# Slumpy



## MrBrown (May 13, 2010)

After a day of dragging people strapped to a gurney into your van with tinted windows and giving them drugs (what? ... you make it sound like something bad) you are sent to a guy passed out in his car on the side of the road.

When you arrive there are two cops and seven firefighters standing round doing nothing and the Engineer who is leaning on the truck looking at the chalkboard menu of the diner he has parked the outside of.

Single male patient in his fifties on the drivers side, slumped down over the seat and passenger seat.

- Unresponsive, GCS 3
- RR 24 PR 90 HR 130 BP 230/120 SpO2 96 BGL 90 (~4 mmol/l) 
- Sinus rhythm on 3 leads
- Clear and equal lung sounds
- Constricted pupils
- Medic alert bracelet says diabetic 

There are two bottles of medication in the centre console; one of Effexor and the other is Captopril.

So while the fireys sit round eyeing up the daily specials what are you gonna do?


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## exodus (May 13, 2010)

He's depressed, and he has HTN.... Awesome! Diabetic, nah, BGL is fine. Unless of course our glucometer is bonked, which I doubt.

What are my skins?


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## MonkeySquasher (May 13, 2010)

I take it vehicle isn't locked, and patient cannot be roused by verbal/pain.

Is the vehicle running?  Any oders?  No possible CO problem or toxic suicide attempt?  (Effexor use can cause suicide attempts.)  Smell of alcohol?

Check the pills in the bottles.  It's not an overdose of either of them, as both would cause hypotension and he's hypertensive.  See if he's taking both medications regularly.  (Date filled compared to pills left)  Have PD check the car (they have the right gloves) for needles/drugs.

Any other medications?  Any ID?  Note?  Emergency Contact?  Cell phone to get ahold of someone?  Maybe run the license plate for home address?

Physically...  Any trauma?  Skin?  Color?  What's his temp like, any hyper/hypothermia?  Any posturing?  Lung sounds?  Any signs of emesis/urination?

What's the weather like, vs his temp?

Once I have some more info I'll work on a plan.  For now, we'll do O2 NC 2LPM and attempt getting him out of the car onto a backboard or topdeck -> cot -> ambulance.


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## MrBrown (May 13, 2010)

Appears compliant with meds

No odours, knives, bombs, weapons, drugs, grenades or Osama Bin Laden in the car

The police are checking for reg owner details (and drinking thier latte) 

Patient is transferred to the ambulance


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## MonkeySquasher (May 13, 2010)

MrBrown said:


> Appears compliant with meds
> 
> No odours, knives, bombs, weapons, drugs, grenades or Osama Bin Laden in the car
> 
> ...




Okay, but that gives me none of the physical assessment questions I was looking for.  lol

Once we're in the rig, make him naked, check his whole person again.  Get an IV, large bore.  Grab bloods.  Check pupils, RR, HR and BP again, on top of all the physical stuff I requested before.  Recheck the monitor on a 4-lead.

What's his breathing pattern?


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## MrBrown (May 13, 2010)

No trauma
Normal skin and color
Temp 37 °C / 98.6°F
No posturing
Patient pee'd himself 

Right pupil is constricted and the left has blown 
PR 140 RR 26 BP 220/120 

We only use 3 lead or 12 lead - what additional lead does a 4 lead show?


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## Veneficus (May 13, 2010)

MrBrown said:


> We only use 3 lead or 12 lead - what additional lead does a 4 lead show?



I'd just give lead 2. 

Looks like he is suffering from effexor side effects which may have caused a hemorrhagic stroke.


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## MrBrown (May 13, 2010)

When you strap him to a gurney and move him into your van with tinted windows to give him drugs (what, man you make it sound like a bad thing, the cops are here aren't they?) he starts to have a seizure and becomes incontinent.

5mg midaz IV settles that down

You now hear rales


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## Smash (May 13, 2010)

Venlafexine (spelling?) is known in some cases to cause prolonged hypertension, and may also cause SIADH and resultant hyponatremia and encephalopathy.  Atypical antipsychotics may also cause seizures.  I'd also like to have a look at his QTc to know how ready I need to be for some torsades.  I'm not aware of any significant interactions between ACE inhibitors and Efexor; I would presume he is on the ACE inhibitor for hypertension, which perhaps isn't working as well as it should be, all things considered.

