# 19y.o AMS



## EMT B (Sep 12, 2013)

This is a scenario we ran at my most recent dept training.

Dispatched via 911 to the local high school for a 19 year old male subject "not acting right." You arrive on scene to find a male sitting in the Nurses office on her bed. He is in no apparent distress. Patient has intact ABCs. When you see him, you recognise him from a couple weeks ago when you took one of his friends to the hospital from a drinking party. The nurse tells you that a teacher brought him in from the lunch room because he was acting "drunk." When you start your interview, all he does is smile or chuckle at your questions. The few words you do get out of him are slightly slurred. Your partner looks at his chart that the nurse provides you. 

NKDA; PMHX of ADHD and Asthma. Pt. is on 5mg Ritalin BID and Albuterol Sulfate 2 puffs PRN.

What are your next steps? What questions do you ask?


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## TechYourself (Sep 12, 2013)

EMT B said:


> This is a scenario we ran at my most recent dept training.
> 
> Dispatched via 911 to the local high school for a 19 year old male subject "not acting right." You arrive on scene to find a male sitting in the Nurses office on her bed. He is in no apparent distress. Patient has intact ABCs. When you see him, you recognise him from a couple weeks ago when you took one of his friends to the hospital from a drinking party. The nurse tells you that a teacher brought him in from the lunch room because he was acting "drunk." When you start your interview, all he does is smile or chuckle at your questions. The few words you do get out of him are slightly slurred. Your partner looks at his chart that the nurse provides you.
> 
> ...



last oral intake, to include drugs and alcohol.


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## EMT B (Sep 12, 2013)

pt had a school lunch and denies doing any drugs or drinking any alcohol. 

school lunch today was green beans, pizza, tater tots, and a milk.


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## TechYourself (Sep 12, 2013)

EMT B said:


> pt had a school lunch and denies doing any drugs or drinking any alcohol.
> 
> school lunch today was green beans, pizza, tater tots, and a milk.



xport with chief complaint of AMS.


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## chaz90 (Sep 12, 2013)

All kinds of potential causes, but what can any of us do pre hospitally? Check BGL, start IV with lab draw, monitor vitals and transport.


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## DesertMedic66 (Sep 12, 2013)

chaz90 said:


> All kinds of potential causes, but what can any of us do pre hospitally? Check BGL, start IV with lab draw, monitor vitals and transport.



This. Run down the list of AEIOUTIPS. Get some vitals. Draw some bloods. Nice transport to the hospital.


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## EMT B (Sep 12, 2013)

just realized i forgot to give the vitals. 

BP: 140/94
Pulse: 81
SpO2: 94
BGL: 117

Here is the 12 lead


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## chaz90 (Sep 12, 2013)

That 12 lead is a bit surprising. A Fib with occasional PVCs. Still doesn't change anything though. Plenty of potential toxicologic or metabolic causes for A Fib in a young person, or it could be a more rare pre existing condition.


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## EMT B (Sep 12, 2013)

you get an 18 in the left AC and as you are drawing your labs the pt has an episode of urinary incontinance before passing out. you start to smell acetone on the breath that you did not notice before.


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## unleashedfury (Sep 12, 2013)

EMT B said:


> you get an 18 in the left AC and as you are drawing your labs the pt has an episode of urinary incontinance before passing out. you start to smell acetone on the breath that you did not notice before.



If he passes, out maintain the airway and treat him with diesel not much we can do in preshospital. Pt. needs labs and possibly a ABG. to determine reasoning behind AMS. 

with a BGL of 117 I doubt a diabetic emergency. but theres other factors will never see that could be the culprit.


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## Handsome Robb (Sep 12, 2013)

This age group I'm looking primarily at drugs and/or alcohol.

Potentially drank rubbing alcohol/ methyl alcohol or something of the sort would be my first guess. Could be regular ETOH as well. 

Abuse of the Ritalin, especially long term, could cause the ectopy and dysrhythmia. With that said it's a side effect that is present in less than 1% of patients.

http://www.ehealthme.com/ds/ritalin/atrial+fibrillation

This screams toxicological emergency to me. Of course the kid is gonna lie about drugs and alcohol.

Any family history of atrial fibrillation? He's a touch gorked so it'd be difficult to determine whether he's been having symptoms consistent with AF prior to today.


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## chaz90 (Sep 12, 2013)

Robb said:


> This age group I'm looking primarily at drugs and/or alcohol.
> 
> Abuse of the Ritalin, especially long term, could cause the ectopy and dysrhythmia. With that said it's a side effect that is present in less than 1% of patients.
> 
> http://www.ehealthme.com/ds/ritalin/atrial+fibrillation



Good thought with the Ritalin. I considered amphetamine use as a cause of the A Fib, and then somehow forgot he was using Ritalin anyway and would have easy access for abuse or just a side effect!


