# Unresponsive



## NomadicMedic (Feb 7, 2013)

Arrive on scene at 1640 to find a 41 year old female, unconscious. Found in bed by her ex husband after daughter called him and said she couldn't wake up mommy. PT has no significant PMHX, NKDA as takes no meds. No indication of alcohol or drug use. 


Vitals on arrival:

Hr: 88 and irregular
Respirs: 24 and shallow
BP: 142/118
ETCO2: 48, non obstructive waveform
Glucose: "lo" (<10)
Skin: cool, dry and ashen. 
GCS: 6. E1,V1,M4
Dried saliva around the mouth. No obvious emesis. 

BLS had just arrived and put the patient on 15 LPN of o2 via NRB. 

... And go.


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## abckidsmom (Feb 7, 2013)

Oh, she's sick. 

Pupils?  Any incontinence? Risk factors for DVT? Signs of DVT?  Gag reflex? Protecting her own airway? Lung sounds?


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## NomadicMedic (Feb 7, 2013)

Pupils 3mm and sluggish. No incontinence. Positive gag and she is protecting her own airway, lungs clear bilat. No recent surgeries, not bed confined. Unknown about BC or smoking history. Is normally active and was last seen this morning.


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## Aidey (Feb 7, 2013)

How about we give the woman some sugar?


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## JMorin95 (Feb 7, 2013)

Is she diabetic? Low sugar is probably playing a large role here.


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## NomadicMedic (Feb 7, 2013)

Multiple IV attempts are unsuccessful. The crew gave 1mg IM glucagon.

This patient is not a diabetic. No history of any hypoglycemic events.


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## abckidsmom (Feb 7, 2013)

Aidey said:


> How about we give the woman some sugar?



I was just getting some information while I started the IV.


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## abckidsmom (Feb 7, 2013)

n7lxi said:


> Multiple IV attempts are unsuccessful. The crew gave 1mg IM glucagon.



That's going to do nothing, I bet.  I give it precisely 5 minutes, then I drill her.


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## NomadicMedic (Feb 7, 2013)

What else would you like...?


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## abckidsmom (Feb 7, 2013)

n7lxi said:


> Multiple IV attempts are unsuccessful. The crew gave 1mg IM glucagon.
> 
> This patient is not a diabetic. No history of any hypoglycemic events.



Anyone in the family a diabetic?


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## JMorin95 (Feb 7, 2013)

Events leading up to? Possibly could gain this from the daughter.


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## NomadicMedic (Feb 7, 2013)

abckidsmom said:


> Anyone in the family a diabetic?



Ex husband doesn't know family history and daughter was at school. She came home and "mom wouldn't wake up"


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## abckidsmom (Feb 7, 2013)

n7lxi said:


> Ex husband doesn't know family history and daughter was at school. She came home and "mom wouldn't wake up"



I mean like anyone living in the house who is a diabetic.  Access to insulin or oral hypoglycemic agents?  Possibility she's pregnant?


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## JMorin95 (Feb 7, 2013)

Any clues around the house as to what could be happening? I.e. pill bottles, alcohol bottles, illegal substances?


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## Aidey (Feb 7, 2013)

How old is the kid?


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## NomadicMedic (Feb 7, 2013)

Initial rhythm.


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## NomadicMedic (Feb 7, 2013)

abckidsmom said:


> I mean like anyone living in the house who is a diabetic.  Access to insulin or oral hypoglycemic agents?  Possibility she's pregnant?



Nope. Nothing in the house. No idea if she's preg. The kid is 12.


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## NomadicMedic (Feb 7, 2013)

JMorin95 said:


> Any clues around the house as to what could be happening? I.e. pill bottles, alcohol bottles, illegal substances?



Nothing found.


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## Wheel (Feb 7, 2013)

What does her skin look like?


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## abckidsmom (Feb 7, 2013)

Those are some peaked T waves, huh?

Can we get another pressure?  I don't like that first one.  It's 5 minutes now, too.  Did the glucagon work?


