# 19 Year Old Male ALOC



## Handsome Robb (May 11, 2013)

So I posted some details of this in the directionless thread, was going to pm it to a select group of people then decided to make it available to the whole world rather than limiting myself. 

It's ~1500 on a beautiful Thursday and you and your partner are returning from a somewhat long psych transfer out of town. Tones drop on you for a "priority 2 unknown problem man down, reported as a male in his early 20s laying in the grass in front of the movie theater" at the mall south of town that you just so happened to be coming up on. En route your call is reconfigured to a "priority 2 diabetic problem".

The mall parking lot is huge and there are a lot of little pieces of lawn around, after about 5 minutes meandering about the mall parking lot you find your patient. An ILS fire crew, mall security and the patient's father are already on scene. 

Fire reports 19 yo male history of insulin-dependent diabetes was found laying on the grass "acting odd." Father states he was out with some friends but was "normal" at 0900 this morning.

Pt is a&ox0, responsive to loud verbal stimuli, GCS 11 (3/3/5) and mildly combative (think aimless, weak swats at hands and grabbing pant legs).

Initial vitals (per fire, there's my first mistake with this crew) of 110/70, pulse of 130 strong and regular at the radial, SpO2 78% on room air, respiratory rate 50 deep and regular. CBG "HI" with a ketone warning (>600 mg/dL on our glucometers.)

Physical exam shows no signs of trauma, skin is pink, hot and very dry, PERRL but sluggish at 4mm (outside in the 85 degree bluebird day) no JVD, trachea midline.
Chest is without signs of trauma, equal rise and fall bilaterally, clear to auscultation anteriorly and posteriorly, no retractions or accessory muscle usage noted. 
Abdomen is soft, no palpable or pulsating masses noted, no guarding. Pelvis is stable, no urinary or bowel incontinence noted.
Lower extremities are unremarkable, upper extremities have a gazillion scars from what appear to be intravenous injections, other than that they're unremarkable, no peripheral edema noted.

History: IDDM and "psychiatric problems", father denied any previous suicide attempts, denies any knowledge of drug or ETOH abuse but states "it wouldn't surprise me."

No known allergies or drug allergies.

Medications: Insulin (father unable to be more specific), Prozac and guanfancine

I wanted to go to the closest facility but father was adamant about going downtown, second mistake. Should have put my foot down but at this point I didn't see anything that lead me to believe he'd take a dump on me like he did. 

I will also add another mistake I made was letting dad **** around on the phone for ~5 minutes trying to find out allergies and the name of the patients medications, should've gone and gotten them from the ER.

What I did:

Non-rebreather at 15lpm, still semi-conscious at this point so tried an NPA that he fought viciously so I let him be since he was doing a decent job of protecting his airway. 4-lead, partner did repeat vitals while I worked on a line. This is where I realized this kid is in a much worse situation than I originally had thought but at this point I had already dismissed fire (third mistake before assuring the vitals they gave me were accurate. Some crews are awesome, this one not so much and I knew it but disregarded it.) I somehow managed to fight an 18g through the scar tissue in his right AC with a liter bag + pressure bag running wide open, partner botched the left AC. 

Repeat vitals were 
100/50
150 BPM, sinus tachycardia without ectopy. I didn't do a 12-lead...it wasn't high on my priority list, frankly it was at the bottom. I didn't see a reason but if I'm missing something please chime in. 
87% on 15 LPM
RR 50 still deep and regular. Classic kussmaul respirations.

From this point it went downhill. We started transport routine and upgraded to code 3 soon after I took another set of vitals. 


GCS reduced to 9 (2/2/5)
BP 74/p (NIBP gave 70/30, I couldn't hear it on our wonderful freeways so I palped it twice to be sure)
HR still 150 sinus without ectopy
SPo2 down to love 80s on 15 LPM 
RR still 50/min, snoring but it was very obvious to me that he was tuckering out.
Lungs still clear from what I could hear, unfortunately the Master Cardiology is a little too good when the sirens are going and I couldn't get a great listen between them and the road nose.

Popped a NC wi 6lpm on, popped him supine, put a pillow behind him and did the most epic head-tilt chin-lift I've ever done and started bag assisting every 4-5 breaths which got him into the low 90s. Again tried an NPA that he fought violently so I again pulled it. Restrained upper extremities at this time because he was going after the only patent line we had and the only other option was an IO, his vasculature was totaled.

Transport was about 20 minutes. I didn't really get a whole lot done after I started bagging him. The ER tubed him straight away, started a CVC, and shipped him to the ICU. Unfortunately this was two days ago and I didn't make it to that ER today so I don't know any labs or an official Dx. Pop's wedding is mañana so I don't work again until Sunday. 

I want the good the bad and the ugly. No holds barred. Criticisms, things to think about, "you're an idiot" or compliments are all welcome. I've had a few DKA patients, none that did anything like this.  Only thing I could think of is potential Sepsis combined with DKA? We learned later he  a discharged from the ICU within the last two weeks and had a foley, CVC, art line although was not on any antibiotics and the father stated he had not been complaining of anything.

Sparknotes of my mistakes: 
1) Should have redone vitals as soon as we got to the pt even with fire already having done them.

2) didn't put my foot down with dad on transport destination and while he was cupcaking around on his cell phone. 

3) dismissing the fire department prior to reevaluating vitals and getting a better picture.

4) he made it to the ER, I thought about diverting to the closer facility but they were on a CC divert so he'd have to be transfered out pretty quickly. With that said, I can disregard diverts if I deem necessary per protocol. *Should I have diverted?* it would have meant a physician with RSI capabilities. Sometimes in situations like this I'm told we can stop, they will control the airway while he's still on our gurney and arrange a rapid transfer to their main facility and we can just continue on our way. When I say rapid transfer though I mean in the range of 20 minutes or so to get through all the hoops they have to jump through.

5) we have nasotracheal intubation capabilities and a protocol to do it. With our 20/20 hindsight this patient probably needed it. Unfortunately, I do not feel comfortable with this procedure, have only been trained on it a handful of times and the general consensus I've gotten is that they're frowned upon by the ER and our QA/I. With that said I have no problem standing up for my actions and being a patient advocate but I felt it would be negligent for me to attempt a procedure I'm not comfortable with, without assistance, jamming down the highway with the disco lights going. Looking back had he gotten much worse or the transport been much longer I would have had to have done something. 

Sorry for the novel and the spelling/grammar, iPad keyboards, a bumpy ambulance and a sleepy paramedic make for a fun read  Ready, set, GO!


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## ItsTheBLS (May 11, 2013)

I don't think you did anything terrible, however you can see where some issues were.

Although I'm a lower cert level than you, I personally wouldn't trust a lower-level provider than myself with obtaining patient vital signs. That is to say, I would not trust the fire department in my area to take proper vital signs. Important things like that I reserve to myself, my partner and higher-level providers. 

As for the father- definitely be firm. He was on the phone to obtain this information for you, thinking he's doing you a favor. If the information is not readily available, spending more time on scene will not help.

With regards to the choice of hospital, if you firmly believed he should go to the closer facility, explain that to the father to the best of your ability. He is not a minor, so I am not sure who has jurisdiction over where he goes from a legal standpoint.

Other than these things I'd say it was handled relatively well, you got his sats up and got a line in. These interventions will probably have helped him significantly.


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## chaz90 (May 11, 2013)

Interesting case for sure...