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## EMT B (Sep 12, 2013)

Grandfather on the fathers side has afib. 

Patient is still unconscious and begins to vomit. You have your partner kick it up to code 3 and you are still 35 min away from the hospital with current driving conditions.


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## Rialaigh (Sep 12, 2013)

alcoholic ketoacidosis strikes me as a possibility.

 If he is inconitant of urine then I am guessing no gag reflex and based on vitals (depending on what they are) taken post passing out I am strongly considering a tube at this point. Im not gona ride around for 35 minutes trying to hold a BvM seal or keep his airway good with an OPA.


Even with the normal blood sugar I may do fluids wide open (especially if I have an airway) with a bag of D5 or an amp of D50. I expect the BP to drop and for him to become tachy shortly (minus any effect of vagaling him down from an intubation).


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## chaz90 (Sep 12, 2013)

EMT B said:


> Grandfather on the fathers side has afib.
> 
> Patient is still unconscious and begins to vomit. You have your partner kick it up to code 3 and you are still 35 min away from the hospital with current driving conditions.



Well, now I'd intubate. Long transport with an unresponsive patient who's not protecting his own airway and vomiting means the RSI drugs are coming out. Changes in vital signs? How about EtCO2 values and an inherent RR prior to me taking his respiratory drive away?

Also, that glucometer reading 117 better be calibrated and accurate. Possible recheck of BGL, since this patient obviously could be acidotic and severely hyperglycemic. Thinking a fluid bolus as well at this point in case of toxicologic causes.


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## chaz90 (Sep 12, 2013)

Rialaigh said:


> alcoholic ketoacidosis strikes me as a possibility.
> 
> If he is inconitant of urine then I am guessing no gag reflex and based on vitals (depending on what they are) taken post passing out I am strongly considering a tube at this point. Im not gona ride around for 35 minutes trying to hold a BvM seal or keep his airway good with an OPA.
> 
> ...



Haha, the echo has struck yet again...


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## Rialaigh (Sep 12, 2013)

chaz90 said:


> Haha, the echo has struck yet again...



good to know Im not just totally crazy :lol:


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## EMT B (Sep 12, 2013)

post syncopal vitals are 

BP 110/81
Pulse 69
SpO2 93
BGL 119 with your trucks second glucometer
Resp 8

12 lead still shows afib with occasional pvcs 


after the patient vomits you suction the airway and hook him up to nasal capnography at 4lpm. ETCO2 is 38 and resp rate is still at 8. You RSI the patient successfully per med control and are now bagging him with 10 lpm of O2 attached. you have created a bag of D5NS that is running wide open. your BLS intercept has taken over the bagging and you are 25 out from the hospital.


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## chaz90 (Sep 12, 2013)

Seeing as my patient would be on a ventilator at this point and I'd be twiddling my thumbs, I'd consult with a doc on initiating Thiamine and D5W. I'm leaning hard towards Alcoholic Ketoacidosis. Keep in mind, I don't even carry Thiamine in real life, but since we're playing the scenario game, I might as well go full tilt.


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## EMT B (Sep 12, 2013)

im surprised nobody has offered to clean the patient yet. hes sitting in his own urine and could get an infection if we dont get him out of the clothes. 

you cut off his clothes and put a johnny on him. as you are tying the johnny in the back you see 3 tampon tails coming out of the anus.


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## GAmedik34 (Sep 12, 2013)

EMT B
you get an 18 in the left AC and as you are drawing your labs the pt has an episode of urinary incontinance before passing out. you start to smell acetone on the breath that you did not notice before.


Vasovagal syncope


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## chaz90 (Sep 12, 2013)

EMT B said:


> im surprised nobody has offered to clean the patient yet. hes sitting in his own urine and could get an infection if we dont get him out of the clothes.
> 
> you cut off his clothes and put a johnny on him. as you are tying the johnny in the back you see 3 tampon tails coming out of the anus.



The back of the ambulance is really not conducive to stripping this patient down and cleaning him up. He's not sitting in a bucket of urine either. Much will be soaked up by clothes, and some will simply soak to the back and stretcher by gravity. Skin breakdown and ulcers aren't going to form in 30 minutes either. That being said, if I somehow saw these tampons, I'd pull them out. More accurately, I'd have my BLS partner pull them out.

Media hysteria has really blown this whole butt chugging and vodka soaked tampon thing out of proportion. Even in a college town with a large state university, we (including the hospital) had zero cases ever.


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## rmabrey (Sep 12, 2013)

EMT B said:


> im surprised nobody has offered to clean the patient yet. hes sitting in his own urine and could get an infection if we dont get him out of the clothes.
> 
> you cut off his clothes and put a johnny on him. as you are tying the johnny in the back you see 3 tampon tails coming out of the anus.