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## Aidey (Feb 7, 2013)

Yes they are. And that looks like some kind of block. It is difficult to tell on such a short strip, but it looks like there is a pattern to the irregularity.


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## jrm818 (Feb 7, 2013)

abckidsmom said:


> Those are some peaked T waves, huh?
> ?



Simple....poor lady thought so too...said "egads!  A bizarre rythm with peaky t waves...must be hyper-K!" and gave herself some insulin to flatten em down a bit...just forgot the D50.


sidenote: how many here have given D50 through an IO?  The one time I saw it attempted it took an awful lot of pushing to get it in (IO flushed fine with NS).  Does it need to be diluted down a bit to get it to flow?


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## abckidsmom (Feb 7, 2013)

I'm going to go ahead and venture a guess that this can be summarized with "metabolic disarray."


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## abckidsmom (Feb 7, 2013)

jrm818 said:


> Simple....poor lady thought so too...said "egads!  A bizarre rythm with peaky t waves...must be hyper-K!" and gave herself some insulin to flatten em down a bit...just forgot the D50.
> 
> 
> sidenote: how many here have given D50 through an IO?  The one time I saw it attempted it took an awful lot of pushing to get it in (IO flushed fine with NS).  Does it need to be diluted down a bit to get it to flow?



I've given it through an IO just once.  I pushed it straight and slow.  It was no big deal, except that the lady woke up and I felt like an evil sadistic person.  More lidocaine next time.


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## jrm818 (Feb 7, 2013)

Huh, that's what I expected for the IO issue, I've heard elsewhere that it works OK.  I wonder what the issue was when I saw it done.

At any rate, "metabolic disarray" sounds about right.

Agree with checking for pill bottles around.  Assuming no drugs/etoh, maybe some unfortunate adrenal problem/Addisons type deal (BP notwithstanding).  or an insulin secreting tumor.  Or hypopituitaryism.  

Dunno what you're going to do about any of that in the field.  Symptomatic Rx at this point sounds about right to me.


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## abckidsmom (Feb 7, 2013)

jrm818 said:


> Huh, that's what I expected for the IO issue, I've heard elsewhere that it works OK.  I wonder what the issue was when I saw it done.



You have to energetically flush it when you first establish the line to clear out the inter medullary space. If you don't give it a vigorous flush, it won't run well.


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## NomadicMedic (Feb 7, 2013)

Okay... Sorry. Just went on a call. 

Here's some answers. 

As stated above. Cool, dry and ashen. 
No pill bottles or alcohol to be found. 

Glucagon did nothing. She got drilled, and an amp of D50. Sugar went from 19 to 15. Per med control, she also got 2mg of Narcan. Which also did nothing (as you'd guess)

Vitals all stayed the same. (No changes of note)


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## NomadicMedic (Feb 7, 2013)




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## abckidsmom (Feb 7, 2013)

Sugar went from 19 to 15?


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## NomadicMedic (Feb 7, 2013)

abckidsmom said:


> Sugar went from 19 to 15?



Yep. 19 after the glucagon ... 15 following an amp of d50.

This was not my call, BTW. I just reviewed the chart and talked with the crew that ran it.


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## abckidsmom (Feb 7, 2013)

And still with that ridiculous pressure?


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## NomadicMedic (Feb 7, 2013)

Next pressure was 132/64. HR 78 irreg. 
respirs 22 and shallow.


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## jrm818 (Feb 7, 2013)

Well bugger.

Assuming your glucometer is working properly, I'm still not convinced that this wasn't an ingestion of some sort.  ASA?  Wouldn't' necessarily notice that pill bottle.

How bout empty bottles of antifreeze in the garage?  I can't find a reference to toxic alcohols causing hypoglycemia, but alcohol can it so perhaps?  

Or unfortunate metabolic derangement/tumor.  Would need a better history to really clue in to that though.

That EKG just looks...well...bizarre.  Hyper K is still my bet.  I don't know what to call the rhythm...if I use my imagination I can see p waves in some places, but not regularly, and certainly not in front of the QRS very often.


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## abckidsmom (Feb 7, 2013)

My money is on a tox problem too.


