# 59YOM - OD, Suicide attempt



## Melclin (Aug 31, 2011)

*0834 :  “Overdose/poisoning”, unconscious (intentional)”.*

You are called to a suicide attempt on a cold morning in semi-rural area. The dispatch information notes that you were dispatched by a third party caller (the pt’s sister), who found a note that had been dropped (ie not posted) in her letter box from the pt, explaining that the pt had taken an overdose and apologising for the grief it would cause. 

*O/A* 
You arrive at the pt’s house to find that police have turned out prior to you and found a gentleman in his late 50's in an altered conscious state. They have found a detailed suicide note and a number of empty packets of medications. The note states that he took the overdose last night and that it included oxycodone and diazepam. 

*O/E*
59YOM lying semi recumbent in bed, eyes closed, looking a bit grey. He does not respond to your presence.
He is rousable to a state in which he will nod or shake his head answering yes or not to questions. 

*-Airway*: His airway seems patent, the trachea intact. Nil jugular venous distension. 
*-Breathing:* Shallow breathing is evident. His chest expansion is equal bilaterally. Inspiratory and expiratory phases are equal. There is no accessory muscle use or any apparent respiratory distress. His chest is clear and equal bilaterally on auscultation, perhaps ? reduced air entry to the bases. RR 24, SpO2: 70 (with a good pleth)
*-Circulation:* He has a regular pulse that appears normal in character and strength. He is greyish in colour and his hands and feet are ice cold. Centrally, he is noticeable warm.  P: 120, BP 125/50
*-Disability*: His GCS is 12 (E3, V3, M6) – he mumbles and groans with the odd few words strung together. He obeys the command to open his eyes and to look left and right, but will not grip your hands. His pupils are equal @ 4mm very minimally responsive to light. 

*Other bits:*
BSL: 5.7mmol/L (102.6 mg/dL). Temp: 39.6 C (103.2 F). Monitored in a sinus tachycardia, with a 1st degree AV block. 

*Secondary Survey*
Entire body is atraumatic. NAD other than a 3 inch vertical surgical scar running across his epigastrum and he is wearing a nappy (diaper). Abdomen is soft with no grimacing or guarding noted on palpation. He has not been incontinent. His skin and mucous membranes look reasonably dry.

*Hx:* He doesn’t answer any questions other than nodding when you ask if he’s been unwell in any way lately. The suicide note makes reference to a year of disability and to renal cell carcinoma that is in remission. The house is well kept and certainly doesn’t look like the kind of house that a bed bound person might live in. Allergies are unknown. 

*Meds:* Oxycodone, Metoclopramide, Diazepam, Quetiapine, Coloxyl with senna. These are found near the bedside by police, nil other meds evident. 


*Lets say you are: *
- 5 mins from a small rural ED. X-ray, CT for ambulant pts only. No surgical service, ICU or HDU. Gen med wards only. 
- 40 mins from what you would call a level two trauma centre I suppose. ICU, CCU, ED with CT. All services except neuro surg and cardio thoracic surg. 
- 40 mins by whirlybird from a hospital that has the lot and a bit more.


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## MrBrown (Aug 31, 2011)

Brown is most concerned about this blokes respiratory status and oxygen saturation so lets pop him on some oxygen

Might not be a bad idea if we can shove a drip into him - even an 18ga in one of his frostellicus like hands wouldn't be a bad idea incase he decides to do something stupid like get crooker.

Reasonably happy with everything else for now.  

Might have a word on the ambophone to the PGY2 House Officer at the little country hospital, see if he will retain faculties if we bring this bloke to his department otherwise he needs to go to the other hospital.


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## Melclin (Aug 31, 2011)

Come on you lazy bloody drongos. I see lots of people rubber necking. *Remember my policy on students and emts. Have a crack guys. *This is a learning friendly zone. You'll go to this job one day and think, bugger, I wish I'd have thrown my hat into the ring when I had the chance at practice. 


Cheers brown 

Whats your differential?

What about treatment? O2 in what form? Fluid? Drugs? Nachos? Whats the go for this bloke?


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## usalsfyre (Aug 31, 2011)

Melclin said:


> You are called to a suicide attempt on a cold morning in semi-rural area. The dispatch information notes that you were dispatched by a third party caller (the pt's sister), who found a note that had been dropped (ie not posted) in her letter box from the pt, explaining that the pt had taken an overdose and apologising for the grief it would cause.


