# Had a Code 3 80 YO M Pt. yesterday



## firemedic0227 (Oct 13, 2011)

Bare in mind I am only a "Student" doing a ride a long while doing team leads with a fire/medic service in my area. Yesterday we were Dispatched to a Male Pt that is unconscious but breathing. We get there and the Engine Company with 2 medics on board are already there. They have no O2 therapy going on this guy, they did a glucose stick revealing 87mmhg. This patient has a hx of Heart Related Problems he's been unconscious for about 20 minutes at this point. We get some 02 therapy get a BP of 90 by Palp respirations at 16 and get him on the Monitor which reveals a HR over 100 and irregular.

So we load him up and get him in the back of the squad get an IV established get him hooked up to a 12 lead which reveals Atrial Fibrillation. We go code 3 to the nearest Medical Center. We arrive in about 4 minutes to the ED and he is still semi-unconscious not alert at all but withdrawing to pain. Should we have done the ACLS protocol for Atrial Fibrillation? We never found out what was actually wrong with this older gentleman. Anyone know if his uncounsiousness is caused by the possible Atrial Fibrillation or maybe another cause. He had no history of Diabetes either.


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## fast65 (Oct 13, 2011)

I'm going to go ahead and say that the a-fib wasn't the cause, granted it was new onset, but I'm still not thinking the a-fib was the cause. I wouldn't have treated the a-fib from what you've said. What was the actual rate?

What other physical findings were there? LS? What other medical history did he have? Medications? 

Did you consider a UTI?


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## Shishkabob (Oct 13, 2011)

First, BGL isn't measured in mmHg.  :unsure:

What made you want to do "O2 therapy"?  What sort of 'heart related problems' did he have a history of?  What medications was he on?  What made you think you should have treated the a-fib?  





Without knowing the possible onset of the a-fib, I wouldn't touch it, especially since no other signs are indicative of it.  High HR (do beats match?), passable BP (even at 90mmHg).  Only thing off is the altered level of consciousness.  Unless they were seen at the doctor yesterday, given a 12-lead showing no a-fib, and they provide you with that 12-lead, I'd be very very very hesitant at touching it.


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## Anjel (Oct 13, 2011)

Linuss said:


> First, BGL isn't measured in mmHg.  :unsure:



:rofl:

I thought that sounded off


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## abckidsmom (Oct 13, 2011)

arharris83 said:


> Bare in mind I am only a "Student" doing a ride a long while doing team leads with a fire/medic service in my area. Yesterday we were Dispatched to a Male Pt that is unconscious but breathing.



It's always a crying shame when people are butt breathing.  I really want to overcome that whenever possible.



> We get there and the Engine Company with 2 medics on board are already there. They have no O2 therapy going on this guy, they did a glucose stick revealing 87mmhg. This patient has a hx of Heart Related Problems he's been unconscious for about 20 minutes at this point. We get some 02 therapy get a BP of 90 by Palp respirations at 16 and get him on the Monitor which reveals a HR over 100 and irregular.



What was the history?  What happened here?  Did the people on the scene just stumble on him, or was there some kind of story about how he was doing before he lost consciousness?  

Glucose sticks are typically in milligrams per deciliter (mg/dL).  Blood pressures are in mmHg.  

How were the o2 sats before and after you put him on oxygen?  How was his airway?  Did he require any airway adjuncts, or just positioning?  

What was his pulse rate?  Did it differ from the rate on the monitor?  Were there non-perfusing beats involved?  How far over 100 was the rate?  At what point would you be worried about a person's tachycardia, and in what conditions?



> So we load him up and get him in the back of the squad get an IV established get him hooked up to a 12 lead which reveals Atrial Fibrillation. We go code 3 to the nearest Medical Center. We arrive in about 4 minutes to the ED and he is still semi-unconscious not alert at all but withdrawing to pain. Should we have done the ACLS protocol for Atrial Fibrillation? We never found out what was actually wrong with this older gentleman. Anyone know if his uncounsiousness is caused by the possible Atrial Fibrillation or maybe another cause. He had no history of Diabetes either.



What ACLS protocol for Afib?  The tachycardia protocol?  Again, think about what his rate was, and whether it was the problem in and of itself or whether it was a symptom of something else.

You maybe could have found out more if you spent a little more time looking for clues, or if you included them in your story-telling for us.

The list of what his problem could have been is long and varied.  Old people who live in afib often have a multitude of other problems.  Afib is almost always a symptom of a problem, not a stand-alone issue.

Ever hear of the coma cause mneumonic AEIOU-TIPS?  Use it when you come on someone who is unconscious.  Don't focus in on the first thing you can drum up, rule in or out the other possible causes, and you'll be way further down the path of helping the hospital figure out what the problem is.