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## NomadicMedic (Feb 7, 2013)

Ok, so here's where we are. 

Arrive at the ED and the pt has had glucagon, dextrose and Narcan. No response. 

Shortly after arrival she was intubated, placed on a vent and moved to ICU. ED doc says hyperK, but is not convinced. In checking with the ICU charge for follow up and will get you guys the full details as soon as I know.


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## abckidsmom (Feb 7, 2013)

I can't get no satisfaction.


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## NomadicMedic (Feb 8, 2013)

abckidsmom said:


> I can't get no satisfaction.



It's gonna keep you awake all night.


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## jrm818 (Feb 8, 2013)

I was going to add that I might be tempted to try to treat her for her "shoot I lost the rest of my prednisone" induced Addisonian crisis, if I had no more answers and this long to think about it.  

wonder how acidotic/metabolically screwed up she was.  

interesting case - look forward to getting an answer.


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## NomadicMedic (Feb 8, 2013)

For what it's worth: the pt had no history of anything. The ex husband is a nurse and found her unconscious. There were no drugs, rx meds, alcohol or anything untoward in the house. Pt was last seen normal this morning.


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## jrm818 (Feb 8, 2013)

gaahh!  this is going to bug me too now....

back to insulin secreting tumor or adrenal dysfunction of her bodies own making


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## abckidsmom (Feb 8, 2013)

I predict her pH to be 6.97.


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## FLdoc2011 (Feb 8, 2013)

What workup was done in the ER?    They for sure at least scanned her head and took basic labs.


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## Handsome Robb (Feb 8, 2013)

I need to pay more attention to this at work...I never get to play! Everything's been covered pretty well already. 

It seems like tox, but adrenal insufficiency would fit too.

Random, had she been depressed recently? There's talk of her *ex* husband. Is this a recent event? Some sort of suicide attempt by ingestion maybe? Any past attempts that the ex knows of?

Any chance we could get the labs from the ED?


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## NomadicMedic (Feb 8, 2013)

I'll get what I can. The hospital to which she was taken is notoriously bad for allowing Paramedic follow up. I've already called the ED doc and the intensivist. 

So again, no history of anything… No past suicide attempts. No history of toxic ingestion. There were no drugs or alcohol found in the house. In a nutshell, "nobody seems to know nothing".


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## Handsome Robb (Feb 8, 2013)

It may have already been asked and answered but had she been sick recently or complaining of anything per daughter? I kinda doubt this is something that just appeared out of nowhere but I'm new and am wrong all the time. Feel like this may have been building over a bit of time then all came to a crashing halt.

Tox seems like it's basically been "ruled out" with what we know. All that leaves is adrenal insufficiency or some sort of pancreatic problem like insulinoma or a problem with beta cells causing excessive release of insulin...can't remember the fancy name for that one. 

They finally gave us these nifty little forms to request followup on our patients from the hospitals. Some of them will gladly just tell us, pull up labs, radiology, all their tests and let us go to town. Others are not so friendly. Helps to be friends in relatively high places at the ER as well


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## NomadicMedic (Feb 8, 2013)

It's a head scratcher. Everything I got said she was normal prior. Ex said he didn't have much contact with her and the kid said as was fine. 

I'm hoping to hear more today. I'm pretty tight with the ED manager, so I'm sure I'll be able to get something...


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## abckidsmom (Feb 8, 2013)

n7lxi said:


> It's a head scratcher. Everything I got said she was normal prior. Ex said he didn't have much contact with her and the kid said as was fine.
> 
> I'm hoping to hear more today. I'm pretty tight with the ED manager, so I'm sure I'll be able to get something...



I'm rushing back to this thread from Girl Scout cookie central just to hear what happened.  I hope I don't end up disappointed.


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## EMT B (Feb 8, 2013)

insulinoma?

that would be my guess. I sorry if i missed it, but how did her blood chem come back?


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## NomadicMedic (Feb 8, 2013)

EMT B said:


> insulinoma?
> 
> that would be my guess. I sorry if i missed it, but how did her blood chem come back?