Dang, if only he had mailed it this would be easy wouldn't it 



Melclin said:


> *O/A*
> You arrive at the pt's house to find that police have turned out prior to you and found a gentleman in his late 50's in an altered conscious state. They have found a detailed suicide note and a number of empty packets of medications. The note states that he took the overdose last night and that it included oxycodone and diazepam.


Two relatively benign meds if he's still conscious and not aspirated...



Melclin said:


> [*O/E*
> 59YOM lying semi recumbent in bed, eyes closed, looking a bit grey. He does not respond to your presence.
> He is rousable to a state in which he will nod or shake his head answering yes or not to questions.
> 
> ...


I MIGHT consider a short trial with a NRB, but likely we're going to start with a BVM trying to get him oxygenated. If he fails to become more alert with oxygenation, he's probably bought a tube at this point. 



Melclin said:


> *-Circulation:* He has a regular pulse that appears normal in character and strength. He is greyish in colour and his hands and feet are ice cold. Centrally, he is noticeable warm.  P: 120, BP 125/50
> *-Disability*: His GCS is 12 (E3, V3, M6); he mumbles and groans with the odd few words strung together. He obeys the command to open his eyes and to look left and right, but will not grip your hands. His pupils are equal @ 4mm very minimally responsive to light.
> 
> *Other bits:*
> BSL: 5.7mmol/L (102.6 mg/dL). Temp: 39.6 C (103.2 F). Monitored in a sinus tachycardia, with a 1st degree AV block.


Barring the suicide note...the above SCREAMS sepsis. Which could go hand in hand with the suicide attempt if he aspirated due to altered LOC from the meds. Let's get a line going and begin fluid resus, probably looking at running two liters. Because of the concern of sepis if we DO end up using meds to get him intubabted I'm going to stay away from etomidate due to the adrenal supression it tends to cause. 



Melclin said:


> *Secondary Survey*
> Entire body is atraumatic. NAD other than a 3 inch vertical surgical scar running across his epigastrum and he is wearing a nappy (diaper). Abdomen is soft with no grimacing or guarding noted on palpation. He has not been incontinent. His skin and mucous membranes look reasonably dry.
> 
> *Hx:* He doesn't answer any questions other than nodding when you ask if he's been unwell in any way lately. The suicide note makes reference to a year of disability and to renal cell carcinoma that is in remission. The house is well kept and certainly doesn't look like the kind of house that a bed bound person might live in. Allergies are unknown.


Return of the cancer is another thought on the pyrexia 



Melclin said:


> *Meds:* Oxycodone, Metoclopramide, Diazepam, Quetiapine, Coloxyl with senna. These are found near the bedside by police, nil other meds evident.


Great, Reglan and Seroquel in the overdose as well....these two are more concerning to me than the narc and benzo...

[





Melclin said:


> B]Lets say you are: [/B]
> - 5 mins from a small rural ED. X-ray, CT for ambulant pts only. No surgical service, ICU or HDU. Gen med wards only.
> - 40 mins from what you would call a level two trauma centre I suppose. ICU, CCU, ED with CT. All services except neuro surg and cardio thoracic surg.
> - 40 mins by whirlybird from a hospital that has the lot and a bit more.


Level Duece by ground should be sufficent here.


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## Digger (Aug 31, 2011)

Initially, managing the airway due to low SpO2, and peripheral cyanosis/color change- I would say high flow NRB, PPV if no change with that after a short amount of time.  IV, start fluids- seems to be compensating right now with a BP of 125/50, but he's dehydrated with dry mucus membranes and shunting blood from extremities to the core.  With that temp I'd also say septic, he could have felt himself getting sicker, thought he was relapsing with the carcinoma (as he well may be) and not wanted to deal with it anymore, hence the attempted suicide with note, oxy and benzos.  Or he could have already had an altered mental status leading him to not think clearly and decide he wanted to end his life.  The note does show some planning and thought went into it though.  DNR status?


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## usafmedic45 (Aug 31, 2011)

> Might have a word on the ambophone to the PGY2 House Officer at the little country hospital, see if he will retain faculties if we bring this bloke to his department otherwise he needs to go to the other hospital.



Take him to the local hospital and have the helicopter meet you there.