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## the_negro_puppy (Oct 13, 2011)

Maybe a stroke due to AF throwing a clot?


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## Fish (Oct 13, 2011)

I just gotta few things, why treat the afib just because it is over 100 BPM? I don't start thinking about treatment until we are up around the 150bpm range and even then I is be all like, hey why the Rapid afib? Is this something I can treat without Cardiazem?

Second, and I am going wayyyyyyyyyy out on a limb here with a stab in the dark guess and I am going to stay this dude had a stroke.

BS is good, you say 12-Lead good, is in Afib. Granted it could be anything including UTI, electrolyte defen. But, I felt like guessing on this one. Call the ER and ask what they found, did they send the patient off to CT right away?


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## jjesusfreak01 (Oct 14, 2011)

fast65 said:


> I'm going to go ahead and say that the a-fib wasn't the cause, granted it was new onset, but I'm still not thinking the a-fib was the cause. I wouldn't have treated the a-fib from what you've said. What was the actual rate?
> 
> What other physical findings were there? LS? What other medical history did he have? Medications?
> 
> Did you consider a UTI?



What in his description tells you the afib is new onset? Is it the RVR?

Also, as an aside, i've been taught that all elderly/NH patients have UTIs until proven otherwise...which happens at the hospital, so they all have UTIs...


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## Fish (Oct 14, 2011)

jjesusfreak01 said:


> What in his description tells you the afib is new onset? Is it the RVR?
> 
> Also, as an aside, i've been taught that all elderly/NH patients have UTIs until proven otherwise...which happens at the hospital, so they all have UTIs...



Elderly/NH? I haven't heard of this abbreviation before


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## fast65 (Oct 14, 2011)

jjesusfreak01 said:


> What in his description tells you the afib is new onset? Is it the RVR?
> 
> Also, as an aside, i've been taught that all elderly/NH patients have UTIs until proven otherwise...which happens at the hospital, so they all have UTIs...



Huh, I could of sworn that I read it was new onset, guess not lol

Oh Fish, NH means nursing home


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## Fish (Oct 14, 2011)

fast65 said:


> Huh, I could of sworn that I read it was new onset, guess not lol
> 
> Oh Fish, NH means nursing home
> 
> ...



Oh, Duh! Brain Fart


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## usalsfyre (Oct 14, 2011)

Stroke or urosepis seems likely. 

Temp?
How far over 100 was the afib?
Gross neurological deficits?

Cardiac complaints are not generally a cause of altered LOC, if they are, it's generally dire.


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## Fish (Oct 14, 2011)

usalsfyre said:


> Stroke or urosepis seems likely.
> 
> Temp?
> How far over 100 was the afib?
> ...



I keep trying to decifer your username.

I got US-ALS_but what is the fyre? Supposed to be Fire?


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## usalsfyre (Oct 14, 2011)

Yeah, from back in my knuckle dragging hose monkey days. "Fire" was taken on whatever I was trying to register for, fyre was not lol.


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## Fish (Oct 14, 2011)

Thats what I thought, hey I see your old employer is offering a 5k sign on bonus!  think they miss u


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## usalsfyre (Oct 14, 2011)

Nahh, fairly sure they don't lol. If your willing to call BS on management, no matter how politely, they won't miss you .


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## abckidsmom (Oct 14, 2011)

usalsfyre said:


> Yeah, from back in my knuckle dragging hose monkey days. "Fire" was taken on whatever I was trying to register for, fyre was not lol.



I think I'm the only person in the world who went to fire school to get a medic job, lol.  Hubby had a good laugh at me, 16 years into a productive career, going to fire class with a bunch of kids born when I was starting in EMS.


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## abckidsmom (Oct 14, 2011)

I get the feeling we're just talking to ourselves on this thread.


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## Fish (Oct 14, 2011)

usalsfyre said:


> Nahh, fairly sure they don't lol. If your willing to call BS on management, no matter how politely, they won't miss you .



How are you liking the new gig?


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## Fish (Oct 14, 2011)

abckidsmom said:


> I think I'm the only person in the world who went to fire school to get a medic job, lol.  Hubby had a good laugh at me, 16 years into a productive career, going to fire class with a bunch of kids born when I was starting in EMS.



Where you workin?


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## Shishkabob (Oct 14, 2011)

usalsfyre said:


> Nahh, fairly sure they don't lol. If your willing to call BS on management, no matter how politely, they won't miss you .



I'm shocked.  I havem't gotten a single call or text, even from dispatch, since I left.   My phone has been utterly quiet, it's eerie.  :rofl:


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## BigBad (Oct 15, 2011)

What did the pupils look like?   People walk around with Afib all the time....