In regards to onset, what does Dad mean when he was fine at 0900 but is as you found him at 1500? Was he out with his son when he suddenly dropped? That obviously doesn't support sepsis or even DKA, but who knows. SpO2 may not be accurate due to poor peripheral circulation with his BP in the tank. Then again, it may be that low with that profound tachypnea. Also, I'd be inclined to agree with you that his BP didn't end up actually crumpling as you were there. Fire probably didn't accurately take/didn't think what they were hearing was correct with a 19 year old and a systolic BP of 70. I would imagine the hypotension is why this patient is altered too, so I'm trying to think what precipitating event caused the sudden decrease in LOC if he was just walking around at the mall and acting relatively normally. 

I know you don't have either of these tools, but if I had this patient I'd put on sidestream capnography and run a POC lactate. If I were a betting man, I'd wager his lactate is elevated and his EtCO2 may be higher than you would normally expect with his marked hyperventilation due to his underlying metabolic acidosis. I really am still leaning towards pulmonary edema due to his tachycardia. To me, this could help explain the precipitous drop in BP that brought him from relatively normal to being your patient. Lung sounds wise, I don't think you could hear the fluid build up due to how low his tidal volume must have been and the road noise. 

I would imagine he has been sick for a couple days (possibly a complication from his invasive procedures last week), which brought on his DKA and fluid retention. His HR has been compensating well until now, which may have allowed the edema to begin to affect his sats and cardiac output. Let me add of course that I could be 100% wrong and blowing smoke everywhere.

As far as my treatments are concerned, I'll operate under the assumption that I have at least one assistant, which I know you did not. I'd look for secondary access somewhere, be that EJ or IO. This patient is critical and does need access, so I have no problem drilling him. Having RSI available, I'd intubate this patient as well. He's hypoxic, won't tolerate less aggressive airway management, and I'm not happy with the results just ventilating him with a BVM. In your situation though, I'd try an NPA one more time and continue with the BVM. My experience with NPAs are that even combative patients tend to forget about them with enough viscous lidocaine after the initial shock of insertion. The pt's hand are restrained, so I'd try to slip it in quickly and see if he forgets about it. 

With that established and the BP not improving after 1 L of fluid pressure infused, I'd be moving towards a Dopamine drip. There's no way I'd want to keep the MAP around 43 mm Hg (from 70/30). I'd start the Dopamine at 10 mcg/kg/minute as I'm hoping for alpha agonist activity over beta stimulation of his poor tachycardic heart. 

As far as your treatments went, I think you did fine considering how hamstrung you were alone in the back. As mentioned earlier, I'd be grabbing someone else on an intercept for this patient. Call dispatch for another medic unit to intercept preferably, or a supervisor, or even a fire station pre alerted by dispatch that you're driving by. NTI would be a nightmare on this patient considering how combative he was to an NPA and how woefully unprepared we are to do that. I've heard it's easier than we imagine, but (anecdote warning) I've only seen it attempted once, and it was a bloody failure. We carry Endotrols here, which are probably used less frequently than crics, and they have a trigger that is supposed to help direct the tube anteriorly. I may have considered diverting for this patient for airway control, but I don't think it would be rapid. This isn't some massive trauma airway that a doc may cric and send on their merry way to a trauma center. The patient would probably be intubated at the divert hospital with a central line placed, pressors, insulin, bicarbonate, potassium, labs (not in that order), and transferred later. 

This really is a cool case! Let us know of any feedback you receive and what the final diagnosis is.


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## Trailrider (May 11, 2013)

Are we talking kussmauls sign or actual kussmauls? Acidosis explains why this poor guy is breathing so fast, well it makes sense to me as he is trying to blow off of the excess h+. Would insulin be an option here for the dka? I am a new student for any other providers responding. Interesting case, thanks!


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## Handsome Robb (May 11, 2013)

Trailrider said:


> Are we talking kussmauls sign or actual kussmauls? Acidosis explains why this poor guy is breathing so fast, well it makes sense to me as he is trying to blow off of the excess h+. Would insulin be an option here for the dka? I am a new student for any other providers responding. Interesting case, thanks!



The problem with just giving insulin is it doesn't fix everything else that's wrong. 

Also the body doesn't tolerate rapid changes well. Perfect example is febrile seizures. They don't seize because they're hot, they seize because the spike a temperature. 

And kussmaul respirations.


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## sir.shocksalot (May 11, 2013)

Well that's quite the case. I agree with your assessment of what could have been improved such as keeping a few extra hands with you. To be honest I don't think the transport time really made much of a difference. While his blood pressure and respiratory status are pretty poopy, they aren't exactly rapidly deteriorating. In all likely hood his blood pressure probably had been in the 70/30 range from the beginning. The pt being "combative" is probably going to skew the results, plus you have some bandwagon effect going on when your partner takes the next set of vitals (who also can't hear it well but picks a number close to fire's number). 

As far as management I think you did well. I agree with Chaz that drilling him would be totally appropriate. Not sure if you would have much luck with an EJ on him considering his mental state. Fluid is good considering he is probably profoundly dehydrated from osmotic diuresis. I don't think I would start pressers on him personally. To me I don't think I would feel like it was a squeeze or pump problem until I had put in another liter of fluid with no changes and in twenty minutes I don't think I'd feel comfortable gauging his response to treatment to start dopamine. His blood pressure is low but I wouldn't feel comfortable saying that all of his symptoms are secondary to the pressure and not an encephalopathy or acidosis. But that may be a comfort thing as I have never initiated dopamine in the field. Airway wise I think you did what you could. I again agree with chaz and think that maybe the SpO2 wasn't entirely indicative of actual tissue oxygenation. RSI would be ideal to assist ventilations, in leu of that I wonder if you could have given versed/valium/Ativan as procedural sedation? Getting an order would be the trick with his pressure in the toilet though. A nasal tube without sedation in this dude would have been bad news, a slight move of the head can result in your tube going down the wrong hole.

I think there is probably a lot more to this patient's story and the father doesn't sound like he actually knows his son that well. For all we know the patient may have been having DKA symptoms for the past day or two and just left father out of the loop.

Trailrider: Trying to correct DKA in the prehospital setting with insulin doesn't work. One reason being that insulin actually causes hypokalemia (it has something to do with the glucose moving into the cell but don't quote me). Severe hypokalemia can result in cardiac arrest. Another reason is that any rapid decrease in intravascular osmotic pressure can cause cerebral edema which causes deadness. Severe DKA treatment is best left to the ICU.


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## FLdoc2011 (May 11, 2013)

Yea, ultimately this kid needed to be intubated and fluid resuscitated.   If it was DKA (which sounds like it probably was) he was probably at least 4-6L down and needs a LOT of fluid.   

DKA is pretty straight forward to treat, but is labor intensive in managing insulin drip,  IV fluids and electrolyte replacement while monitoring frequent labs.   

Pulm edema is low on my list of issues here.   He's currently in shock, likely hypovolemic shock from DKA or septic shock causing his hypoxia and not in pulm edema.   Tachycardia of 150 in a young pt shouldn't cause acute heart failure to lead to pulm edema.

I think you did what you could with a very sick guy.    Certainly in hindsight going to a closer facility may have been a good choice but you've already recognized some of those decisions.


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## Arovetli (May 11, 2013)

All I would add is an extension of what FLdoc2011 touched on: The average DKA pt. is down about 100cc/kg of fluid...so you can being to note the scope of fluid, and subsequent electrolyte, loss.

good article: http://care.diabetesjournals.org/content/29/12/2739.full


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## Sublime (May 11, 2013)

Sounds like you did fine, other than that I really don't have much to add.


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## chaz90 (May 11, 2013)

I'm still trying to figure out the rapid onset. What are your guys thoughts on how he was up and walking around at the mall to suddenly crumping that rapidly?