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## Cup of Joe (Aug 31, 2011)

O2 via NRB, possibly cover with blankets (depending...how warm is noticeably warm?), transport in left lateral recumbent to closed ED where they might be able to give him some reversal agent(s) (if warranted).  If not, as usafmedic45 said, helicopter to nearest capable facility.


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## Hunter (Aug 31, 2011)

Melclin said:


> *0834 :  “Overdose/poisoning”, unconscious (intentional)”.*
> 
> You are called to a suicide attempt on a cold morning in semi-rural  area. The dispatch information notes that you were dispatched by a third  party caller (the pt’s sister), who found a note that had been dropped  (ie not posted) in her letter box from the pt, explaining that the pt  had taken an overdose and apologising for the grief it would cause.
> 
> ...



I'll swing at it, might be helping this patient acomplish his goal... so...

Okay so I think... so my instincts say... his breathing is probably the most immediat threat and because he's sating at 70 and shallow respirations his tidal volume is through the floor so... cpap? or maybe RSI?

Get a line in him ummm not sure what medications and I think I would probably opt to not give him any medications since he's overdosing and I'd be concerned for adverse reactions. Maybe a 250ML NS bolus to try and bring up the BP although it's not too terribly bad.

Minimal on scene time and I would opt for the 40min heli transport since I'm concerned that because he's having trouble breathing going higher into the atmosphere which would have less atmospheric pressure may reduce the workload of his labored breathing and help him breath better since both CPAP and Intubation would deliver 100% O2...


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## usalsfyre (Aug 31, 2011)

Hunter said:


> Minimal on scene time and I would opt for the 40min heli transport since I'm concerned that because he's having trouble breathing going higher into the atmosphere which would have less atmospheric pressure may reduce the workload of his labored breathing and help him breath better


Just a quick word, research Dalton's law, and how gas moves across the alveolar membrane to see why this would have the opposite effect of what you want. This might seem a little counterintuitive, but trust me, reduced atmospheric pressure is BAD for hypoxic patients.


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## Handsome Robb (Aug 31, 2011)

I'd go straight to PPV to try and get his SpO2 up. Once you got it up there give him a chance on the NRB to see if he will maintain them otherwise back to PPV and possibly RSI, but I'll get into that at the bottom of the post.

With the possible opiod onboard I'd be tempted to possibly try a touch of Narcan titrated to effect on respirations once we had him loaded and strapped down. I don't particularly like patients punching me, and if the narcan works I'm pretty certain he won't be happy that he is alive considering the planning behind the attempt.

I was thinking sepsis as well with the temp and shunting of blood to the core to try and support his end-organs but I don't know if I believe he could become septic this quickly, and from what? I'd go more for the CNS depression and lowered perfusion to his organs causing him to shunt all his blood out of his extremities.

Give him a line and give him some fluids, I don't know if I'd go straight for 2L probably just hit him with 1 and see how that treats him.

Ground to the Level II. This guy doesn't seem like he is going to need a cardiothoracic or nuero surgeon but then again I am new at this.

I'f you really wanted to fly this guy he probably is going to need a tube, which sounds like is going to require RSI, I'd stay away from Succ with this guy since he already is hyperthermic. The drop in PiO2 as the chopper climbs isn't going to help him, he needs more air not less.


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## usalsfyre (Aug 31, 2011)

NVRob said:


> I'd stay away from Succ with this guy since he already is hyperthermic.



MH has to do with how succinycholine acts in the synapse, not hyperthermia itself. It's safe to use in patient's who have a fever. I WOULD be concerned about the posibility of hyperkalemia from undetected rhabdo, since we have no clue how long he's been lying in one spot.


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## Handsome Robb (Aug 31, 2011)

usalsfyre said:


> MH has to do with how succinycholine acts in the synapse, not hyperthermia itself. It's safe to use in patient's who have a fever. I WOULD be concerned about the posibility of hyperkalemia from undetected rhabdo, since we have no clue how long he's been lying in one spot.



That makes sense. How long would someone have to be stationary for rhabdo to become an issue though?


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## phideux (Aug 31, 2011)

I'd start with the basics, keep his airway open, get some O2 in him. You said all his meds are present and accounted for on his bedside table. Are the actual meds there, or just the empty bottles???? How about a pill count of the bottles to narrow down what he took too much of, if anything.


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## usalsfyre (Aug 31, 2011)

NVRob said:


> That makes sense. How long would someone have to be stationary for rhabdo to become an issue though?



