# ... For the unconscious unresponsive



## EMTswag (Oct 17, 2011)

you are a BLS unit dispatched to an extended care facility for a 66 YOF reported unconscious and unresponsive but breathing. Upon arrival find the pt unconcious unresponsive breathing irregularly at a rate of 12/min on 2 lpm nc. Staff stated pt was found this way approx 5 minutes prior to her calling. Sternal rub reveals pain response. Pt hx includes, among other things, etoh dependence drug addiction (opioids) ESRD HTN CVA and CHF. Pt found with fixed unresponsive pinpoint pupils. No other significant physical findings. Pt placed on 10 lpm via NRB which raises her breathing rate to regular at 14. Pts meds include simvastin for htn and oxycodone for pain. bp 142/76 pulse 86 spo2 90% on 10lpm nrb. 

I called for ALS who treated all the way to ER. Partner disagreed saying she didnt need ALS as "there was nothing they could have done for her."

What do you think?


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## Handsome Robb (Oct 17, 2011)

Sounds like the painkillers made someone sleepy. When was the last time this pt received their oxycodone and at what dose? ALS could have given narcan to bring them around but they were spontaneously breathing with no signs of hypoxia, I wouldn't be super quick to wake this pt up unless their respirations started to decrease. Monitor and transport. My other thought is with a history of opioid abuse/dependance and the (assumed) history of chronic pain, antagonizing the opioid receptors could lead to a sticky situation.

What was the pt's normal BP? 142/76 is elevated but that depends on how well the HTN is controlled. What was their SpO2 on the 2 lpm via NC?


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## truetiger (Oct 17, 2011)

How far was it to the ED? Could you have gotten there quicker than it took to call and wait for ALS?


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## DrParasite (Oct 18, 2011)

EMTswag said:


> I called for ALS who treated all the way to ER. Partner disagreed saying she didnt need ALS as "there was nothing they could have done for her."


you called for ALS, who treated her all the way to the ER.... so apparently they saw something that warranted them treating.  good call.

your partner is an idiot, sounds like you did the right thing.

BTW, unconc/unresponsives who are breathing have a bad habit of becoming cardiac arrests when EMS arrives.  ALS should be sent on the initial dispatch, and any old person who is still unresponsive should get an ALS assessment.


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## usalsfyre (Oct 18, 2011)

Your partner hasn't moved beyond the "patch and skill set" mentality. Paramedics should be more useful for what they know than what they can do.


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## EMTswag (Oct 18, 2011)

truetiger said:


> How far was it to the ED? Could you have gotten there quicker than it took to call and wait for ALS?



About 14 minutes to the ER. ALS was on scene by the time we got the pt to the truck.


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## EMTswag (Oct 18, 2011)

DrParasite said:


> you called for ALS, who treated her all the way to the ER.... so apparently they saw something that warranted them treating.  good call.
> 
> your partner is an idiot, sounds like you did the right thing.
> 
> BTW, unconc/unresponsives who are breathing have a bad habit of becoming cardiac arrests when EMS arrives.  ALS should be sent on the initial dispatch, and any old person who is still unresponsive should get an ALS assessment.



I would have thought so too but apparently they werent.. something i found out when i asked for their ETA.


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## chuck stank (Oct 18, 2011)

Agreed that it is an ALS run and to monitor the patient.


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## Akulahawk (Oct 18, 2011)

Something to consider: you have an unconscious, unresponsive patient with pinpoint pupils and has a SpO2 of 86% on 2L... While your patient is breathing, they're not moving enough volume to adequately oxygenate the blood... or remove CO2. The fact that the SpO2 reading came up with increased O2 concentration means that there's certainly some airflow that's reaching the alveoli. Using the BVM to supplement the patient's natural breathing drive just using room air (basically you give a breath every time the patient takes one) would probably have seen a rapid increase in SpO2 levels... 

It was a good call on your part to get ALS rolling because they can do some things to further provide care. Naloxone, _carefully_ titrated, might just be the thing this patient needed.


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## Handsome Robb (Oct 18, 2011)

Akulahawk said:


> Naloxone, _carefully_ titrated, might just be the thing this patient needed.



You did a much better job wording what I was trying (and failing) to say.


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## clibb (Oct 19, 2011)

What you have to think is "What is right for the patient", not "How can I show off". Depending on your protocols, it depends on ALS vs BLS. In our protocols, I can push Narcan for a DO or Paramedic indication. 
Any trauma findings on the patient?
If the O2 fixed the irregular breathing, then why fix something with a drug that's already fixed? Just keep an eye on the breathing, vitals. I'd rather have her sleeping with stable vitals, then fighting me in the back 
Would I had attended this call? No.


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## imadriver (Oct 20, 2011)

I'm an EMT, but work with a Medic on an ALS truck. So I'm not sure on the treatment part, 

however, I do know between the Unconsious, with Pain Response, and the "fixed unresponsive pinpoint pupils" with a Hx of drug addiction and a known access to opiates, I'd differently tell my medic I think this is a Narcan candidate. She is showing all the right signs of an opiate OD.

Long story short, I think you did the right thing.


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## Akulahawk (Oct 20, 2011)

clibb said:


> What you have to think is "What is right for the patient", not "How can I show off". Depending on your protocols, it depends on ALS vs BLS. In our protocols, I can push Narcan for a DO or Paramedic indication.
> Any trauma findings on the patient?
> *If the O2 fixed the irregular breathing, then why fix something with a drug that's already fixed?* Just keep an eye on the breathing, vitals. I'd rather have her sleeping with stable vitals, then fighting me in the back
> Would I had attended this call? No.