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## medicsb (May 11, 2013)

I agree that this was probably DKA.  Likely, there was something else going on.  Outside in 85 degree weather could have pushed his dehydration from compensated to uncompensated.  12 lead would have been nice to have, only to assess for hyperK+, which can occur with DKA or any acidosis.  (one of the body's responses to a high H+ is to ramp up H+/K+ exchange transporters - basically, cells will take up H+ and spit out K+.)  

Also, if he happened to be down long enough, he could have been hyperthermic (cooking in the sun) and have rhabdo (on the ground, not moving, leading to muscle break down adding to H+ buildup and also hyperK+).  

I do not think it would have been unreasonable to try nasally intubating him if you had experience with the procedure.  But, it is something that could make things worse (worsened hypoxia as you try to place the tube, or, causing a nose bleed that mucks up his airway more).  Experience with the procedure would be paramount, and with CPAP basically killing NTI, you, like me, never got an opportunity to do it.  So, BVM was fine choice, and likely the best choice for the situation.  

As far as going with the hospital further away vs. the closest - it happens.  You're going to make a decision that when viewed through the retrospectoscope is wrong.  I did it with a PE patient years ago.  In retrospect either choice would have pissed someone off and the patient outcome would not have changed.  (Lucky for you, your patient didn't code immediately after arrival.)

It sounds like a messy, frustrating call.  Any medic with enough time on, will have a number of these calls.  Learn from it and move on.  All in all, sounds like you handled it fairly well.


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## Sublime (May 11, 2013)

chaz90 said:


> I'm still trying to figure out the rapid onset. What are your guys thoughts on how he was up and walking around at the mall to suddenly crumping that rapidly?



Combination of dehydration and acidosis got the best of him while walking in the sun is my guess.

I would think that this really wasn't a rapid onset and rather that this problem has been brewing over the course of the week and finally reached the tipping point while he was walking at the mall.


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## Clare (May 11, 2013)

This is an interesting one; the patient has a GCS of 9 so technically has coma rather than a reduced/altered LOC and is considered status one.

I would however say that his condition is likely to improve fairly rapidly with the right treatment and even if he gets ventilated for 12 hours or something he is unlikely to need massive ongoing ICU care or something unless he has a had a massive cerebral ischaemic event.

I would take him to the regular hospital and not divert to a major trauma centre.


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## NomadicMedic (May 11, 2013)

Rob, doesn't seem like a bad job. Not taking a fire rider wasn't a fatal mistake, but i bet the extra hands would have come in handy.

I wouldn't have hesitaed to drill him and I would have RSI'ed him. Did you get his pressure up with just fluid? After two liters, I'd be moving toward dopamine. 

I think everyone else has kicked it around enough. Nobody thinks you did a bad job, you just sent the help away too soon. (Something I think we've all done.)


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## Carlos Danger (May 11, 2013)

medicsb said:


> I agree that this was probably DKA.  Likely, there was something else going on.  Outside in 85 degree weather could have pushed his dehydration from compensated to uncompensated.



This is basically my assessment as well. DKA might take a day or two to develop, but once it becomes clinically apparent, it can progress very quickly, especially with increased physical activity. He could have gone from not feeling the best that morning (but not feeling remarkably bad, either) + walking around the mall + heat = DFO a few hours later.

Given what you had to work with Robb, I'd say you did fine.

On scene: 

I would not have done a 12-lead. Probably would have enroute, if I had time and the patient was cooperating, but definitely not before loading. Because the chances of it revealing anything that would change your treatment at all is very slim.

Labs would have been nice to have, but few of us have that in the field, and again, probably wouldn't changed your treatment anyway. 

I definitely would not have intubated him on scene. Just no indication for it, based on your description.

You got an IV and started fluids; that's probably the extent of what I would have done before leaving.​

Once the guy started to crump when you were enroute: 

I think you did all you could do.

RSI was probably not a practical option, since you were alone in the back.

NTI would not have ended well, based on how you describe the situation. I mean, if the guy wouldn't take an NPA, then he certainly wouldn't take a 6.0 ETT....plus, blind NTI is a technically difficult procedure that requires quite a bit of practice. It's certainly harder than orotracheal intubation. There is good reason you never see it done anymore. ​

Sounds like one of those clumsy, difficult calls that you wish had gone better, but really couldn't have done much different. We've all had them and will have more of them.


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## Dwindlin (May 11, 2013)

I agree with those saying this is DKA.  And as to the suddenness of it, I doubt it was.  DKA develops over days/weeks.  His likely just caught up with him at the mall.

You did fine, not much to do with these pre-hospital.  I'm surprised the ED was so aggressive with the airway, I wouldn't have been.  Chances are he'll be doing much better and stabilize out after several liters and an insulin/glucose drip.  

While I love pulse oximetry, I wouldn't put too much faith in it with this particular patient.  If you're confident about that pressure I'm not surprised it was reading in the 80's, unless you were seeing some other indications he was hypoxic wouldn't put much faith in its accuracy (if he were truly in the 80's there should be some cyanosis somewhere).


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## abckidsmom (May 12, 2013)

I agree with almost everyone. Sick guy, very dry.

The only thing I have to add is the thought that usually patients this sick with DKA are profoundly acidotic. I've seen a couple of live people in DKA with pH of less than 6.9. It is worth considering an amp of bicarb if you have it, and being extremely alert for hyperkalemia and keeping that in your Hs and Ts in case of arrest.


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## Dwindlin (May 12, 2013)

There is only one (maybe two) good reason to push (and I mean over like 10 minutes) an amp of bicarb, and it isn't for severe acidosis.  Absolutely no reason to give an amp of bicarb as a "push" (i.e. faster than 10 minutes).


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## FLdoc2011 (May 12, 2013)

Would be interesting to see his initial labs (chemistry and ABG) at the ER if you can get them.

I agree,  wouldn't recommend giving this kid bicarb pre-hospital without an extremely good reason.


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## Akulahawk (May 12, 2013)

I clipped out some... 


Robb said:


> Fire reports 19 yo male history of insulin-dependent diabetes was found laying on the grass "acting odd." Father states he was out with some friends but was "normal" at 0900 this morning.
> 
> Pt is a&ox0, responsive to loud verbal stimuli, GCS 11 (3/3/5) and mildly combative (think aimless, weak swats at hands and grabbing pant legs).
> 
> Initial vitals (per fire, there's my first mistake with this crew) of 110/70, pulse of 130 strong and regular at the radial, SpO2 78% on room air, respiratory *rate 50 deep and regular. CBG "HI" with a ketone warning* (>600 mg/dL on our glucometers.)


RR=50 and CBG = >600 + ketone warning is a key thing.





Robb said:


> Physical exam shows no signs of trauma, *skin is pink, hot and very dry*, PERRL but sluggish at 4mm (outside in the 85 degree bluebird day) no JVD, trachea midline.
> Chest is without signs of trauma, equal rise and fall bilaterally, *clear to auscultation anteriorly and posteriorly*, no retractions or accessory muscle usage noted.
> Abdomen is soft, no palpable or pulsating masses noted, no guarding. Pelvis is stable, *no urinary* or bowel *incontinence *noted.


No incontinence noted possibly because he's so very dry now that he's not producing urine.





Robb said:


> Lower extremities are unremarkable, upper extremities have a gazillion scars from what appear to be intravenous injections, other than that they're unremarkable,* no peripheral edema note*d.


Chest clear to auscultation to me means probably not hypervolemia problem or HF problem.