Depends heavily on the health status and how stationary. This guy...probably not long.


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## MrBrown (Sep 1, 2011)

Lets pop this bloke on 10lpm NRB and see if his sats go up, if not lets try a bag mask ans see what happens. 

Brown is of the mind that if his oxygenation does not improve we can just RSI him and go to the level 2 hospital.

He could be septic, with clear chest he probably hasn't aspirated so Brown is not sure where the sepsis is coming from.  The hyperthermia could be neurogenically related to the meds he has scoffed down.


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## Aprz (Sep 1, 2011)

Heh, I feel crazy for saying this, but I am not convinced this patient would be a candidate for high flow oxygen or PPV. In fact, I was a little shock that people said they'd PPV him, or even intubate him. If you removed the SpO2 from the post, I bet a lot of people wouldn't be saying NRB or PPV right now. Both the hands and feets are cold, core is warm, the patient is gray, RR is 24, which isn't bad. They aren't accurate when low, and I think they aren't accurate for tachycardic HR either, but 120 isn't THAT bad either. I'd probably try a pulse ox on the earlobe instead, see what an NC does, but I'm actually not too concern with his breathing right now.

Thank God I am not a Paramedic and this is a place where I can put my bizarre answers, I am currently thinking I'd transport him to the 5 minute spot; I don't think he needs anything surgical or an ICU.


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## MrBrown (Sep 1, 2011)

Aprz said:


> If you removed the SpO2 from the post, I bet a lot of people wouldn't be saying NRB or PPV right now. Both the hands and feets are cold, core is warm, the patient is gray, RR is 24, which isn't bad. They aren't accurate when low, and I think they aren't accurate for tachycardic HR either, but 120 isn't THAT bad either. I'd probably try a pulse ox on the earlobe instead, see what an NC does, but I'm actually not too concern with his breathing right now.



You raise an interesting point and something of a management paradox; do we treat this bloke who has such a poor SPO2 as not needing oxygen shoved down his gob because he has no central signs of cyanosis? Or do we treat him as being crook and in need of lots of oxygen because his SPO2 is absolutely in the loo?

It is possible he is hyperventilating to blow off some sort of acid imbalance or because his noggin is nunngered from the medication lolly scramble he scoffed down - that might also explain the hyperthermia too.

What Brown would do is put him on a NRB at 10lpm and see if that helps, if not then manually ventilate him.


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## Aidey (Sep 1, 2011)

I think there is something else going on besides the OD. The sister found the note in the morning, and the pt supposedly took the OD the night before. The OD included 3 medications that cause significant decreased LOC and respiratory drive.* This guy is remarkably conscious and he is breathing 24 times a minute. I suspect he may be coming out of the OD, unless the doses he took were not very large. 


* I've had a couple of Seroquel ODs that have ended up on vents for a day or so until the medication wears off.


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## usalsfyre (Sep 1, 2011)

Aidey said:


> I've had a couple of Seroquel ODs that have ended up on vents for a day or so until the medication wears off.



This and the Reglan are probably more important than the other meds here...


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## usalsfyre (Sep 1, 2011)

Aprz said:


> If you removed the SpO2 from the post, I bet a lot of people wouldn't be saying NRB or PPV right now. Both the hands and feets are cold, core is warm, the patient is gray, RR is 24, which isn't bad.


He's gray, has a seriously altered LOC and and is tachypneic. You pretty well have to suspect hypoxia in this case. In addition, if his LOC doesn't improve with oxygenation, he needs airway protection, and while I've been critical of being quick to RSI in the past, RSI is the best way to accomplish this in this patient.


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## Melclin (Sep 1, 2011)

usalsfyre said:


> Barring the suicide note...the above SCREAMS sepsis. Which could go hand in hand with the suicide attempt if he aspirated due to altered LOC from the meds.



It screams it from the roof tops. I was not expecting that temp. I was expecting it to be low. I thought, he's been lying here all night in the cold in an altered conscious state and his hands feel icy...hypothermia! Imagine my surprise.  

Is it enough time to become septic from aspiration if he's taken the meds last night? 

Also, when you have sepsis of a respiratory origin, do you worry about iatrogenic pulmonary oedema when you're talking about a fair amount of fluid. Our service is always so scared of iatrogenic APO, its so hard to tell if its warranted or not in some situations. 



