that her multifunction oxidases were well saturated along with her conjugation enzymes and she could not excrete if she wanted. 

I also figure that chances are good she took something other than the opioids for chronic pain.




Melclin said:


> If there is some ASA involved and she is progressing to mixed resp/metabolic acidosis with pulmonary odema (?junky lungs), then isn't intubation indicated?



She may at some point be intubated, but it is not an automatic indication, as well in ASA OD, the tox experts I have read feel intubation actually probably harms. But like I said, this is going to be complex. Renal fnction will have to be assessed before diuretics are considered for the edema. I think in this case it is probably caused by the rapid HR and decreased LV filling backing it all up.



Melclin said:


> Aside from the ASA: I suppose "shallow vents" is subjective, but I picture a person with severely reduced tidal volume, with an elevated end tidal, and reduced SpO2. Surely ventilating them is a good idea. Hypoventilation is bad regardless of whether or not its the primary problem, or on top of metabolic acidosis.



I don't disagree, but in this case, with the toxic issues as well as the harm caused by fighting a noncompliant patient, ventilating and intubating are not one in the same. As I said, the risk/benefit this early in management does not play out well in my mind.  



Melclin said:


> Opiate induced hypoventilation Vs Metabolic acidosis induced hyperventilation. Is there going to be a winner? Or are you going to see an unpredictable merging of affects?



With a RR of 40+/min I think acidosis is winning. I understand that with the increased ATP demands vs. the amount being produced, it is not a good long term solution.  But if you "control" ventilation and the systemic or local organ PH is still rising, which without serial labs, will probably be detected prehospitally as coma or arrest, what then? Run the ACLS algorythm and consider hypoxia as a reversible case addressed? How far or who is going to be quick on the bicarb trigger on this one if she does code? (other than me)



Melclin said:


> I'm still not sold on the naloxone. Her MAP is now 67 after only a litre of fluid. I wanted about 1400, and I'll say now she can have another 1400 (although we'd better keep an eye on these 'junky' lungs of hers). I don't see the benefits of waking up a hypoxic patient (and so probably non-compliant and mildly violent) in resp distress and pain in the hopes that her hypotension (which is now rising to more acceptable levels) is caused by the opiates,



I don't think her hypotension is caused by opiates, I think it is caused by a myriad of other things, one of which being alpha1 blockade and the inability to mitigate its effects in the short term because of failure to metabolize the prozac or now possibly TCA doing it. By eliminating the opioid effect, it can potentially (no promises) act in a vasoconstrictive manner than is potentially not acievable by the other a1 agonist meds. Otherwise with gross systemic afferent arteriole dilation, you are going to need way more than 2800ml of fluid to help. Especially if she is in renal failure or has ATN. 



Melclin said:


> while taking away my MICA backup's ability to tube her if they feel she's indicated as it stands, or if she goes down hill. I think she can wait the 5-10 mins it will take for a rendezvous with MICA and then I'd be more open to narcing her if they decide not to tube. There have been a few jobs like this floating around where naloxone has been considered ill-advised on account of polypharmacy and aspiration.



I am not overly impressed with narcan myself usually, but I think in this case the problem isn't so much the opioid loss of respiratory control, but the polypharm that already exists. The more you add to it, the tougher it becomes.


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## Melclin (Jan 5, 2011)

Veneficus said:


> Ventilate sure, if you can without fighting her. But it was already described as not tolerable.



Yeah, thats why I make mention of our closed circuit. Its much easier to tolerate and spontaneously breathe through than a BVM (hence my reluctance about a BVM) and one can also discern spontaneous resps/assist vents, as well as monitor RR and get a rough idea of Vt trends. In the end, I suspect its probably still considerably less desirable in the eyes of the baked pt than lying undisturbed in a comfy puddle of drool.



Veneficus said:


> I would not intubate her because of the unreliable history and the already difficult toxicity issues. In my risk/benefit analysis, adding a RSI to a pt who is fairly maintaining the airway prehospital vs complicating the management later doesn't pay.



Fair point. 



> If she wasn't breathing, I would be more inclined to the benefit side, but also consider the hypervent may be a compensatory mechanism to the metabolic acidosis and when you control the rate at 12-20 you are knocking that mechanism out.



Do you have to control the rate? Why cant you maintain the hypervent?



Veneficus said:


> To use an experience on how well there can be respiratory compensation, I saw a GCS 3 renal failure patient who had dialysis removed as part of withdrawel of efforts, with textbook Kussmal's resps compensate for 9 days before expiring. My conclusion is that respiratory compensation can be considerable and sometimes beneficial.



I wasn't aware that compensation like that could go on for so long. Very interesting. 



> I think I was more worried about a combined alkalosis/acidosis from potential mixes when I wrote that up and it just came out focsed on ASA.



Gotcha.



> I don't disagree, but in this case, with the toxic issues as well as the harm caused by fighting a noncompliant patient, ventilating and intubating are not one in the same.



True. Was it you that had a mentor or lecturer that said something in the order of, "No one ever died from not having a plastic tube in their throat"? I think about that one liner often lately. I feel like I'm a bit quick on the intubation trigger in scenarios. Doesn't matter terribly since I won't be doing it for 4-5 years, but good to consider all the same.  