Robb said:


> History: *IDDM *and "psychiatric problems", father denied any previous suicide attempts, denies any knowledge of drug or ETOH abuse but states "it wouldn't surprise me."
> 
> No known allergies or drug allergies.
> 
> Medications: *Insulin *(father unable to be more specific), Prozac and guanfancine


Insulin another key med.





Robb said:


> Non-rebreather at 15lpm, still semi-conscious at this point so tried an NPA that he fought viciously so I let him be since he was doing a decent job of protecting his airway. 4-lead, partner did repeat vitals while I worked on a line. This is where I realized this kid is in a much worse situation than I originally had thought but at this point I had already dismissed fire (third mistake before assuring the vitals they gave me were accurate. Some crews are awesome, this one not so much and I knew it but disregarded it.) I somehow managed to fight an 18g through the scar tissue in his right AC with a *liter bag + pressure bag running wide open*, partner botched the left AC.


Probably a good thing to get the IV going wide open like that. 





Robb said:


> Repeat vitals were
> 100/50
> 150 BPM, sinus tachycardia without ectopy. I didn't do a 12-lead...it wasn't high on my priority list, frankly it was at the bottom. I didn't see a reason but if I'm missing something please chime in.
> 87% on 15 LPM
> RR *50 still deep and regular. Classic kussmaul respirations*.


I may not have done a 12-lead either. With the classic Kussmaul resps going on, the low BP, and so on... I'd be betting this guy is well into DKA and not going to get better any time soon.





Robb said:


> From this point it went downhill. We started transport routine and upgraded to code 3 soon after I took another set of vitals.
> 
> 
> GCS reduced to 9 (2/2/5)
> ...


Is that 6 lpm in addition to the 15 lpm you already have on him? After restraining the upper extremities, perhaps starting an EJ might have been an idea, but he may fight that. If I was worried about not being able to start an EJ safely, I'd have done an IO, as others have suggested.

On the whole, I think you did a reasonably good job with this patient given what you knew of him and what tools you had at hand. 12-lead would have been nice at some point just to watch for signs of hyper-K. Giving him as much NS as you can over that 20 minutes would have at least diluted the K+ level some. I also have no doubt that he's severely acidotic and may have benefited from Bicarb, but certainly if he crumped in front of you, that would have been among the considerations, and (presumably) hyper-K. I probably wouldn't have attempted NTI as that would have been an awful mess and he'd have fought you even more viciously than he did with the NPA.


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## Akulahawk (May 12, 2013)

Dwindlin said:


> There is only one (maybe two) good reason to push (and I mean over like 10 minutes) an amp of bicarb, and it isn't for severe acidosis.  Absolutely no reason to give an amp of bicarb as a "push" (i.e. faster than 10 minutes).





FLdoc2011 said:


> Would be interesting to see his initial labs (chemistry and ABG) at the ER if you can get them.
> 
> I agree,  wouldn't recommend giving this kid bicarb pre-hospital without an extremely good reason.


I agree about the bicarb push idea... as in don't. I was thinking perhaps added to a drip so that it goes in slower, or perhaps as a bolus only in a code. In that guy's state, the IVP idea might have been too much of a correction too quickly and caused more problems. That's pretty much what I meant by the bicarb in my post above. The edit time ran out on me before I could edit it to reflect the slow admin or just remember it for crump time idea. 

Just for my own education, I'd have loved finding out what his labs were.


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## Dwindlin (May 12, 2013)

Akulahawk said:


> I agree about the bicarb push idea... as in don't. I was thinking perhaps added to a drip so that it goes in slower, or perhaps as a bolus only in a code. In that guy's state, the IVP idea might have been too much of a correction too quickly and caused more problems. That's pretty much what I meant by the bicarb in my post above. The edit time ran out on me before I could edit it to reflect the slow admin or just remember it for crump time idea.
> 
> Just for my own education, I'd have loved finding out what his labs were.



For acid/base purposes, if I'm going to use bicarb my standard is 3 amps in a bag of D5, this gets you a SID close to plasmalyte, and run it at 100 - 200 cc/hr.  

Only time I can see pushing an amp is in TCA overdose and impending herniation due to elevated ICP (standard bicarb is 8.4% sodium bicarb, which is crazy hypertonic).


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## abckidsmom (May 12, 2013)

Akulahawk said:


> I agree about the bicarb push idea... as in don't. I was thinking perhaps added to a drip so that it goes in slower, or perhaps as a bolus only in a code. In that guy's state, the IVP idea might have been too much of a correction too quickly and caused more problems. That's pretty much what I meant by the bicarb in my post above. The edit time ran out on me before I could edit it to reflect the slow admin or just remember it for crump time idea.
> 
> Just for my own education, I'd have loved finding out what his labs were.



For the record, I was thinking about adding it into a liter of saline. 

But I do understand how sketchy it sounds.


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## FLdoc2011 (May 12, 2013)

abckidsmom said:


> For the record, I was thinking about adding it into a liter of saline.
> 
> But I do understand how sketchy it sounds.



Why normal saline?   Now you've made it hypertonic.


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## Akulahawk (May 12, 2013)

Dwindlin said:


> For acid/base purposes, if I'm going to use bicarb my standard is *3 amps in a bag of D5*, this gets you a SID close to plasmalyte, and run it at 100 - 200 cc/hr.
> 
> Only time I can see pushing an amp is in TCA overdose and impending herniation due to elevated ICP (standard bicarb is 8.4% sodium bicarb, which is crazy hypertonic).


That makes sense, actually.


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## Dwindlin (May 12, 2013)

FLdoc2011 said:


> Why normal saline?   Now you've made it hypertonic.



This.  Need to add bicarb to a hypotonic solution (D5W, D5-1/2NS, 1/2NS, etc.).


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## abckidsmom (May 12, 2013)

Dwindlin said:


> This.  Need to add bicarb to a hypotonic solution (D5W, D5-1/2NS, 1/2NS, etc.).



Got it. I understand that. 

Obviously, I don't have a good understanding of that.


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## Sublime (May 13, 2013)

medicsb said:


> I agree that this was probably DKA.  Likely, there was something else going on.  Outside in 85 degree weather could have pushed his dehydration from compensated to uncompensated.  12 lead would have been nice to have, only to assess for hyperK+, which can occur with DKA or any acidosis.  (one of the body's responses to a high H+ is to ramp up H+/K+ exchange transporters - basically, cells will take up H+ and spit out K+.)
> 
> Also, if he happened to be down long enough, he could have been hyperthermic (cooking in the sun) and have rhabdo (on the ground, not moving, leading to muscle break down adding to H+ buildup and also hyperK+).



Please correct me if I'm wrong, but isn't hypokalemia more prominent in DKA?


My understanding is the serum K+ levels may present high in early stages of ketotic acidosis due to the shift of K+ from intracellular to extracellular spaces (due to the H/K exchange you mentioned).

In later stages total body K+ becomes low due to osmotic duiresis. I would assume this patient was well into late stage DKA because of his neurological status.

Once again correct me if on wrong on this, but that is my understanding of it.


----------



## Dwindlin (May 13, 2013)

Sublime said:


> Please correct me if I'm wrong, but isn't hypokalemia more prominent in DKA?
> 
> 
> My understanding is the serum K+ levels may present high in early stages of ketotic acidosis due to the shift of K+ from intracellular to extracellular spaces (due to the H/K exchange you mentioned).
> ...



Yes early on the body will try to compensate for the elevated H+ by exchanging it for K+, so potassium can be elevated.  Regardless of labs however they are likely potassium deficient and generally it is added to their fluids because once you start hydrating and giving insulin/dextrose they will correct very quickly.