Hunter said:


> I'll swing at it, might be helping this patient acomplish his goal... so...
> 
> Okay so I think... so my instincts say... his breathing is probably the most immediat threat and because he's sating at 70 and shallow respirations his tidal volume is through the floor so... cpap? or maybe RSI?
> 
> Minimal on scene time and I would opt for the 40min heli transport since I'm concerned that because he's having trouble breathing going higher into the atmosphere which would have less atmospheric pressure may reduce the workload of his labored breathing and help him breath better since both CPAP and Intubation would deliver 100% O2...



You don't want to trial some PPV first? I'm not sure I understand the reasoning behind less atopheric pressure making it easier to breath.



phideux said:


> You said all his meds are present and accounted for on his bedside table. Are the actual meds there, or just the empty bottles???? How about a pill count of the bottles to narrow down what he took too much of, if anything.



Yep, good thought. There is certainly a few left of each med in the packets available. The original boxes are nowhere to be found so it is impossible to say when or how many in todal were prescribed. 



usalsfyre said:


> This and the Reglan are probably more important than the other meds here...



I would say so.



Right so I tried to follow up on this bloke today to give you all some better answers but unfortunately he got moved to a different hospital so I have a lot less info than I'd like. 

Anyway, I just got a job. I'll post a little more in an hour or so.


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## usafmedic45 (Sep 1, 2011)

> I would probably opt to not give him any medications since he's overdosing and I'd be concerned _for adverse reactions_.



Such as?  You know that it's OK to simply admit that something is beyond the scope of your knowledge right?  We won't fault you for it but we will take you to task if you try to BS through it. 



> Minimal on scene time and I would opt for the 40min heli transport



You know that's a contradiction of terms right?



> he's having trouble breathing going higher into the atmosphere which would have less atmospheric pressure may reduce the workload of his labored breathing and help him breath better



You do realize that helicopters don't normally fly high enough to do that and....



> Just a quick word, research Dalton's law, and how gas moves across the alveolar membrane to see why this would have the opposite effect of what you want. This might seem a little counterintuitive, but trust me, reduced atmospheric pressure is BAD for hypoxic patients.



...see the above.  Specifically look up the changes of oxygen tension (levels) in the atmosphere with changes in altitude and you might want to check out "high altitude pulmonary edema" to see why your idea of reduced work of breathing at altitude tends to fall apart.



> I'm not sure I understand the reasoning behind less atopheric pressure making it easier to breath.



He's probably going for the idea that reduced altitude equals thinner air which to him might equate a reduced work of breathing.  Think why heliox is used but in much more of a half-assed sort of unscientific approach.


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## usafmedic45 (Sep 1, 2011)

> The drop in PiO2 as the chopper climbs isn't going to help him, he needs more air not less.



As long as they don't get above 5,000 or 6,000 feet or so, it's not going to be a huge difference assuming the flight crew aren't total morons and are paying attention.  We regularly fly with cabin altitudes of 4-6K AMSL (the high end of "normal" flight altitudes for most medical helicopters outside of mountainous terrain) and there's no deleterious effect.


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## Melclin (Sep 1, 2011)

Righto, back to it. Called to a woman who was texting the caller and who didn't text back. Didn't text me back? Must be seriously ill. Better call 000 <_<

Anyway, 

I think we can all agree this bloke needs some O2. I trusted the original SpO2. We had a good pleth and it matched his appearance. 

The most common idea seems to be some supplemental.

You pop on 15 litres by NRBM and his SpO2 rises to between 91-93%. After two failed attemps (he was a difficult stick, thats my story and I'm sticking too it  ) you heroicly manage a 20 in his R medial cube. His conscious state does not improve. Surprisingly though, with some coaxing and a little support he is able weight bear and sit on our wheel chair.

Usal is ganna give him some fluids.

To those wanting the chopper, what is your rationale for aeromed over ground and for the lev 1 hospital over the 2? 

What now *****cats?


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## usafmedic45 (Sep 1, 2011)

> To those wanting the chopper, what is your rationale for aeromed over ground and for the lev 1 hospital over the 2?



Are the following valid answers?
"Because the girl with the flight suit on and unzipped to her navel said it was a good idea."
"Free pizza and t-shirts"
"I want to be like Rabbit on Trauma!"
"Helicopters give me a stiffy."