Anyway, this chap appears to have, if you'll excuse my technical terminology, blown his FooFoo Valve.  Depending on transport time and so forth, I would consider RSI, supportive care, driving of the big white truck to the big white building where the clever people with drills can fossick around in his head for a bit.


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## MrBrown (May 13, 2010)

Smash said:


> I would presume he is on the ACE inhibitor for hypertension, which perhaps isn't working as well as it should be, all things considered.



HX HTN RX ACEI



Smash said:


> Anyway, this chap appears to have, if you'll excuse my technical terminology, blown his FooFoo Valve.  Depending on transport time and so forth, I would consider RSI, supportive care, driving of the big white truck to the big white building where the clever people with drills can fossick around in his head for a bit.



What, Black and Decker aint in your scope of practice?

If you want to RSI that'd be my consideration I mean he's gonna get it at the hospital anyway (presumably) for a CAT scan and whatnot.


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## MonkeySquasher (May 13, 2010)

MrBrown said:


> No trauma
> Normal skin and color
> Temp 37 °C / 98.6°F
> No posturing
> ...





MrBrown said:


> he starts to have a seizure and becomes incontinent.
> 
> You now hear rales



Brain hemorrhage, probably Pons bleed.  Rales are probably secondary pulmonary HTN.  RSI, drive fast but safe, check for organ donor card.


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## Smash (May 15, 2010)

MrBrown said:


> HX HTN RX ACEI
> 
> 
> 
> ...



Well, there's an EZ-IO floating around the rig somewhere, I could have a red hot go with that I reckon. He's already coning, so what harm can I do?! 

So what was wrong with the chap? Did we do good?


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## MrBrown (May 15, 2010)

Apparently his HTN caused a neuro bleed which resulted in seizures, pulmonary edema 2° to an infarct which was caused by some massive sympathetic response.


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## reaper (May 15, 2010)

So what was on that menu board?


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## MrBrown (May 16, 2010)

reaper said:


> So what was on that menu board?



What would you like?


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## reaper (May 16, 2010)

T-bone and mashed potatos!


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## firetender (May 16, 2010)

*Let me take a stab; at the risk of getting skewered!*



MrBrown said:


> So while the fireys sit round eyeing up the daily specials what are you gonna do?



A Dinosaur's approach:

With all the local inattention, get him away from prying eyes to save my butt because I'd start yelling and they'd do nothing but get in my way. 

On site, I'd do no more than assure airway, assess, but in that include check for head/neck trauma before placing on a transferring device and get him in the rig.

Inside, start IV, draw bloods, start ambulance after BP found to be approximate same as first one taken. 

*THEN I'D FIGURE OUT HOW MUCH TIME BETWEEN THERE AND THE HOSPITAL* (Oh, you know, one of those nagging little details that determine EVERYTHING that follows)

Once the pupil blows and he starts seizing, sure try whatever it was you did to stop the seizure, but that's en route and only to keep him from doing the tuna on you, 

but at this point, hey, let's face it, why waste one second entering into a juggling contest of seeking deeper diagnosis/understanding (for what and for who's satisfaction?) or application of further meds, the longer I jerk around with the guy the worse his prognosis becomes. 

A stroke is a stroke. How many have you reversed in the back of the rig and how much time do you want to spend on handling symptoms of a much deeper and more critical etiology?


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## MrBrown (May 16, 2010)

Good point, I know we all advocate for deeper knowledge/assessment/treatment regimes by Paramedics but this guy is one of the people who needs a hospital pretty quick


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## firetender (May 16, 2010)

For a while there, it looked like no one thought there was a hospital!

...and not once did anyone call in for orders; isn't that done anymore?


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## MrBrown (May 16, 2010)

firetender said:


> ...and not once did anyone call in for orders; isn't that done anymore?



Hmm, orders for what?


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## Smash (May 16, 2010)

MrBrown said:


> Hmm, orders for what?



Orders for lunch off the menu of course! What other orders can there be?


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## MrBrown (May 16, 2010)

Smash said:


> Orders for lunch off the menu of course! What other orders can there be?



You never know, some people might start wandering from the program and getting crazy, calling up for orders to all sorts of stuff.  Lasix springs to mind.