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## medicsb (May 13, 2013)

Sublime said:


> Please correct me if I'm wrong, but isn't hypokalemia more prominent in DKA?
> 
> 
> My understanding is the serum K+ levels may present high in early stages of ketotic acidosis due to the shift of K+ from intracellular to extracellular spaces (due to the H/K exchange you mentioned).
> ...



As mentioned, it's the whole body K+ that is low (or normal).  DKA can have normal serum K+, but they may become hypoK once you correct the acidosis and hyperglycemia.  In that case you need to replete the K+.  Hypo[electrolyte] or hyper[electrolyte] typically refers to the electrolyte in the blood serum and not the whole body.


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## Brandon O (May 13, 2013)

Akulahawk said:


> RR=50 and CBG = >600 + ketone warning is a key thing.



You probably know, but just to clarify for anyone unclear, standard glucometers do NOT test for ketones. (There are special ketone strips that do, but you probably don't have 'em.) The "ketones" flag you usually see is just a reminder to consider DKA that kicks in whenever you test a sugar over a certain number (varies by meter, ours is like 300 mg/dl I think, the OP's is apparently 600). It's a reminder, it doesn't add any info.


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## Akulahawk (May 13, 2013)

Brandon Oto said:


> You probably know, but just to clarify for anyone unclear, standard glucometers do NOT test for ketones. (There are special ketone strips that do, but you probably don't have 'em.) The "ketones" flag you usually see is just a reminder to consider DKA that kicks in whenever you test a sugar over a certain number (varies by meter, ours is like 300 mg/dl I think, the OP's is apparently 600). It's a reminder, it doesn't add any info.


It's been so long since I've seen a glucometer in the field that I figured by now they'd not only caution about ketones, they'd also remind the user to wipe off that 1st drop of blood, periodically calibrate themselves, and even cook breakfast when it notices a low reading. :blink:

Seriously though, if my glucometer was prompting for ketones (for whatever reason), I'd take it as a clue that the glucose level was way too high and to check for the presence of ketones... and also to take a step back for a second and be sure that I'm going down the right treatment path.


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## the_negro_puppy (May 13, 2013)

Brandon Oto said:


> You probably know, but just to clarify for anyone unclear, standard glucometers do NOT test for ketones. (There are special ketone strips that do, but you probably don't have 'em.) The "ketones" flag you usually see is just a reminder to consider DKA that kicks in whenever you test a sugar over a certain number (varies by meter, ours is like 300 mg/dl I think, the OP's is apparently 600). It's a reminder, it doesn't add any info.



Yep i've had a pt with a specific Ketone meter that looks similar to a glucometer. It was able to give us a ketone reading.

I think if its over 1.5mmol its pretty indicative of DKA


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## Handsome Robb (May 14, 2013)

Brandon Oto said:


> You probably know, but just to clarify for anyone unclear, standard glucometers do NOT test for ketones. (There are special ketone strips that do, but you probably don't have 'em.) The "ketones" flag you usually see is just a reminder to consider DKA that kicks in whenever you test a sugar over a certain number (varies by meter, ours is like 300 mg/dl I think, the OP's is apparently 600). It's a reminder, it doesn't add any info.



I'm not sure what triggers ours. I've had "HI" readings with and without the warning for ketones. 

I like where this thread is going, I'm on my 7th consecutive day, well dads wedding broke it up, and it's past my bedtime and I have to teach dynamic cardiology to the medic class mañana so I will rejoin you ladies and gentleman tomorrow.


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## Brandon O (May 14, 2013)

Robb said:


> I'm not sure what triggers ours. I've had "HI" readings with and without the warning for ketones.



Would be curious what make and model. It's possible someone has some other fancy-pants diagnostics incorporated into a regular glucometer.


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## Handsome Robb (May 14, 2013)

Brandon Oto said:


> Would be curious what make and model. It's possible someone has some other fancy-pants diagnostics incorporated into a regular glucometer.



Most carry the Bayer Contour glucometer but some medics, myself included, somehow ended up with the Precision Xtra as well, so I have two glucometers. Originally the plan was to test the Precision and potentially replace the Bayers but most preferred the Bayer so there are Xtras floating around. We don't have separate ketone strips for the Xtra though so I'm starting to think you're correct when you're saying they just say ketones as a reminder.

I personally prefer the Contour, it's easier to use, doesn't require coding and in my experience more accurate/consistent.

Unfortunately I wasn't able to get lab values, I didn't get a chance to attempt to follow up for a couple days and no one could remember. The only number the nurse remembered was his VBG was >1300 mg/dL. They admitted him with a Dx of DKA + Sepsis. 

I'm having a tough time grasping the hyper vs hypo K in these patients, I would think their blood serum would be hyperK since its not glucose that drives potassium into the cells it's the insulin that causes the shift and since they do not produce insulin and are generally non-compliant with their medications it seems like hyperK would be more common. 

With that said, as much fluid as these patients require I could definitely see how during long term treatment hypokalemia would be a concern.

As far as bicarbonate, fixing their pH alone won't fix the problem, I could see how it would be beneficial in conjunction with an insulin drip, and electrolyte replacement therapy but by itself it doesn't seem like it would accomplish anything other than attempting to "fix numbers" and as Veneficious has pounded through my brain, "just because you fixed the numbers doesn't mean you've fixed the problem."

We don't carry hypotonic solutions so a drip wouldn't even be plausible here.

Ill try to answer questions that I remember, I'm on my phone so I can't go back and look while replying.

As far as an EJ, I considered it. He had a great one but with how much he was fighting I didn't want him to jerk and get into his IJ or carotid or poke myself, or cause him more harm. I agree I should've probably gone for a second line, I was really hesitant to drill him due to the infection risk and my assumption that he took crap care of himself. Had I been unable to get the first line it wouldn't be a question but I had a patent, large bore IV that was flowing well. Shoulda paid closer attention I the pressure bag, I got so flustered with his airway I forgot to add pressure to it as the bag emptied. Probably could have gotten a fair amount more on board had I been cognizant of this.

I had a question about ETCO2...Could I have put the online probe in between the mask and bag and gotten an accurate reading off of it? I've heard of people doing this but it seems like you wouldn't get enough airflow during exhalation to get an accurate reading. Please correct me if I'm wrong. At the same time I could see it working because PEEP works just fine provided you keep a solid face-to-mask seal so why wouldn't ETCO2 be the same with a solid seal?

Time out while I smoke my roommate in MLB 2K12 and I'll be back to review the thread and get to the questions I missed.


----------



## NomadicMedic (May 14, 2013)

We use an end tidal nasal cannula under a CPAP mask, NRBs, Neb masks and BVMs. It's usually enough to give you some ETCO2 numbers for trending and see a waveform. It's not a number I'd hang my hat on without question, but when you've got no other real means of assessing ventilation, it's a handy tool.


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## Dwindlin (May 14, 2013)

Robb said:


> I'm having a tough time grasping the hyper vs hypo K in these patients, I would think their blood serum would be hyperK since its not glucose that drives potassium into the cells it's the insulin that causes the shift and since they do not produce insulin and are generally non-compliant with their medications it seems like hyperK would be more common.



The increased serum potassium is due to the acidosis (H+/K+ exchange), but as said these patients are losing a ton of potassium in the urine.  So while their serum potassium remains high (as long as they remain acidotic) if you looked at total body potassium it is likely profoundly low.  That will present itself fairly rapidly after you start treatment.