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## systemet (Sep 1, 2011)

usafmedic45 said:


> Are the following valid answers?
> "Because the girl with the flight suit on and unzipped to her navel said it was a good idea."
> "Free pizza and t-shirts"
> "I want to be like Rabbit on Trauma!"
> "Helicopters give me a stiffy."




I pick 1,2,4 and 1.  And 1 again.


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## Hunter (Sep 1, 2011)

usalsfyre said:


> Just a quick word, research Dalton's law, and how gas moves across the alveolar membrane to see why this would have the opposite effect of what you want. This might seem a little counterintuitive, but trust me, reduced atmospheric pressure is BAD for hypoxic patients.



well I understand that but since I would've placed him on a cpap wouldn't the cpap create its own pressure?


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## usafmedic45 (Sep 1, 2011)

> well I understand that but since I would've placed him on a cpap wouldn't the cpap create its own pressure



Yes, but it still negates your reasoning for flying the patient to reduce work of breathing. More than anything we were just trying to get you to study and understand the "why" and not just the "what".  


NO ONE ELSE ANSWER THIS.  I WANT HUNTER TO THINK THIS ONE THROUGH:
Can you explain to me why a central-mediated (such as drug induced) low tidal volume is not going to be helped much by CPAP and therefore your choice is a poor one?


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## Cup of Joe (Sep 1, 2011)

usafmedic45 said:


> NO ONE ELSE ANSWER THIS.  I WANT HUNTER TO THINK THIS ONE THROUGH:
> Can you explain to me why a central-mediated (such as drug induced) low tidal volume is not going to be helped much by CPAP and therefore your choice is a poor one?



ahhhh....I really wanted to take a shot at that question.  :sad:


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## Hunter (Sep 2, 2011)

usafmedic45 said:


> Yes, but it still negates your reasoning for flying the patient to reduce work of breathing. More than anything we were just trying to get you to study and understand the "why" and not just the "what".
> 
> 
> NO ONE ELSE ANSWER THIS.  I WANT HUNTER TO THINK THIS ONE THROUGH:
> Can you explain to me why a central-mediated (such as drug induced) low tidal volume is not going to be helped much by CPAP and therefore your choice is a poor one?




just writing down my thought proccess so might seem a little messy...
I'm thinking that what you're trying to get to is the way that the respiratory drive is affected by the drugs and cpap is used mostly in edema Pts where theres already pressure from the fluid in the lungs you're just trying to work against it... since its drug induced low tidal volume the person isn't breathing correctly and the cpap isn't gonna help them as far as increasing how the  respiratory drive...

okay so just to put the above statements into order, CPAP wouldn't help because of something having to do with the actual respiratory drive? Im just guessing I actually don't know the answer to this.


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## IBleedJDM (Sep 2, 2011)

Melclin said:


> *0834 :  “Overdose/poisoning”, unconscious (intentional)”.*
> 
> You are called to a suicide attempt on a cold morning in semi-rural area. The dispatch information notes that you were dispatched by a third party caller (the pt’s sister), who found a note that had been dropped (ie not posted) in her letter box from the pt, explaining that the pt had taken an overdose and apologising for the grief it would cause.
> 
> ...



All of the things i put in bold point to septic shock but then again reglan can cause fever and suicidal thoughts so that may be the issue as well. First things first, his airway is patent but at a 70% sat his breathing is safe to call ineffective. I would begin with a NRB @ 15 LPM and move him to the ambulance rapidly where I would probably transition to a CPAP and that should free up both of my hands to start bilateral large bore IV's probably 18g or 16g and get him on the monitor. Then I would hang a NS drip. Considerations, to me would be romazicon or Narcan, however that would solve only a small portion of the concoction that he ingested and may cause further issues. I would also suffice to say that the rural ED would be fine and I would have the helicopter meet me there.


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## usafmedic45 (Sep 2, 2011)

> I'm thinking that what you're trying to get to is the way that the respiratory drive is affected by the drugs and cpap is used mostly in edema Pts where theres already pressure from the fluid in the lungs you're just trying to work against it...



You're partly right.  CPAP is used primarily for three reasons:
1. To decrease work of breathing through its effects on airway resistance
2. To keep the alveoli inflated
3. To help to minimize or reduce pulmonary edema.

It doesn't have to involve pulmonary edema to be used.  It's quite effective as an adjunctive (secondary/assisting) treatment in asthmatic and COPD patients in keeping them from buying themselves a stint on the ventilator.



