# Help with this scenario



## rhan101277 (Jul 4, 2010)

Location: Club
Time: 3:30AM

Pt is 24 y/o female with c/c of asthma attack secondary to cigarette smoke. 

General impression:  Pt having difficulty breathing laying on floor in club.

Initial assessment:  Pt lungs are clear bilaterally, but breathing pattern is not normal.  I have to do a sternal rub at intervals because she stops breathing.  At this time I have no access to a pulse ox, so I have to rely on mucosa and skin/color/condition for perfusion status.  Cardiac monitor shows sinus tach.  Friend says she has 1 strawberry diaqari, I don't smell alcohol on her breath.

Patient is only responsive to pain and will not answer any of my questions.  I have a BVM ready and she is hooked to NRB mask.  EKG not showing signs of PVC or anything that will lead me to think of oxygenation issues.  She never totally stops breathing but has extremely shallow respirations at which time I the only way I can get her back to normal breathing is a sternal rub.

Further information from friend is that she does have a history of asthma, but no asthma inhaler, and she has been up a long time w/o sleep.  Her pupils are fixed and eyes appear dry, eyes sometimes make erratic movements to the left.

At this time I am thinking maybe she is having some kind of brain bleed, I can't understand what is causing her respirations to be like they are.

I stay calm and keep her breathing, it is all I can focus on.

I was by myself for 10 minutes or so on this one and it kinda felt like a my first call as medic, even though I am not one yet.  Got 30 more days to go  and take registry etc.

Any thoughts on above scenario


----------



## rhan101277 (Jul 4, 2010)

Call took place with supervision of a paramedic


----------



## Chimpie (Jul 4, 2010)

So, you were by yourself or not?

How did you arrive? POV? Ambulance?


----------



## Fox800 (Jul 4, 2010)

BP/heart rate? BGL? ETCO2? Temp? 12-lead EKG? Med history? (Epilepsy, diabetes, etc.)
Possible overdose?

Did you consider intubation? Shallow breathing and genuine unconsciousness and all...


----------



## MrBrown (Jul 5, 2010)

Could be some sort of overdose, almost sounds like the ketamine stare


----------



## WTEngel (Jul 5, 2010)

Just a couple of points to ponder...

First, absence of wheezing does not always mean that the patient is not suffering from complications of asthma. It is not uncommon to give a patient with no wheezing and "tight" breath sounds a treatment and when the airways begin to open up and the patient begins to move more air, the wheezing will become profound. Without hearing the breath sounds first hand, I can't say whether I would have this suspicion or not.

Second, many of the clues here lead one to go down the recreational drug pathway. While it is important to use the clues around us (time of night, club setting, etc.) it is also important to give the patient the benefit of the doubt too.

I just wanted to add those two things... I am not critiquing or monday morning QBing, I just thought this was a good chance to throw those out there.

Without a little more to work with, definitively going down any path with this patient isn't really possible. Treat the treatable, take away the pain, do no further harm...if additional information comes to lit and leads you in a more specific direction, act on it. Until then it is a guessing game...start with ABC...

TE


----------



## Smash (Jul 5, 2010)

Could be a million and one things. One thing that springs to mind is possible OD on gamma-hydroxy butyrate. Classic symptoms are very labile GCS (profound coma but when stimulated, agitation/aggression), labile resps similar to GCS. Pupils may be constricted and nystagmus (the jerking movement of the eyes to one side) may be present. 

It could also be pretty much anything else...


----------



## rhan101277 (Jul 5, 2010)

Thanks for the help so far.  Pt was moving air fine, no diminished sounds at all.


----------



## Roam (Jul 5, 2010)

How about blood glucose, a sugary alcoholic drink can send a diabetic over the edge. Also depending on the PT sugars from alcohol can cause a crash then shoot bgl through the roof. Would also explain the mental state...

If her bgl is normal then I am also on the path of bad combination of drugs or prescription interaction...
Tell us more!


----------



## firetender (Jul 5, 2010)

Prepare for Transport.

Protect the airway.

Check for needle marks.

Save any drinks.

What did you DO? 

Understanding *what *is going on is always secondary to taking action. In this case, it's keep moving.

First comes the decision to prevent any downward spiral. You are supposed to understand what is life-threatening and what is not. Then prepare for it and get going.


----------



## PrincessAnika (Jul 7, 2010)

how long has she been up? did she take anything to help stay awake?  vitals?  history?  drug indication around?


----------



## Sam Adams (Jul 10, 2010)

Supine asthmatics concern me. They typically are doing everything they can to sit up. Off the bat I'm thinking she's either a very sick asthmatic or it's not her asthma. With her friends statement of having been awake for an extended period of time, substance abuse is high in my list of differentials, particularly cocaine and meth. You mention that her pupils are fixed. Are they dilated? constricted? different sizes?


----------



## legion1202 (Jul 16, 2010)

with my little emt training i would rule out astma attack. No weezing and clear breath sounds. I would think overdose or some kind of head trauma maybe..


----------



## clibb (Jul 17, 2010)

In a club?
Her friend said that she only had 1 strawberry diaqari. How late in the night was this?

One of the worries that shouts out at me is Ecstasy or that she has been slipped something in that "1" daiquiri.


----------



## socalmedic (Jul 18, 2010)

idk how old you are or if you have been to a club before but; first off i dont know of any clubs that are open at 0330 (last call is usualy 0130 and closing is generally 0200), and second i would doubt that she has only had one drink, third if she had an "asthma attack" after being exposed to smoke (most likely on the smoking patio OUTSIDE why was she back on the dance floor. my gut is going with OD on God knows what club stimulant.

i would, ABC, cardiac monitor, BGL, IV, O2, follow local ALOC/OD protocol and Tx C-3.

also find out how close of a friend she is. if close she is going with us, front seat of course, to talk to the doc/get Hx from family. transporting her too eliminates the liability of her DUI to the ED, eliminates the chance that she will get scared and not got the the ED, provides the doc with a point of contact to the event, Hx, and family.


----------



## CAOX3 (Jul 20, 2010)

Im going with overdose and in my expeience friends and bystanders are reluctant to offer information on amount of alcohol consumed or drugs taken.

So its a guessing game until you politely explain to them that your not the cops and every second wasted playing games is another step closer their friend gets to the cabbage patch. I mean not in those exact terms but you get the gist.

Cold stark reality usually lights a fire under their butts, in some case their singing like canaries in others their friends are to worried about their stash to even give a crap about what their friends final outcome is as long as they can go home and get their high on.


----------



## Melclin (Jul 20, 2010)

Smash said:


> Could be a million and one things. One thing that springs to mind is possible OD on gamma-hydroxy butyrate. Classic symptoms are very labile GCS (profound coma but when stimulated, agitation/aggression), labile resps similar to GCS. Pupils may be constricted and nystagmus (the jerking movement of the eyes to one side) may be present.
> 
> It could also be pretty much anything else...



This.

And status epilepticus...maybe. I find it hard to actually understand what was happening. When you present a case study, it really helps if you are far more systematic with the presentation of your assessment and the scenario.


----------