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## Brandon O (May 14, 2013)

Robb said:


> Most carry the Bayer Contour glucometer but some medics, myself included, somehow ended up with the Precision Xtra as well, so I have two glucometers. Originally the plan was to test the Precision and potentially replace the Bayers but most preferred the Bayer so there are Xtras floating around. We don't have separate ketone strips for the Xtra though so I'm starting to think you're correct when you're saying they just say ketones as a reminder.
> 
> I personally prefer the Contour, it's easier to use, doesn't require coding and in my experience more accurate/consistent.



We use the Contour. It's a really good meter for EMS in my opinion -- great range in both directions, high accuracy, no coding, and no error from a lot of the things that typically can cause it.

It looks like the Precision Xtra actually can measure ketones with the same meter, but you still do need separate strips.


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## SpecialK (May 15, 2013)

Dwindlin said:


> The increased serum potassium is due to the acidosis (H+/K+ exchange), but as said these patients are losing a ton of potassium in the urine.  So while their serum potassium remains high (as long as they remain acidotic) if you looked at total body potassium it is likely profoundly low.  That will present itself fairly rapidly after you start treatment.



This.  One of the effects of DKA is for the shift of potassium to move intracellular via the H+/K+ ATPase which means that in reality their hyperkalaemia is really only high serum potassium as opposed to high total potassium and once you correct the acidosis the potassium falls rapidly; so if you leave your DKA patient in the hallway on an insulin drip and come back they might just have had a hypokalaemic cardiac arrest and died.


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## RocketMedic (May 15, 2013)

Robb said:


> Most carry the Bayer Contour glucometer but some medics, myself included, somehow ended up with the Precision Xtra as well, so I have two glucometers. Originally the plan was to test the Precision and potentially replace the Bayers but most preferred the Bayer so there are Xtras floating around. We don't have separate ketone strips for the Xtra though so I'm starting to think you're correct when you're saying they just say ketones as a reminder.
> 
> I personally prefer the Contour, it's easier to use, doesn't require coding and in my experience more accurate/consistent.
> 
> ...



It wont work well with a NRB in that position because the oxygen coming in "washes" any CO2 that may have escaped the vents up high "path of least resistance". Remember, an NRB plastic bag is your next breath. What you can do though is either put it in front of them if they can comply or cut an endotracheal tube to NPA length and drop it down their nose with the sensor mounted as if you were intubating (or go full-on NTI). Its not ideal, but it works.


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## NomadicMedic (May 15, 2013)

Actually, the nasal cannula ETCO2 "scoop" prevents washout so you will get a fairly accurate reading. 

*As a disclaimer, our ops manager also works for Oridian and is a master in the ways of capography.


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## RocketMedic (May 15, 2013)

DEmedic said:


> Actually, the nasal cannula ETCO2 "scoop" prevents washout so you will get a fairly accurate reading.
> 
> *As a disclaimer, our ops manager also works for Oridian and is a master in the ways of capography.



They don't have the cannulas, DE, just the inline EtCO2 tube monitors. Weird, right?


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## NomadicMedic (May 15, 2013)

Ohhh. My bad. Disregard.


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## shfd739 (May 15, 2013)

Rocketmedic40 said:


> They don't have the cannulas, DE, just the inline EtCO2 tube monitors. Weird, right?



How useless is that? A lot of useless.


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## Handsome Robb (May 15, 2013)

shfd739 said:


> How useless is that? A lot of useless.



Obnoxiously useless.


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## shfd739 (May 15, 2013)

Robb said:


> Obnoxiously useless.



lmao. I dont use the nasal ones often but when they do get used its an awesome tool.


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## Trashtruck (May 15, 2013)

The Precision Xtra will give you a warning reading 'KETONE' if the reading is over 300 mg/dL. 
It's a reminder to check for ketones, not a confirmation of presence. 
You have to have separate strips to test for ketones.


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## BigBad (May 25, 2013)

I would have slammed 5mg of droperidol or 2mg of versed,   if his sats are tanking, i have no trouble bagging him all the way to the hospital.   Drop an opa and tube him if needed.   Weve all been there man, good job.


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## NomadicMedic (May 26, 2013)

Why would you have "slammed" droperidol or versed?


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## Handsome Robb (May 26, 2013)

DEmedic said:


> Why would you have "slammed" droperidol or versed?



I was wondering the same thing. 

I'm assuming that its because of the combativeness. In NV that would get my card yanked since it could be argued I did a medication assisted intubation which is not in my scope of practice for this state. Now sedating him and using BLS airway techniques could be possible but not exactly ideal.


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## chaz90 (May 26, 2013)

I'm a bit wary of half assing attempts at medication assisted intubation. Right now, the patient is breathing. While it may be nice to have him calm down a bit and accept either an NPA, BVM, or even a tube, I wouldn't be a fan of knocking out the respiratory drive without paralyzing. If I'm planning on taking away a patient's ability to breathe, I'd like to maximize my chances of placing an ET tube. Obviously this person could still be ventilated using a BVM, but still...wouldn't be my preferred course of action.


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## NomadicMedic (May 26, 2013)

Agreed. The idea of "some" sedation, no paralytics and a healthy dose of brutane to intubate a patient goes against everything I know. However, it still happens in a lot of places, and I hope that those paramedics look at those "medication assisted intubations" as a last resort instead of an acceptable everyday practice.

As long as your guy was protecting his airway, you could always continue to use BLS techniques and some BVM assistance. It may make for some pucker factor, but if you deliver a breathing patient to the ED where e can be intubated properly, in a controlled environment, you did the right thing. 


As an aside, I take issue with anyone "slamming" a medication. But, that's just me.


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## BigBad (May 26, 2013)

DEmedic said:


> Why would you have "slammed" droperidol or versed?



For combative behavior but more so to manage the pt  airway effectively without documenting it that way.


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## chaz90 (May 26, 2013)

BigBad said:


> For combative behavior but more so to manage the pt  airway effectively without documenting it that way.



So purposely circumventing protocol for some nebulous belief that it provides better patient care * AND * not documenting it, aka telling the hospital staff what medications are already on board?? There's a reason Versed and Droperidol aren't primary induction agents for intubation. I'm not the type to blindly follow protocols without thinking, but taking drugs that are provided as chemical restraints and trying to create ad hoc RSI is a whole different animal.


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## BigBad (May 26, 2013)

chaz90 said:


> So purposely circumventing protocol for some nebulous belief that it provides better patient care * AND * not documenting it, aka telling the hospital staff what medications are already on board?? There's a reason Versed and Droperidol aren't primary induction agents for intubation. I'm not the type to blindly follow protocols without thinking, but taking drugs that are provided as chemical restraints and trying to create ad hoc RSI is a whole different animal.



If the pt is combative and impeading proper care im not going to sit and wait for him to crash.   The story you painted for me equals droperidol..   Why else did the doctor RSI him?


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## Akulahawk (May 26, 2013)

BigBad said:


> For combative behavior but more so to manage the pt  airway effectively without documenting it that way.


I would hope that you have protocols that specifically cover combative behavior with medication/sedation. I would also very much hope that any protocol authorizing sedation also allows you to provide definitive airway management in the even that you inadvertently knock out the respiratory drive. Otherwise, I see some skating on some very, very thin ice.

I also have an issue with "slamming" almost every medication there is... except for one. Adenosine.


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## VFlutter (May 26, 2013)

BigBad said:


> Why else did the doctor RSI him?



I do not think anyone is trying to argue the patient did not need to be RSI'd but it needs to be done the correct way. I am sure the ER doctor did a proper RSI induction and not a half *** sedative only attempt. 