> since its drug induced low tidal volume the person isn't breathing correctly and the cpap isn't gonna help them as far as increasing how the respiratory drive...



Good job.  Now what non-invasive ventilation mode (related to CPAP) could be used in this setting and would be a better option (assuming that the patient was able to protect his own airway)?



> okay so just to put the above statements into order, CPAP wouldn't help because of something having to do with the actual respiratory drive? Im just guessing I actually don't know the answer to this.



No, you didn't guess. You reasoned your way through it.  Nice work.  Exactly, the problem- at least not the primary one- is not an alveolar recruitment (inflation) issue, pulmonary edema or increased work of breathing but simply depression of the drive to breath.


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## Melclin (Sep 4, 2011)

Okay, I think we've given this one enough time, and I'm glad to see some students/newbies having and crack and getting something out of it. 

I left it at 15lpm. I was happy enough with SpO2 of 92 during transport. My concern was  ventilation. I would like to have had an end tidal reading to play with, I was quite worried that he was hypo-ventilating (and had been for quite some time). More correctly, that he was _still_ hypo-ventilating (I think its pretty reasonable to suggest that ventilation was his issue originally). In the end with constant stimulation I could bully him into taking the odd deeper breath and keep him reasonably awake. His end tidal at hospital was 40, so I guess it worked out for the best. As some have said, this just screamed sepsis. All I could think was that he had somehow managed to try and kill himself on top of being really crook. At the same time, fluid resus in this pt would be walking a bit of a thin line, guideline wise. Iatrogenic pulmonary oedema is something we are taught to be ridiculously scared of (rightly or wrongly I wonder?) in any fluid resuscitation, and I felt that if he had a respiratory origin for sepsis, or had some kind of myocardial depression from sepsis or whatever else he had taken, that my fluid might end up in his lungs and I'd get a new arsehole torn for me. So I held off on the fluids *What do people think about this? Especially given that I cannot initiate an inotrope, is this a legitimate fear or am I being too much of a wanker about it.*

I'm surprised at home many people put this guy on the chopper. I'm still a newbie, and I'm still very much in the process of learning, but I have no doubt that I would have had my arse handed to me if I had the chopper out for this bloke. I wasn't even thinking intensive care paramedics, although, I'd like to have nicked their monitor for capnography. 

Anyway, he start shivering quite a lot on the way to the level 2 hospital, with some movements that I couldn't identify but that looked like some kind of neuro posturing (it didn't seem like normal shivering anyway, I figured maybe the metaclopramide was at fault, but it wasn't dystonic either), was fluid resuscitated in hospital to good effect, received 200mcg IV naloxone, which affected a mild change in conscious state but changed nothing else (resp status, BP etc). His saturation remained at 92%.

At last look, Neuroleptic Malignant Syndrome (due to the seroquel) with an unknown combination of other affects re polypharmacy OD, was the working diagnosis. I was expecting to be able to give you all something more solid when I posted this scenario, but as I mentioned I was disappointed to hear he was moved to a different hospital and I was not able to follow up further. I only know that he was not tubed, and not admitted under ICU, but that he was moved to the other hospital for a specialist bed which would have been either HDU or Mental health. 

I will post more I come across the treating docs or nurses again.


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## Hunter (Sep 5, 2011)

sorry this has taken me so long, lost my internet for a few days.



usafmedic45 said:


> Good job. Now what non-invasive ventilation mode (related to CPAP) could be used in this setting and would be a better option (assuming that the patient was able to protect his own airway)?


 
Honestly have no idea.


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## bigdogems (Sep 6, 2011)

Not sure of what the protocols are of the OP. But it sounds like multiple problems in one pt. It is actually a really good example of why a good assessment is required. Its easy to get tunnel vision on the whole suicide attempt part. But a suicide attempt isnt going to give you a 103 temp.

Id go with 15L NRB.Nasal airway. If that didnt increase his SPO2 move to BVM. 18g IV. If your concerned about fluid overload you can start with small 250 boluses and reassess. Some Narcan to see if it helps with the resp depression. If your protocols allow for it I would be very careful before considering Romazacon due to possible seizures. The 1st degree block in itself isnt a problem. Id ground transport to the higher level ER. The pt doesnt sound like there are any issues that would require the care of a level 1 trauma center. Plus depending on the ETA for a lifeflight you may be able to have him to the hospital quicker by a quick load and go rather than waiting on the bird.