If you dont have time to go code 1, you dont have time to clean and put on a diaper


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## Tigger (Sep 12, 2013)

chaz90 said:


> Media hysteria has really blown this whole butt chugging and vodka soaked tampon thing out of proportion. Even in a college town with a large state university, we (including the hospital) had zero cases ever.



Good luck finding actually documented cases of it period. Just one of those "stories" that the media caught on to and did not let go, despite little if any proof of it actually occurring at any significant rate.

And for what it's worth, I have no problem cleaning patients but the back of the ambulance while transporting emergent with an RSIed patient is just not one of those places. We try very hard not to unnecessarily move intubated patients to prevent tube dislodgement. Our patients are usually spider strapped to backboards with a c-collar and tube tie, and on a vent. So moving them around isn't exactly an easy proposition.


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## Medic Tim (Sep 12, 2013)

I have actually had a pt who attempted this. He passed out while trying to insert it.


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## EMT B (Sep 12, 2013)

Tigger said:


> Good luck finding actually documented cases of it period. Just one of those "stories" that the media caught on to and did not let go, despite little if any proof of it actually occurring at any significant rate.
> 
> And for what it's worth, I have no problem cleaning patients but the back of the ambulance while transporting emergent with an RSIed patient is just not one of those places. We try very hard not to unnecessarily move intubated patients to prevent tube dislodgement. Our patients are usually spider strapped to backboards with a c-collar and tube tie, and on a vent. So moving them around isn't exactly an easy proposition.



the way the instructor did this scenario was that as soon as the pt goes unconscious  you cut everything and do a rapid trauma scan to cover your ***. during this scan is when you most likely would have found the tampons.


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## Tigger (Sep 12, 2013)

Medic Tim said:


> I have actually had a pt who attempted this. He passed out while trying to insert it.



No kidding. Wow.



EMT B said:


> the way the instructor did this scenario was that as soon as the pt goes unconscious  you cut everything and do a rapid trauma scan to cover your ***. during this scan is when you most likely would have found the tampons.



It might be a thought to get some clothes off him once he became unable control his own airway and intubation was considered. But not just to clean him as was earlier presented.


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## DesertMedic66 (Sep 12, 2013)

Tigger said:


> Good luck finding actually documented cases of it period. Just one of those "stories" that the media caught on to and did not let go, despite little if any proof of it actually occurring at any significant rate.
> 
> And for what it's worth, I have no problem cleaning patients but the back of the ambulance while transporting emergent with an RSIed patient is just not one of those places. We try very hard not to unnecessarily move intubated patients to prevent tube dislodgement. Our patients are usually spider strapped to backboards with a c-collar and tube tie, and on a vent. So moving them around isn't exactly an easy proposition.



I had a 13 year old girl do it at a party when her parents were out of town.


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## Rialaigh (Sep 12, 2013)

If we are in the middle of transport, and the guy isnt bleeding out, and I can control the airway from the airway seat while belted in, I'm not unbuckling if the guy pee's two gallons and craps himself twice....We can take care of it when we get to the hospital.


And are we still shooting at alcoholic ketoacidosis or are we just saying alcohol poisoning at this point


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## DesertMedic66 (Sep 12, 2013)

EMT B said:


> im surprised nobody has offered to clean the patient yet. hes sitting in his own urine and could get an infection if we dont get him out of the clothes.
> 
> you cut off his clothes and put a johnny on him. as you are tying the johnny in the back you see 3 tampon tails coming out of the anus.



Not enough room in the back of the ambulance to try to clean a patient up. Let alone cleaning them is the least of my concerns when the patient has other issues going on. 

What is a Johnny?


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## EMT B (Sep 12, 2013)

johnny


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## NomadicMedic (Sep 12, 2013)

A ridiculous zebra scenario. 

It was fine until we got to "tampon tails". 

Nice try, but a fail.


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## Handsome Robb (Sep 12, 2013)

So since we have a controlled airway and stable vitals why are we going code 3? 

Seconded on the BLS partner removing the tampons.

Thiamine isn't a bad idea. Rally bag anyone?

He's tubed lets do an NG/OG and hook it to suction so we don't have to clean up any more puke.

Also, he's 19 with no appreciable medical history...I'm not really worried about an infection from sitting in his urine for a few minutes. Hell, urban outdoorsman sit in their urine and sometimes feces for days on end without going septic.


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## EMT B (Sep 13, 2013)

we are going code 3 because the high school is 40 mins from the hospital. also in my system if you have someone tubed you better be going code 3

why a rally pack? are you worried about WKS?