And what you described is getting close to that whole "Practicing medicine without a license" thing...


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## chaz90 (May 26, 2013)

BigBad said:


> If the pt is combative and impeading proper care im not going to sit and wait for him to crash.   The story you painted for me equals droperidol..   Why else did the doctor RSI him?



There's a big difference in sedating a combative patient who's pulling lines out and resisting airway assistance vs. "slamming" the wrong medications in an attempt to make the patient lose his gag reflex (and respiratory drive) to pass a tube. I agree you want to stay ahead of the curve and not wait for your patient to crash, but in this case, the patient at least breathing seems better to me than taking that away and risking still not being able to get the tube. If the patient stops breathing spontaneously and loses his gag reflex, intubate away. Also, you're choosing to fast push IV Versed in someone this profoundly hypotensive? Again, wouldn't be my chosen course of action. The ED doc properly intubating this patient with a full repertoire of drugs is really not the same scenario as you describe.


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## Akulahawk (May 26, 2013)

BigBad said:


> If the pt is combative and impeading proper care im not going to sit and wait for him to crash.   The story you painted for me equals droperidol..   Why else did the doctor RSI him?


The last time I checked, RSI usually meant using a paralytic and a sedative of some sort. Using just a sedative such as droperidol or versed isn't going to be anywhere near optimal. The doses needed to snow them enough for either to be effectively induced into anesthesia is going to be quite a bit greater than what you'd need to sedate them enough that they'll never remember what you're doing to them. The paralytic takes care of the musculoskeletal relaxation... 

To me, an unconscious combative patient = restraints to prevent further injury to themselves. If I were then to consider using a sedative, I'd use just enough to allow me to use the BVM, not to obliterate the respiratory drive. I would imagine that the reason for the RSI would be greater control of Tidal and Minute Volume as well as definitive airway control. The Doc's going to have a LOT more tools at hand to accomplish controlling the airway than you'll likely have in the back of your ambulance.


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## BigBad (May 26, 2013)

Chase said:


> I do not think anyone is trying to argue the patient did not need to be RSI'd but it needs to be done the correct way. I am sure the ER doctor did a proper RSI induction and not a half *** sedative only attempt.
> 
> And what you described is getting close to that whole "Practicing medicine without a license" thing...



Never did i say push these medications to rsi him.   You are however trained to manage his airway should it need be.  If he is being combative, treat it so you can treat your patient  My protocols allow me to manage my patients.  If my patients are managing me then im behind the 8 ball.


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## Akulahawk (May 26, 2013)

Chase said:


> I do not think anyone is trying to argue the patient did not need to be RSI'd but it needs to be done the correct way. I am sure the ER doctor did a proper RSI induction and not a half *** sedative only attempt.
> 
> And what you described is getting close to that whole "*Practicing medicine without a license*" thing...





chaz90 said:


> There's a big difference in sedating a combative patient who's pulling lines out and resisting airway assistance vs. "slamming" the wrong medications in an attempt to make the patient lose his gag reflex (and respiratory drive) to pass a tube. I agree you want to stay ahead of the curve and not wait for your patient to crash, but in this case, the patient at least breathing seems better to me than taking that away and risking still not being able to get the tube. If the patient stops breathing spontaneously and loses his gag reflex, intubate away. Also, you're choosing to *fast push IV Versed in someone this profoundly hypotensive*? Again, wouldn't be my chosen course of action. The ED doc properly intubating this patient with a full repertoire of drugs is really not the same scenario as you describe.


I certainly agree that this patient needs airway control, among other things... but it certainly wouldn't be my choice either to fast push droperidol or versed into a patient that's hypotensive either. to me, that just screams BIG BAD OUTCOME!


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## Akulahawk (May 26, 2013)

BigBad said:


> *Never did i say push these medications to rsi him*.   You are however trained to manage his airway should it need be.  If he is being combative, treat it so you can treat your patient  My protocols allow me to manage my patients.  If my patients are managing me then im behind the 8 ball.


No, but you implied it... or at least indicated that you thought that the fact that it's a side-effect that you'd desire (being able to intubate him) is one of the reasons you'd give those drugs. 

If you can manage the combativeness, that's great... great care should be undertaken to prevent him from losing his respiratory drive and maintain vascular tone. Otherwise that may put you in a very unenviable position of can't intubate/ventilate and must do CPR because you caused him to crump by using sedatives that can dump pressure... and this patient is probably several liters dry to begin with.


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## usalsfyre (May 26, 2013)

BigBad said:


> Never did i say push these medications to rsi him.   You are however trained to manage his airway should it need be.  If he is being combative, treat it so you can treat your patient  My protocols allow me to manage my patients.  If my patients are managing me then im behind the 8 ball.



I'll go ahead and say it, cowboy bull puckey like this is what will get intubation taken away from paramedics (and rightfully so). This course of action is dangerous to the patient and patently stupid. The reason you don't have RSI in your protocols is your medical director (apparently in a very intelligent move) has decided field medics can't be trusted with it. You do nothing with actions and statements like this to dissuade that notion. I suggest you learn a bit about physiology and pharmacology before you try to manage airways at the big kids table.


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## NomadicMedic (May 26, 2013)

I was just writing something along these same lines!


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## Handsome Robb (May 26, 2013)

I agree with both of y'all but I like this thread so hopefully it doesn't die.



BigBad said:


> If the pt is combative and impeading proper care im not going to sit and wait for him to crash.   The story you painted for me equals droperidol..   Why else did the doctor RSI him?



While I agree with you, there is no way I an "chart around" giving a sedative then attempting airway control. Like I said in the OP he was doing a decent job of protecting his own airway, just wasn't really happy with the BVM assisted ventilation and the NPA. 

I'm not waiting for him to crash either but I also cannot work outside of protocols or my state and county defined scope of practice. I hate medicine by cookbook but at the end of the day I need to pay my bills and only have one job so...

The doc used sux and etomidate for the intubation. First thing that happened when we rolled into the ER since I had my partner call ahead after id already given my report and tell them I was having difficulty controlling the his airway.

As far as crumping, I  was more worried about hemodynamic stability rather than his airway. While his spo2 wasn't great, it wasn't god awful either. On the other hand, his MAP sucked. 

I have no issues "painting outside the lines" in the best interest if I can justify why I did or did not do something but blatantly violating my scope is not something I'm willing to do. No patient is worth losing my livelihood over, sorry.

We don't carry droperidol, only versed, so I'm thinking this kid is going to require at least 7 mg IV (using .15mg/kg, which is 7 times the amount I can give, IV , on standing orders in a single dose). Realistically probably even more than that to render him sedated enough to allow for an intubation without paralytics. (Thinking probably .2-.3 mg/kg.) That much versed, slammed, with a BP like he had sounds like a great recipe for causing him to decline into a PEA arrest. So, in that case, not only did I violate protocol and my scope but I also killed my patient....sounds like an easy job for a lawyer to take my card, my job and all my money along with a bunch from my agency as well.


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## BigBad (May 26, 2013)

usalsfyre said:


> I'll go ahead and say it, cowboy bull puckey like this is what will get intubation taken away from paramedics (and rightfully so). This course of action is dangerous to the patient and patently stupid. The reason you don't have RSI in your protocols is your medical director (apparently in a very intelligent move) has decided field medics can't be trusted with it. You do nothing with actions and statements like this to dissuade that notion. I suggest you learn a bit about physiology and pharmacology before you try to manage airways at the big kids table.



Not only do I have rsi, i have central lines big dog.....again im treating combative behavior.


