# 37 Year Old Male Unconscious



## Anjel (Jan 7, 2014)

*Hello All... Let me preface this by saying this is NOT a guess what is wrong with the patient scenario. It is more of walk me through your treatment and thoughts. *

Lets Begin...

It is a a cold winter morning . The temperature outside is -15 degrees with a windchill of -40.  You are sitting in your frozen truck and here the lovely sound of the Motorola gods say "Alpha 123(2 medics) and Bravo 321(2 basics) respond priority 1 for a diabetic". 

You arrive to a familiar residence that you frequent often. There is someone waving at you from outside. He runs up to your truck and says that one of the men renting a room in the house is a diabetic and" not acting right". You walk into the dark house and start sliding on ice. The house is cold, and there are no lights. 

You walk to the back bedroom to find your patient. Pt is a 37 yom laying on his side on the floor of the room. Pt is responsive to pain and is moaning. You notice a large sore on his right forearm that looks nectrotic and is draining a foul greenish color discharge. There appears to be no trauma. There is a steak knife in his left hand and a bowl of spaghetti that his head is laying in. Also there is a 5 gallon container full of urine and feces. 

Vital Signs:

Very weak carotid pulse- 48/min regular. BP- Unable to obtain. Automatic wouldn't read, and you couldn't hear or feel a pulse to auscultate. Resp 14- deep non labored. Pupils are dilated (6mm) non reactive. 

You are 1 mile from the nearest level 2 trauma center. 4 miles from the nearest cardiac care facility. 

Anddd go... lol


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## unleashedfury (Jan 7, 2014)

first things first full assessment to include ECG, and BGL. 

Since you said no lights in the house I sure hope you have a flashlight 

If BGL proves within normal limits, I would try and gather a solid pt. history from the gentlemen of the residence. 

However at this time, Establish IV access, ECG Monitoring and initiate transport based on the information you gave I am suspecting a sepsis alert patient. The poor living conditions Feces and Urine buckets, and a necrotic wounds with discharge is leading me in that direction, 

But reassessing to confirm my theory, Temperature? skin condition and color?


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## Anjel (Jan 7, 2014)

Bystander states the pt has insulin in the fridge and that is all he knows. He knows his first name, but not the last, and does not know when the last time anyone saw him was. 

Pt was carefully lifted to the stretcher and taken to the truck. 

EKG- Junctional rhythm at a rate of 50. 

BGL- Reads- High (Over 600). 

Skin- Pale... he is ice cold to the touch and hard. Cap refill in the extremities is >5 seconds. Your thermometer reads low (Less than 90* F). 

You cannot establish peripheral access. After 3 attempts. Still cannot get a BP.


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## exodus (Jan 7, 2014)

Go IO, hang your IV bag in front of the heater port to keep it from being freezing cold, start a bolus on him to attempt to get the pressure up and dilute the glucose.  Let sidestream him to see how his oxygenation and gas transfer status is.  Not much we can do.  If his airway is patent, just manage it BLS. Code 2 to the cardiac facility. Too close and dangerous for code 3.

Edit: Wrap him up in blankets as well.


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## unleashedfury (Jan 7, 2014)

Hmmm... In my area the Level 2 and 1 trauma centers are a one stop shop. cardiac, stroke, trauma, peds kinda convieneint. 

Skin temp reading low 90's and poor prefusion, unknown downtime, only known problem and meds are insulin. Try to passively warm, and since you need access after three failed attempts I'd go with the IO. if you carry warmed fluids go for it. if not wrap some tubing in a hot pack. ETA I wouldn't waste time on location trying to establish an IV. your so close to a ED that can provide much more than we can in the back of a ambulance.

I am still wondering if the underlying condition is septic leading to a hypothermic state from the patient lying where he was for a prolonged period of time.


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## NomadicMedic (Jan 7, 2014)

He's getting drilled or an EJ. At least 1000 of warm fluid and a ride to the hospital a mile away. You guys don't have lactate POC testing, right.  

Any further away and he'd be tubed.


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## FLdoc2011 (Jan 7, 2014)

Lactic at this point really isn't/shouldn't change what you do.   I think it's safe to assume it's going to be high in this case.... guy is in shock with likely DKA and sepsis.


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## Anjel (Jan 7, 2014)

Since we had one of our back up monitors, I didn't have etco2. However, I will give you guys some numbers that the ER got.

*Temp- 79.3!!!!!!*
Etco2- 15
BGL- 1300
BP- 52/26

I BLS'd his airway, started an IO. I got 500mls in by the time we go to the hospital 1 mile away. Also doc ordered 2mg Narcan. It had no effect- I wasn't surprised. 