> With a RR of 40+/min I think acidosis is winning. I understand that with the increased ATP demands vs. the amount being produced, it is not a good long term solution.  But if you "control" ventilation and the systemic or local organ PH is still rising, which without serial labs, will probably be detected prehospitally as coma or arrest, what then? Run the ACLS algorythm and consider hypoxia as a reversible case addressed? How far or who is going to be quick on the bicarb trigger on this one if she does code? (other than me)



If she arrests then yeah bicarb is up front. Def. Its not even that big a leap, it'd be per guidelines.. sort of.



> I don't think her hypotension is caused by opiates, I think it is caused by a myriad of other things, one of which being alpha1 blockade and the inability to mitigate its effects in the short term because of failure to metabolize the prozac or now possibly TCA doing it. By eliminating the opioid effect, it can potentially (no promises) act in a vasoconstrictive manner than is potentially not acievable by the other a1 agonist meds. Otherwise with gross systemic afferent arteriole dilation, you are going to need way more than 2800ml of fluid to help. Especially if she is in renal failure or has ATN.



I'm ganna have to get my hands on a copy of Goodman and Gilman's. Its becoming increasingly apparent to me that my pharm book learning is grossly inadequate. 


10char


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## Veneficus (Jan 5, 2011)

Melclin said:


> Do you have to control the rate? Why cant you maintain the hypervent?



What is the point? She is compensating for metabolic acidosis with increased rate. What would bagging at that rate really do? The body only needs roughly 11% O2 to survive, Room air is usually around 21%

You could increase the partial pressure of o2, but I think if you are going to maintain the rate, what would be the point? If you were going to slow the rate, to say 20-30, you are still degrading the natrual compensation.




Melclin said:


> True. Was it you that had a mentor or lecturer that said something in the order of, "No one ever died from not having a plastic tube in their throat"? I think about that one liner often lately. I feel like I'm a bit quick on the intubation trigger in scenarios. Doesn't matter terribly since I won't be doing it for 4-5 years, but good to consider all the same.



Yes, it was one of my anesthesia lecturers.  





Melclin said:


> If she arrests then yeah bicarb is up front. Def. Its not even that big a leap, it'd be per guidelines.. sort of.



I think it is the proper clinical decision if you are making them and not being a protocol junky. But you know how the game works in many US systems, bicarb is way down the list. Sometimes even needing an order.




Melclin said:


> I'm ganna have to get my hands on a copy of Goodman and Gilman's. Its becoming increasingly apparent to me that my pharm book learning is grossly inadequate.



That is a great book.

But it also is how you se your knowledge. You can know there is A1 blockade, but you can also reason in this case there is some opioid induced dilation. Of course you can try to saturate A1 agonists, but you might also get something from removing the opioid. If you were really desperate to increase the BP, you could even pace the pt or add some digoxin  But I wasn't thinking that radical. Volume will still be needed.


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## Melclin (Jan 5, 2011)

Veneficus said:


> What is the point? She is compensating for metabolic acidosis with increased rate. What would bagging at that rate really do? The body only needs roughly 11% O2 to survive, Room air is usually around 21%
> 
> You could increase the partial pressure of o2, but I think if you are going to maintain the rate, what would be the point? If you were going to slow the rate, to say 20-30, you are still degrading the natrual compensation.
> 
> But it also is how you se your knowledge. You can know there is A1 blockade, but you can also reason in this case there is some opioid induced dilation. Of course you can try to saturate A1 agonists, but you might also get something from removing the opioid. If you were really desperate to increase the BP, you could even pace the pt or add some digoxin  But I wasn't thinking that radical. Volume will still be needed.



Well put.  

Cheers, as always, for taking the time with me  

You, Ventmedic (surly though she was) and Usafmedic45 should apply to my uni for a stipend seeing as though you guys are responsible for a considerable portion of my education


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## boingo (Jan 5, 2011)

It would seem this patient could benefit from mechanical ventilation.  Her work of breathing requires a huge amount of o2 and energy, both could be better used elsewhere.  She is also failing to oxygenate/ventilate, some PEEP would likely come in handy, although with her BP we need to be careful.


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## Veneficus (Jan 5, 2011)

Melclin said:


> Well put.
> 
> Cheers, as always, for taking the time with me
> 
> You, Ventmedic (surly though she was) and Usafmedic45 should apply to my uni for a stipend seeing as though you guys are responsible for a considerable portion of my education



Anytime, 

you are always welcomed to encourage your uni to pay my way down there to come and speak. I'd be more than happy to make an appearance for travel and lodging.


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## MrBrown (Jan 5, 2011)

Doors open .... hmm looks well clear, clear to ground, illegal Mexicans running away one o'clock low, well clear, skids coming on, load coming off ....

*Brown leaps out and hands Oz his orange "PARAMEDIC" jumpsuit and David Clark headset,

Come quick Oz, now that Brown missed this one he has a chance to redeem himself, she's a go-er, an RTA, persons trapped, Ambulance on scene ....

Ambulance, Medivac airborne


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