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## chaz90 (May 26, 2013)

BigBad said:


> Not only do I have rsi, i have central lines big dog.....again im treating combative behavior.



Oh sweet baby Jesus. Please don't let field central line access come back to life.

I suppose I'll allow myself to be baited for the obvious questions though. Why, if you have RSI, would you not use those drugs to facilitate intubation of a conscious patient instead of slamming Versed and Droperidol? 100% of the time, combativeness ceases post paralytic administration. Also, this still doesn't address the issue of hypotension exacerbated by rapid IV sedative administration.


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## VFlutter (May 26, 2013)

BigBad said:


> Not only do I have rsi, i have central lines big dog.....



Hold on while I get on my knees and bow down to you...

Do yourself a favor and don't brag about outdated interventions that have no proven benefit and most likely cause more harm than good, Big Dog.


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## Handsome Robb (May 26, 2013)

BigBad said:


> Not only do I have rsi, i have central lines big dog.....again im treating combative behavior.



This is starting to make sense to me now...

Ill echo Chaz and say why droperidol or versed when you carry medications to do a proper RSI? I'm assuming you're catering your response to my system since I stated we do not RSI. Still, I don't see how it would be an option in your eyes with a profoundly hypotensive patient.

Yes treating combative behavior is all fine and dandy if that's all that's going on but I'm not willing to risk a CV/CI scenario with a attention who has no respiratory drive and can no longer protect their airway...always wanted to do a crich but not because I created the situation to indicate it. 

I don't claim to be the smartest, best paramedic in the world. Far far far from it, I still haven't come close to wiping all the green off of me yet, but "treating the combative behavior" with high dose, vasoactive sedatives is not an option for this patient in my eyes. Maybe I made it seem like he was more combative than he really was...yea he freaked when I went to drop the NPA and kept turning his head when I tried to bag him but after he was restrained physically and I got control of his head between my forearms it wasn't nearly as severe as I may have made it sound and for that I apologize.


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## usalsfyre (May 26, 2013)

BigBad said:


> Not only do I have rsi, i have central lines big dog.....again im treating combative behavior.


Good for you. Me personally I'd rather have the education needed as to when's and how's of properly taking an airway (and why it damn well may be fatal in this case if done with the wrong pharmacology), but why do that when you can be macho?

The point of "slamming versed or droperidol" to control a combative patient that needs intubation (per you) is what exactly? My guess is you have VERY narrowly defined RSI guidelines, and so you feel the need to side step the system. Again you exemplify "cowboy".


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## Akulahawk (May 26, 2013)

BigBad said:


> Not only do I have rsi, i have central lines big dog.....again im treating combative behavior.


That's all fine, well, and good. If you've got RSI can you're able to use it, why use other drugs to treat his combativeness and allow you to intubate him as a side-effect and not document your use of those drugs for that? Remember, both droperidol and midazolam have (as very common side effects) the ability to cause hypotension. Feel like worsening the problem when the patient's BP is something like 70/? Have you forgotten that this patient is also probably very dry. At best, his BP is what, 100/50 and I'd bet that's with his vasculature about as constricted as it's going to be in an attempt to maintain pressure. What does that mean? It means that you're going to want to select a drug that doesn't normally cause hypotension when it's administered. One of those drugs is etomidate. Guess what was the induction agent the Doc used?

If you're truly good at RSI and doing Central Lines, at the BIG DOG level, you'd already know this. You'd be able to call-in to med control and be able to get an order for RSI using etomidate instead of droperidol or midaz because you know those choices aren't good. It sounds very much like you don't understand how poor of a choice either of those agents really is for that specific situation.

Incidentally, slamming either droperidol or midaz to deal with a combative patient when their BP is so very low is quite dangerous. If it was absolutely necessary to sedate that patient, I'd use some very low doses just to lightly sedate the patient without dumping his pressure. That should be sufficient to allow him to tolerate the BVM. That or just physically restrain him and augment his ventilatory efforts with the BVM a few times per minute, which is what the OP did.

Don't get me wrong: I'm all for being very highly aggressive in providing care for my patients. It's that I'm also very much pro-appropriate care and sometimes that appropriate care is doing essentially nothing to the patient except judicious monitoring and keeping a very close watch on the patient. I've done both. Oh, and I don't "forget to document" things when the desirable side-effect happens to be off-protocol and my actual goal. I have no issue with running several protocols simultaneously, but you can certainly bet that I can articulate exactly why I used each one.


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## eprex (May 26, 2013)

I would have (and you hit most of these)

Gotten a set of vitals immediately

Gone to the nearest ER. This is a true emergency

Ventilated him way sooner


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## Handsome Robb (May 27, 2013)

eprex said:


> I would have (and you hit most of these)
> 
> Gotten a set of vitals immediately
> 
> ...



May I ask why you would have ventilated him "way sooner"? Not trying to start a fight, just wondering your reasoning behind it. He's created a respiratory alkalosis to attempt to compensate for his severe metabolic acidosis, I'm not to keen on trying I overrule his body's natural compensatory mechanisms. Like I said, his SpO2 wasn't great but wasn't god awful either. His BP tanking is what had me on edge, especially with the increased intrathoracic pressure created by positive pressure ventilation causing a reduction in preload in a patient who's extremely volume depleted. 

Closer hospital could go both ways. Tiny facility with no available ICU beds (critical care divert), one physician and 2 maybe 3 nurses for an 11 bed ER. Not exactly the greatest nurse to patient ratio for someone this sick who's going to require a great deal of attention in the beginning of his "stabilization".

Vitals I wholeheartedly agree on and it's a change I've made. Unless its a crew that I trust I repeat vitals right off the bat. Unfortunately I generally have to do them myself now because I lost a little faith in my very green partner and her ability to obtain a manual BP or be honest when she can't hear it after what happened on this call. I don't remember how brought it up but someone made the statement that its possible she picked a number near what fire had because she couldn't hear them and I asked her about it and she told me, reluctantly, that's what happened and then we had a very firm discussion about it. Smart girl, gonna be one helluva provider one day but she's got a lot to leave to solidify her basics. Made that a priority lately. She was asking me a lot of really complex questions and coming up with complex differentials and what not, looking for zebras rather than horses if that makes sense.


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## RocketMedic (May 27, 2013)

BigBad said:


> For combative behavior but more so to manage the pt  airway effectively without documenting it that way.



Are you an idiot?


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## rmabrey (May 27, 2013)

BigBad said:


> I would have slammed 5mg of droperidol or 2mg of versed,   if his sats are tanking, i have no trouble bagging him all the way to the hospital.   Drop an opa and tube him if needed.   Weve all been there man, good job.



I dont have much to add that everyone else hasn't covered, but as much of a trainwreck as this patient already is, I doubt you would have to slam 2mg of versed to get the desired (or undesired) effect you're looking for.


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## Carlos Danger (May 27, 2013)

BigBad said:


> I would have *slammed 5mg of droperidol* or 2mg of versed,   if his sats are tanking, i have no trouble bagging him all the way to the hospital.   Drop an opa and tube him if needed.   Weve all been there man, good job.



"Slamming" droperidol in an acidemic, hyperkalemic, hypotensive patient is a potentially fatal.

And why would you use a neuroleptic medication in a patient who is agitated due to poor perfusion, anyway? I can see possibly using a couple mg of midazolam as a premedication to make them compliant for pre-oxygenation while you prepare to intubate, but that's about it.

Yet you have protocols for central lines and RSI......just brilliant. I'm sure you never unnecessarily expose patients to the risks of those procedures. 

And we wonder why paramedicine hasn't advanced......


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