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## VCEMT (Oct 15, 2011)

Did fire only do a finger stick?

Was the pt. normally altered? 

If not, onset < 3 hours?

Dementia?

Hx of traumatic or non traumatic brain injury?


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## mike1390 (Oct 18, 2011)

Im thinking you all scared him away... good going guys and gals now we will never know the real story!!!!


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## firemedic0227 (Nov 3, 2011)

I wasn't scared away, I was looking for help because I am a Student I got nothing but crap from everyone and hardly any insight so I gave up on the post. I got help with this patient from my instructors and other paramedics that I can see face to face.


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## usalsfyre (Nov 3, 2011)

I saw little crap, lots of questions in an attempt to narrow down a diagnosis though...


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## Handsome Robb (Nov 3, 2011)

arharris83 said:


> I wasn't scared away, I was looking for help because I am a Student I got nothing but crap from everyone and hardly any insight so I gave up on the post. I got help with this patient from my instructors and other paramedics that I can see face to face.



Grow a thicker skin, dude. No one talked down to you. 

The assessment as pretty much already been covered. I'm thinking urosepsis, or cardiogenic shock secondary to an MI (maybe, possibly?) CVA is possible but I don't really see how new onset a-fib would have time to form a clot, then throw it, the blood needs time to pool and clot.


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## fast65 (Nov 3, 2011)

If you thought you were getting crap, then you really must spend some more time around here...you haven't seen anything yet.

We asked questions about the post and got no feedback, there was nobody being a jerk to you.


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## DV_EMT (Nov 3, 2011)

the_negro_puppy said:


> Maybe a stroke due to AF throwing a clot?



Exactly what I was thinking. New onset AFIB could throw a clot and cause the lack of responsiveness.

If it was me, High Flow O2 for Cardiac/Neuro, monitor and transport. If he was responsive and field stroke assessment had yielded a positive inclination for stroke, initial dosing of TPA could be indicated..... only if he was alert and responsive though.


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## Firemedic746 (Nov 4, 2011)

Maybe this, maybe that... Treat your pt not your monitor.


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## mycrofft (Nov 4, 2011)

*You went to your instructor and peers...good!*

As an a-fib subject and former EMT  employee of American (now Omaha) Ambulance...
1. Atrial fib can cause LOC in a few ways, ranging from CVA, to evolving/eventual cardiac failure.
2. Syncope upon standing up leading to fall and head-plant on floor or furniture.
3. Anytime you see a pt in a nursing home suspect polypharmacy, or infrequently adjusted meds. He could be overdosed on beta blockers, or ingesting a combination of meds that will drop him.
 4. Atrial fib can  be so irregularly-irregular that it confounds electronic monitors and and can be hard to characterize in charting. SOme EKG recognition software will even label it "occasional PVC's". Palpated BP with a-fib is basically worthless in one sense, BUT palpated pulse can give a _rough_ feel for how many _effective_ beats per minute are occurring.

If the glucose is normal and the airway is patent/pt is breathing, can name any other unconscious states you can solve on scene? Especially sitting in a nursing care facility? Get and go, you are going to do that anyway, and especially since you aren't out in Cherry County somewhere with a two hour ride to a hospital. (Who was your receiving hospital, by the way?).


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## Handsome Robb (Nov 4, 2011)

Firemedic746 said:


> Maybe this, maybe that... Treat your pt not your monitor.



Stupid line.

Tell usalsfyre that and see what he has to say about it. No wait, I'll just tell you what he told me:

The monitor is a tool used in conjunction with a thorough patient assessment as well as other tools to form treatments and differential dxs.


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## truetiger (Nov 4, 2011)

Oxygen saturation/ETCO2? Lungs clear? Skin? Pupils?


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## mycrofft (Nov 4, 2011)

*Again, what in a four minute drive can be done?*

1. Any LOC is going to the hospital.
2. It is four minutes away.
3. Blood glucose was WNL, airway was patent and pt was breathing.

Everything else is academic.


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## fast65 (Nov 5, 2011)

NVRob said:


> Stupid line.
> 
> Tell usalsfyre that and see what he has to say about it. No wait, I'll just tell you what he told me:
> 
> The monitor is a tool used in conjunction with a thorough patient assessment as well as other tools to form treatments and differential dxs.




Exactly, telling someone to basically not pay attention to what they see on the monitor is ludicrous, why even put the monitor on if you're just going to discard it's findings? We need to use all of our tools in conjunction to treat a patient, that includes our mind, our monitor, and whatever else we may have.


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## usalsfyre (Nov 5, 2011)

Your learning well grasshoppers 

(Yes, I really do hate that cliche and have for most of my career. So does JPINFV, he wrote a heck of a blog post about it. Two words "clinical correlation". Look it up).


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