If anybody out there uses IV GTN would you consider a nitro drip (I was thinking for the edema but perhaps [also] for the hypertension?).

Oh and here is the specials board for today:

Seafood marinara cooked with chilli, garlic and lemon served with pasta
Genuine homemade cheeseburger and fries
Leek, potato and carrot soup served with bread
Fresh grilled chicken salad
Italian tomato and herb soup
BLAT (bacon, lettuce, avacado and tomato)

Brown does cook you know


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## vquintessence (May 16, 2010)

MrBrown said:


> You never know, some people might start wandering from the program and getting crazy, calling up for orders to all sorts of stuff.  Lasix springs to mind.
> 
> If anybody out there uses IV GTN would you consider a nitro drip (I was thinking for the edema but perhaps [also] for the hypertension?).



Well without all them gizmo's and no more than two pairs of hands, I'd avoid the GTN like the plague.

A lot is presently pointing towards a popped brain (intracerebral hemmorhage).  There was no sign of trauma, he's hypertensive, seized (no hx inferred from the med list found), blown pupil, acute AMS presumed (he WAS operating a vehicle until he had the foresight to pull on over).  You said BGL was WNL?

Giving a vasodilator to deal with some rales & HTN seems a dangerous walk.  The poor soul is already unresponsive, he shouldn't be too tough to ventilate; but lets watch for trismus and the likely emesis.  IMHO, the ambu for this gentleman is truly for rapid transport after allowing for the assessment which yall have already discussed.


EDIT:  I'll take a BLT with pickles and light mayo


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## mycrofft (May 16, 2010)

*Only one person suggested spinal immobilization?*

Oh, the protocols, the poor disrespected protocols. He might have pulled over unobserved, opened the door, stood and banged his neck on the top of the door a few times at different angles, run arund the car three times and done jumping jacks, then slid back in, closed up, taken one look at the eatery's prices and stroked out.

Firetender and I are of a generation, as they say. Bedrock EMS!


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## Veneficus (May 16, 2010)

MrBrown said:


> You never know, some people might start wandering from the program and getting crazy, calling up for orders to all sorts of stuff.  Lasix springs to mind.



Lasix for what? because of some rales? That is a little overzealous. 



MrBrown said:


> If anybody out there uses IV GTN would you consider a nitro drip (I was thinking for the edema but perhaps [also] for the hypertension?).



Not a chance. Until Neuro sees this guy he is getting supporting care.

Looking a little deeper, effexor raises BP. So when that starts to taper off (whenever that is), what will his BP drop to? (a little too much mad scientist mixing chemicals for me) 

I would bet dollars to doughnuts this is a bleed. Even if you lower his BP it doesn't mean the bleeding will stop. With the blown pupil, it already looks like the increased bp is needed to maintain CPP. I would also bet the bleed somewhere in the anterior arteries with the rapid onset and presentation.

Based on his apparent GCS signs and rapid deterioration, this isn't a small artery bleeding. Wouldn't waste anymore time than absolutely required. With no apparent damage to the vehicle I wouldn't immobilize this guy.  

The only thing worthy of calling in for is to have Neuro surg meet you at the door with some power tools. They will likely want a CT (they always do ABC, airway, breathing, ct)
Maybe they just want to see how great the shift is? 



MrBrown said:


> Oh and here is the specials board for today:
> 
> BLAT (bacon, lettuce, avacado and tomato)
> 
> Brown does cook you know



Never had it with avacado, that sounds worth trying. BLT with a healthy dose of guacamole.

Sounds like the patient is having whatever was on the farm he just bought and will be admitted to the vegetable garden or the ECU.


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## mycrofft (May 16, 2010)

*Get Mexican avacados unles your raise your own.*

Not many folks as gone as this one come back. Hold his order.


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## MrBrown (May 17, 2010)

This gentleman is now helping Ma tend to the garden unfortunately.

It seems the stroke caused a neurogenic edema and that in turn caused so much strain on his heart he had an infarct.

I was curious about GTN as its the mainstay of pulomary edema management through lowering preload, if this guy has reduced left ventricular compliance it would seem to marry up that reducing preload is a good thing.  However that said, with hie neuro bleed it probably is not.


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