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## STXmedic (Sep 13, 2013)

EMT B said:


> we are going code 3 because the high school is 40 mins from the hospital. also in my system if you have someone tubed you better be going code 3



Your system needs work, bud. A tube is a great reason _not_ to go emergent. The immediate airway danger is done. Good job. Now you (both) get to breathe easy on the way in.


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## Akulahawk (Sep 13, 2013)

EMT B said:


> we are going code 3 because the high school is 40 mins from the hospital. also in my system if you have someone tubed you better be going code 3
> 
> why a rally pack? are you worried about WKS?


The ETT itself isn't a reason for Code 3 travel. The reason for Code 3 travel has to do with the patient's condition. I've done Code 3 travel for patients that were awake, alert, oriented... and not intubated, but their condition necessitated it. I've gone Code 2 with many, many more... even those intubated. Your Medical Director probably feels that if a patient was emergently intubated, the underlying issue is the trigger for Code 3 travel. They may have had some problems with providers not recognizing the underlying issue was the problem... therefore now it's "Mongo intubated patent, Mongo take patient to hospital very fast."


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## Akulahawk (Sep 13, 2013)

EMT B said:


> im surprised nobody has offered to clean the patient yet. hes sitting in his own urine and could get an infection if we dont get him out of the clothes.
> 
> you cut off his clothes and put a johnny on him. as you are tying the johnny in the back you see 3 tampon tails coming out of the anus.


Couple of things... if the patient becomes unconscious and then incontinent of urine on scene, I might cut off the clothes, but I'm not going to put a "johnny" on the patient. Also, someone that far "out" is going to get an OPA. If they "take" the OPA, then I'm going to place an ETT. If the patient becomes incontinent of urine or stool during transport from the field, cleaning him up is probably the last thing I need to do. If I can get to it, great. If I've got the room and the supplies, I'll get it done ASAP. In the field, I won't have the room or the supplies (usually) and people won't usually get any skin breakdowns that quickly. It's going to be mentioned to the team at the destination, so he'd be cleaned up very quickly at that point.

After the ETT placement is done, if necessary/protocol allows, I'd also place an NGT just because of that whole stomach decompression/vomiting thing...


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## Handsome Robb (Sep 13, 2013)

EMT B said:


> we are going code 3 because the high school is 40 mins from the hospital. also in my system if you have someone tubed you better be going code 3
> 
> why a rally pack? are you worried about WKS?



That's unfortunate for you to have to endanger yourself and the public. A long transport isn't an indication for code 3, either. Now if this were a BLS truck or you were unable to secure the airway then by all means lets haul the mail.

WKS? A rally bag is a liter bag with some thiamine, frolic acid and a touch of mag. If you're allowed to do them prehospital lot it's generally only going to be thiamine and fluid. See: "banana bag"



STXmedic said:


> Your system needs work, bud. *A tube is a great reason not to go emergent. *The immediate airway danger is done. Good job. Now you (both) get to breathe easy on the way in.



Agreed. Bolded the key phrase.


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## Akulahawk (Sep 13, 2013)

Robb said:


> That's unfortunate for you to have to endanger yourself and the public. A long transport isn't an indication for code 3, either. Now if this were a BLS truck or you were unable to secure the airway then by all means lets haul the mail.
> 
> WKS? A rally bag is a liter bag with some thiamine, *frolic acid* and a touch of mag. If you're allowed to do them prehospital lot it's generally only going to be thiamine and fluid. See: "banana bag"
> 
> ...


Frolic Acid... it's the latest craze. :rofl:

I'm going to have to have mine with a good cup of java...

Now back to our regularly scheduled program...


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## EMT B (Sep 13, 2013)

Robb said:


> WKS?



Wernicke-Korsakoff syndrome

we use banana bags in the ER to prevent WKS in alcoholics


http://www.nlm.nih.gov/medlineplus/ency/article/000771.htm


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## Handsome Robb (Sep 14, 2013)

EMT B said:


> Wernicke-Korsakoff syndrome
> 
> we use banana bags in the ER to prevent WKS in alcoholics
> 
> ...



They're two separate things. 

Wernicke's encephalopathy and Korsakoff Syndrome.

Both similar but definitely different. 

No, I'm not. Unless homeboy is a raging alky and has been for years.


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## Handsome Robb (Sep 14, 2013)

Akulahawk said:


> Frolic Acid... it's the latest craze. :rofl:
> 
> I'm going to have to have mine with a good cup of java...
> 
> Now back to our regularly scheduled program...



Dude...it's the shiznit!!!


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## Carlos Danger (Sep 14, 2013)

Robb said:


> They're two separate things.
> 
> Wernicke's encephalopathy and Korsakoff Syndrome.
> 
> Both similar but definitely different.



They used to be viewed as separate, but since they are essentially just different phases of the same process (chronic thiamine deficiency) and can be difficult to distinguish clinically, these days they are often referred to as a single syndrome.


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