That's the problem. It may not have actually fixed the breathing problem. The O2 probably merely covered up an inadequate ventilation problem. Very careful titration of naloxone will knock just enough opiate off the receptor sites to allow for a less-suppressed respiratory drive without completely reversing the opiate-induced sedation. If your protocols do NOT allow for titration to a desired effect, you then have to determine if your patient is adequately ventilated... and which way you need to correct an underventilated patient: BVM or naloxone.


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## Ryan3294 (Nov 14, 2011)

Well the medic could have downgraded you to BLS if they didn't feel it was worthy of ALS treatment. Also, at least for my protocols, any altered mental (in this case unconscious) requires a medic


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## DrankTheKoolaid (Nov 14, 2011)

*re*

You did the right thing by calling ALS.  

Also note that Spo2 is a horrible indicator of ventilitory status if patient is on ANY supplimental O2.  Patient can receive a hypoxic injury before the spo2 drops.  Either use side stream etco2 monitoring or treat your patient.  Not the spo2 monitor.  Tabers will give a great explination of the differances between respiration / ventilation / oxygenation


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## usalsfyre (Nov 14, 2011)

I'm really not trying to pick on you tonight I promise...but


Corky said:


> Patient can receive a hypoxic injury before the spo2 drops


Huh? SpO2 has its issues but unless you suspect a severe anemia or a cytotoxic issue preventing tissue oxygenation SpO2 is generally a safe indicator. I've seen it read falsely low often but I can't say I've ever gotten a falsely high reading.



Corky said:


> Either use side stream etco2 monitoring


ETCO2 tells you zippity about oxygenation. Hypercapneia perhaps, ventilatory status maybe, even a bit about cardiac output but not one whit about oxygenation.



Corky said:


> or treat your patient.  Not the spo2 monitor.


Suppose your wrong and the pulse ox is right? A better choice of words is correlate all information you have to come up with a treatment plan, don't automatically dismiss information that doesn't fit your hypothesis, explain it.


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## DrankTheKoolaid (Nov 14, 2011)

*re*

Let me rephrase the first.

Patient will continue showing a falsely high O2 saturation because of the supplimental oxygen and it being dissolved in plasma and not on hemaglobin.

He said nothing about ventilatory status and just said a respiratory rate ..  they are not the same.  Tidal volume etc etc

This is where etco2 will come in with a better realtime account of ventilatory status

If there is an elevated etco2 that equals less O2 binding ability. Rfer back to first point.

But thanks for forcing me to make that first point more clear.  And if I am incorrect about his, please do school me as I am always trying to better my understanding of it all.

** cough ** oxyheamaglobin dissociation curve


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## usalsfyre (Nov 14, 2011)

Corky said:


> Let me rephrase the first.
> 
> Patient will continue showing a falsely high O2 saturation because of the supplimental oxygen and it being dissolved in plasma and not on hemaglobin.


Errr, wrong. SpO2 uses differences in light wavelengths to detect saturated hemoglobin. It will not give any information about PaO2. It's also worth noting here that oxygen unloads of the hemoglobin into the plasma and then into the cell, not directly off the hemoglobin into the cell.



Corky said:


> He said nothing about ventilatory status and just said a respiratory rate ..  they are not the same.  Tidal volume etc etc


Very true, many factors make up ventilatory status.



Corky said:


> This is where etco2 will come in with a better realtime account of ventilatory status


But again tells you little about oxygenation and hypoxia. It's entirely possible (and indeed I've seen) patients who are oxygenating on room air just fine but have elevated ETCO2 due to other conditions.



Corky said:


> If there is an elevated etco2 that equals less O2 binding ability. Rfer back to first point.


Yes but this is a good thing. Oxygen unloads off hemoglobin better in acicdic conditions (such as elevated ETCO2) meaning it gets into the plasma and therefore the cell easier. Also remember the majority of CO2 is not carried bound to hemoglobin but rather tied up in the bicarbonate and phosphate buffer systems. So elevated CO2 doesn't mean less binding sites are available. 

Finally understand that ETCO2 is not a direct reflection of PaCO2, many factors such as lung condition and cardiac output end up making up this value. The only thing you can safely assume is that PaCO2 is at least equal to ETCO2 as it's a downhill gradient. I've seen however patients with ETCO2 values that were below normal have PaCO2 in the >80mmHg range because they couldn't breathe the CO2 out.



Corky said:


> But thanks for forcing me to make that first point more clear.  And if I am incorrect about his, please do school me as I am always trying to better my understanding of it all.


No problem, hope that helps. There's people that are a heck of a lot smarter than I am on here that maybe can explain it better.


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## DrankTheKoolaid (Nov 14, 2011)

*re*

Couple valid points there US.  

And yeah  I understand its not a measure of PAco2, but both that and cardiac output.  Yup only 10% or so will bind to hemglobin. equaling 10% less O2 binding to it's sites.

You seem like someone who would also enjoy listening to this guy as much as I do. 

Dr. Scott Weingart

He's an Emergency Room Intensivist who loves to teach and do Podcasts.  He does a great talk on ETco2.  Give it a listen and you will see why my standpoint is what it is on alot of things.

Emcrit.org and Crashingpatient.com


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## usalsfyre (Nov 15, 2011)

I listen to Dr Weingart as well. He and Dr Rich Levitan (another clinical stud) have done some work on "apenic oxygenation" that pretty clearly demonstrates the difference between oxygenation and ventilation. 

I'm still trying to digest his acid-base lecture though. Maybe one day I'll be edumacated enough I don't start feeling like the class idiot around episode 3 .


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## DrankTheKoolaid (Nov 15, 2011)

*re*

Lol i cant even recall the number of times ive listened to Acid-Base III!


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