I am working on getting his labs. All I overheard was a bicarb level of 4 and a pH of 7.1


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## FLdoc2011 (Jan 7, 2014)

Surprised his pH wasn't lower.


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## abckidsmom (Jan 7, 2014)

Wow. 79. Dang.


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## Rialaigh (Jan 7, 2014)

Honestly with a hospital a mile away that has a level 2 trauma center (and I would assume a semi capable ICU) I am putting this guy on a stretcher and going, not bothering to try an IV, not bothering with an EKG, certainly not bothering to try and take a medical history, whoever knows him best can ride with us. 

I don't care what treatment you can offer in the field or what you can find out, Its -15 outside and you can have the guy at a capable hospital in under 3 minutes, I am not delaying transport to do ANYTHING. If you want to attempt an IO en route...fine I guess but I don't really see it making any difference at all. This guy could have a central line in 10 minutes if you don't stay and play at all. Guy could have a bear hugger, EJ, warmed fluid, cardiac monitor, and a full staff and physician taking care of him less then 10 minutes after you get on scene if you just load and go.


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## Anjel (Jan 7, 2014)

From the time we were on scene till at the hospital was 17 minutes. While I was attempting IV access the basics did the EKG.  And my partner got the IO. 

Once at the ER he was Intubated, ultrasound was used to try and find peripheral access, that was unsuccessful so a femoral line started, bear hugger in place, and was receiving warm saline.

That's the last I know. I will follow up tomorrow.

Say you weren't so close to the ER. Would you have addressed HR and BP with more than just fluids. I was under the impression you couldn't because of the hypothermia and rewarming process. My partner said we could of gave dopamine.

Thoughts?


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## Rialaigh (Jan 8, 2014)

Anjel said:


> From the time we were on scene till at the hospital was 17 minutes. While I was attempting IV access the basics did the EKG.  And my partner got the IO.
> 
> Once at the ER he was Intubated, ultrasound was used to try and find peripheral access, that was unsuccessful so a femoral line started, bear hugger in place, and was receiving warm saline.
> 
> ...



If we were talking 30 minutes + transport time 

I might be tempted to give an atropine possibly to give me a couple minutes to get some more fluids in and see what the atropine did in terms of sustained higher HR or BP, kind of kick start the system while we try and warm him and get some fluids in. my next choice would be an epi drip.


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## unleashedfury (Jan 8, 2014)

Anjel said:


> From the time we were on scene till at the hospital was 17 minutes. While I was attempting IV access the basics did the EKG.  And my partner got the IO.
> 
> Once at the ER he was Intubated, ultrasound was used to try and find peripheral access, that was unsuccessful so a femoral line started, bear hugger in place, and was receiving warm saline.
> 
> ...



This is what I was also taught,, that medications are generally useless with a core temp that low. I was taught to focus on rewarming as the body naturally goes into a "hibernation process" when the core temp drops significantly. Warm Fluids with the ED probably focusing on getting a Central Line. 

If I was on a long distant haul, I'd still focus on maintaining the airway, and rewarming the patient, thats my primary focus.


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## abckidsmom (Jan 8, 2014)

unleashedfury said:


> This is what I was also taught,, that medications are generally useless with a core temp that low. I was taught to focus on rewarming as the body naturally goes into a "hibernation process" when the core temp drops significantly. Warm Fluids with the ED probably focusing on getting a Central Line.
> 
> 
> 
> If I was on a long distant haul, I'd still focus on maintaining the airway, and rewarming the patient, thats my primary focus.




Yep. We have an hour to get to the hospital. Temp less than 90? Warming and airway win. It's important to remember to lay these people on a couple of thermal blankets too. The cot mattress sucks heat out of them also.


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## Anjel (Jan 9, 2014)

I did a quick follow up. Nurse wouldn't give me labs...

However she did say that he is intubated in the ICU, temp back to normal, still in DKA, and 6%brain function.


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## unleashedfury (Jan 9, 2014)

Anjel said:


> I did a quick follow up. Nurse wouldn't give me labs...
> 
> However she did say that he is intubated in the ICU, temp back to normal, still in DKA, and *6%brain function*.



So the unfortunate matter is that this guy is most likely going to be a vegtable.

Ironically I had a hypothermia call tonight, and thought of this thread, Except mine was a little different, Dementia lady went wandering fell outside in the back yard. was out there for possibly 2 hours. core temp upon arrival to ED was 92.4,


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