Luckily, through the magic of the Internet, you CAN'T miss anything in a threaded discussion if you go back and read from the beginning.

I haven't posted any of the labs, because I haven't obtained that information yet.


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## abckidsmom (Feb 8, 2013)

EMT B said:


> insulinoma?
> 
> that would be my guess. I sorry if i missed it, but how did her blood chem come back?



Insulinoma would be so neat and tidy.  And hypoglycemia from insulinomas I've seen comes with less diaphoresis.  I'd say no to that since she's in the ICU.  But I'm still on the edge of my seat.


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## NomadicMedic (Feb 8, 2013)

Dana, she was not diaphoretic... She was cool and dry.


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## NomadicMedic (Feb 8, 2013)

Just got off the phone. CT of her head was negative. pH was 7.1. K+ 7.5. 

Verdict is acute liver failure. 

Turns out she was a long term APAP abuser and fried her liver. Transferred out today to university hospital to get on the transplant list.


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## FLdoc2011 (Feb 8, 2013)

Nice.   She wasn't jaundiced initially on exam?


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## NomadicMedic (Feb 8, 2013)

FLdoc2011 said:


> Nice.   She wasn't jaundiced initially on exam?



No. According to the crew, "ashen".


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## abckidsmom (Feb 8, 2013)

n7lxi said:


> Just got off the phone. CT of her head was negative. pH was 7.1. K+ 7.5.
> 
> Verdict is acute liver failure.
> 
> Turns out she was a long term APAP abuser and fried her liver. Transferred out today to university hospital to get on the transplant list.



Interesting.  Thanks for the followup.  You didn't know her temp, did you?


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## NomadicMedic (Feb 8, 2013)

abckidsmom said:


> Interesting.  Thanks for the followup.  You didn't know her temp, did you?



I don't. I know we're having trouble getting our lifepak temp probes to correlate with the hospital thermometers.


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## abckidsmom (Feb 8, 2013)

n7lxi said:


> I don't. I know we're having trouble getting our lifepak temp probes to correlate with the hospital thermometers.



We're having trouble getting our medics to think that temperature is something they need to check.


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## DesertMedic66 (Feb 8, 2013)

abckidsmom said:


> We're having trouble getting our medics to think that temperature is something they need to check.



We don't carry thermometers.....


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## NomadicMedic (Feb 8, 2013)

We have an axillary probe for the LP15. It's not usually right. We also have the "temp strips" that give you a guesstimate at temp.


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## abckidsmom (Feb 8, 2013)

You'll have more success if you lay it in the inguinal fold (fat crease in the groin).


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## NomadicMedic (Feb 8, 2013)

abckidsmom said:


> You'll have more success if you lay it in the inguinal fold (fat crease in the groin).



So I've heard, however... Physio says we're doing it correctly and we want to continue to do it this way and attempt to correlate the temps with the hospital. I think they want the data...


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## URI (Feb 8, 2013)

If you guys can pardon my ignorance:

Im just trying to get a better understanding of why the D50 didn't raise her bG. 
I can understand that in liver failure she's not going to produce glucose from glycolysis. So giving her glucagon did nothing. But can someone explain to me why giving her an amp of dextrose IV didn't at least raise her levels? Is it because her insulin levels that far off because her pancreas and liver not talking? I guess I was under the impression that by giving the Dextrose your no longer relying on the liver to produce glucose and the pancreas will simply supply the insulin.  

Thanks for additional clarification


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## Aidey (Feb 8, 2013)

Probably because she was so profoundly hypoglycemic that it simply wasn't enough sugar.


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## NomadicMedic (Feb 8, 2013)

Because the liver is damaged, it's not converting glycogen to glucose, which causes an over abundance of insulin, or hyperinsulinemia. This means that any dextrose the medics give will be quickly used. Like Aidey said, there just wasn't enough sugar.


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## URI (Feb 8, 2013)

Wow, that seems to me like that's a lot of sugar to do absolutely nothing. But what do I know.


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## URI (Feb 8, 2013)

Thanks for the clarification guys. That does help, I just didn't realize the body would produce that much insulin in the absence of glycogen.


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## Shishkabob (Feb 8, 2013)

URI said:


> Wow, that seems to me like that's a lot of sugar to do absolutely nothing. But what do I know.



I had a patient a few months ago... I personally gave 3 vials of D50 to no effect on her sugar level, hospital gave a crap load more on top of mine, still to no effect.

Damn oral hypoglycemia / insulin overdoses.




n7lxi said:


> We also have the "temp strips" that give you a guesstimate at temp.



Most of my patients are between 95* and 103*.  I don't need yo stinking technology!


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## VFlutter (Feb 8, 2013)

n7lxi said:


> We also have the "temp strips" that give you a guesstimate at temp.



Are they TempaDots? From my experience they are fairly accurate if you correctly use them.


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## NomadicMedic (Feb 9, 2013)

Chase said:


> Are they TempaDots? From my experience they are fairly accurate if you correctly use them.



Nope. They're these guys:


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## Veneficus (Feb 9, 2013)

n7lxi said:


> Nope. They're these guys:



That looks useless.


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## abckidsmom (Feb 9, 2013)

I really prefer the thermometer where you hold the one part in your hand and stick the other part in somewhere and the the part in your hand tells you what the temperature is. 

Must be the nurse in me.


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## Veneficus (Feb 9, 2013)

abckidsmom said:


> I really prefer the thermometer where you hold the one part in your hand and stick the other part in somewhere and the the part in your hand tells you what the temperature is.
> 
> Must be the nurse in me.



I am guessing there is a reason other than nurse preference that continuous temperature monitoring in the ICU is not done with an axial probe or a light refractory chrystal. 

Just a thought...


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## abckidsmom (Feb 9, 2013)

Veneficus said:


> I am guessing there is a reason other than nurse preference that continuous temperature monitoring in the ICU is not done with an axial probe or a light refractory chrystal.
> 
> Just a thought...



I meant the nurse in me who loves precision. I think that continuous temperature monitoring in EMS is neat, but unnecessarily complicated in all but a very few applications. And that trusty thermometer has a monitoring mode for those.


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## Veneficus (Feb 9, 2013)

abckidsmom said:


> I meant the nurse in me who loves precision. I think that continuous temperature monitoring in EMS is neat, but unnecessarily complicated in all but a very few applications. And that trusty thermometer has a monitoring mode for those.



Lol.

I must really find a way to better express my intent and sarcasm on here. 

I was not suggesting continuous monitoring for EMS, just one of those probe things you stick somewhere.

That whole "vital sign" thing i guess. 

While I understand temperature alone is not reliable for all infective dx, it does provide a very good clue when it is found. There are only a handful of pathologies that cause temperature increase. (not all infective) But up regulation of IL-1 can definately provide a very good clue where all of those follow on providers need to start looking.

I find it very interesting that EMS is quick to embrace a host of technological quantatative assessment device, but for some reason see no need for temp. 

It reaffirms my position that EMS is not using these devices for advanced care, they are using them as a very expensive crutch.


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## Handsome Robb (Feb 9, 2013)

abckidsmom said:


> We're having trouble getting our medics to think that temperature is something they need to check.



I'll admit I don't take a temperature often unless it's indicated by their complaint, if they feel absurdly hot/cold or if I have a long transport and have run out of things to do, questions to ask and if they aren't interesting to talk to and/or wont stop talking...sticking the thermometer in their mouth gains me some peace and quiet for a couple seconds at least... :lol:

It's a useful piece of information but it's not high on my list in many of the patients I see.

Pediatric seizures all get temps as well of course, usually rectal via mom, dad, a firefighter or my partner 



n7lxi said:


> Nope. They're these guys:



At least we get a normal thermometers. We carry your standard run-of-the-mill oral thermometer with the sterile covers. I still think we should ahve one for rectal temps and one for oral temps though...even with the probe coveres and cavi-wiping the hell out of it I still feel bad asking someone to hold it in their mouth..."if only you knew where that thing had been..."

We supposedly cary the tempadot things too, only used them a few times and they were too smart for me. It's hit or miss if they're stocked in the ambulance or not. 

We also carry the disposable continuous temperature monitoring probe for the MRx. Use it as either an esophageal or rectal probe for temp monitoring of post VF/VT arrest patients for our hypothermia protocol. The King LTD provides a fantastic way to place it in the esophagus but that hole is usually filled with an OG tube so refer to my above statement about checking a temp in pediatric seizures


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## Veneficus (Feb 9, 2013)

Robb said:


> At least we get a normal thermometers. We carry your standard run-of-the-mill oral thermometer with the sterile covers. I still think we should ahve one for rectal temps and one for oral temps though...even with the probe coveres and cavi-wiping the hell out of it I still feel bad asking someone to hold it in their mouth..."if only you knew where that thing had been..."
> 
> 
> > Well I guess the only difference is the taste right?
> ...


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## NomadicMedic (Feb 9, 2013)

Veneficus said:


> That looks useless.



Agreed. We also have the little sticky probe for the LP, but like I said, it seems to not correlate with the "shove a probe in the mouth or bum" measurement that is obtained at the hospital. I've not had a "correct" temp yet.

It's an issue that I'm sure will be addressed...eventually. 
I like to take a temp and include it in my vital sign work up. (But I think I'm in the minority)


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## KingCountyMedic (Feb 9, 2013)

We use the Exergen TAT-500 temporal artery thermometer that works pretty well. They cost about $400 a piece. We also have the esophageal temp probe on our LP15 that is really good but only for intubated patients. Sounds like a sick lady.


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## Summit (Feb 9, 2013)

Fascinating


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## NomadicMedic (Feb 9, 2013)

Yeah. I don't know why we don't carry some other "real" thermometer... Kind of annoying. 

And yeah... She was sick.


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## lightsandsirens5 (Feb 9, 2013)

abckidsmom said:


> I really prefer the thermometer where you hold the one part in your hand and stick the other part in somewhere and the the part in your hand tells you what the temperature is.
> 
> Must be the nurse in me.



That's what we have


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## Handsome Robb (Feb 10, 2013)

Veneficus said:


> It is probably not a good idea to use the same thermometer interchangably.



I agree. Unfortunately we only have one, and sometimes (more often than not, but I don't trust them. Never have been reliable for me) the tempadot things and it's pretty difficult to convince grandma with the GCS of 15 and obviously high fever to let me put the thermometer where the sun don't shine. 

We use sterile covers and I cavi-wipe the hell out of it after I use it ever time but, like you said, ideally we would have one for rectal and one for oral temperatures.


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## Veneficus (Feb 10, 2013)

Robb said:


> We use sterile covers and* I cavi-wipe the hell out of it after I use it ever time* but, like you said, ideally we would have one for rectal and one for oral temperatures.



Does everyone else?


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## NomadicMedic (Feb 10, 2013)

Back on topic please.


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## Christopher (Feb 11, 2013)

n7lxi said:


> Back on topic please.



Something I didn't hear noted was a differential of TCA OD or sodium channel blocker OD. (I've read thru it all and saw the actual Dx, just adding something based on the ECG)


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## NomadicMedic (Feb 11, 2013)

Christopher, there was nothing there that overtly pointed at a TCA overdose. No history of TCA use, no bottles in the house... I agree that it should have been added to the differential.


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## Clare (Feb 15, 2013)

Wow, this lady looks pretty sick! 

What is APAP?

I'd have called for an Intensive Care Paramedic for RSI I think.


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## Aidey (Feb 15, 2013)

Paracetamol.


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## Clare (Feb 15, 2013)

Oh yeah that stuff is just nasty for the liver, but you have to take huge quantities of it, something like ten grams (twenty tablets) and ew, panadol tastes so horrible that's got to be a difficult task!


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## Aidey (Feb 15, 2013)

Not really. 4 grams a day, every day for an extended time has been shown to cause permanent liver damage. For an acute overdose it does take quite a bit to kill off enough of the liver to be an immediate issue, but you can still do quite a bit of damage. In the US you can buy bottles of 500mg pills that have hundreds of pills in them.


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