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## KingCountyMedic (Sep 7, 2011)

ABC's

Two big lines and a ET Tube/ETCO2/Ballard ET suction cath every time.

Blood draw, 12 Lead ECG. Then you got your bases covered now you can think about other things.

Put in an OG/NG tube and suck out that gut.

My policy is suicide patients DO NOT fly in choppers. I won't risk a flight crew for someone that wants to die in the first place.

:beerchug:


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## systemet (Sep 7, 2011)

KingCountyMedic said:


> My policy is suicide patients DO NOT fly in choppers. I won't risk a flight crew for someone that wants to die in the first place.



That's a joke, right?


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## Smash (Sep 7, 2011)

KingCountyMedic said:


> ABC's
> 
> Two big lines and a ET Tube/ETCO2/Ballard ET suction cath every time.
> 
> ...



Is that the same dangerous, suicidal patient you have just intubated?  Do you not provide sedation and analgesia to all intubated patients?


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## epipusher (Sep 7, 2011)

systemet said:


> That's a joke, right?



Wow, written or unwritten policy, that's horrible. They probably do not fly homeless people either.


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## Aidey (Sep 7, 2011)

epipusher said:


> Wow, written or unwritten policy, that's horrible. They probably do not fly homeless people either.



WTF does one have to do with the other? If you are going to criticize the policy go ahead, but making wild emotion based accusations is silly.


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## KingCountyMedic (Sep 7, 2011)

:rofl:


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## KingCountyMedic (Sep 7, 2011)

Wow this is a friendly place huh?

If I am within driving distance of a hospital and the flight time vs. drive time is absolutely not going to make a bit of difference and the patient is a suicidal then yea I'll drive thanks. Obviously some of you have never lost close friends in helicopter crashes. It may sound harsh but I will never risk a flight crew for someone that has attempted to take their own life unless it is absolutely the only option. If you are working someplace that has no local hospital then obviously things are different.

If you have a patient that is looking like sepsis, the best way to manage that patient is RSI ASAP. Take away the demand of breathing and let the body handle the other problems, not tubing these people is just pushing them to end organ failure and death.

And if it is a poly drug OD with opiates and benzos I'm not going to push more opiates and benzos:wacko:


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## epipusher (Sep 7, 2011)

Aidey said:


> WTF does one have to do with the other? If you are going to criticize the policy go ahead, but making wild emotion based accusations is silly.


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## Smash (Sep 7, 2011)

KingCountyMedic said:


> Wow this is a friendly place huh?
> 
> If I am within driving distance of a hospital and the flight time vs. drive time is absolutely not going to make a bit of difference and the patient is a suicidal then yea I'll drive thanks. Obviously some of you have never lost close friends in helicopter crashes. It may sound harsh but I will never risk a flight crew for someone that has attempted to take their own life unless it is absolutely the only option. If you are working someplace that has no local hospital then obviously things are different.



It doesn't sound harsh so much as it not making sense in the context of this scenario.  I have no problem with not flying a combative patient if nothing has been done to mitigate the risks, and in fact I have no problem in not flying this patient at all.  However if, as you have stated, you have intubated this patient, why then would you not fly him? (if indeed aero-medical transport was necessary at all)



> If you have a patient that is looking like sepsis, the best way to manage that patient is RSI ASAP. Take away the demand of breathing and let the body handle the other problems, not tubing these people is just pushing them to end organ failure and death.


  I'll certainly grant that in some setting early RSI may be an important step in the management of a patient with sepsis/severe sepsis/septic shock, but jumping straight in with a tube seems to be missing a large number of quite important steps in the mean time.



> And if it is a poly drug OD with opiates and benzos I'm not going to push more opiates and benzos:wacko:



So with respect to this patient, if the decision was made to intubate him, how would you actually go about doing this, and how would you maintain that ETT if or when it was passed?


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## usafmedic45 (Sep 7, 2011)

> Obviously some of you have never lost close friends in helicopter crashes.



I've lost ten friends in HEMS crashes including one less than two weeks ago.  Also, I'm the last one to ever advocate HEMS transport unless it's a last resort.


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## KingCountyMedic (Sep 7, 2011)

Didn't really clarify myself I guess 

RSI to me is using a lot of drugs, MS, Valium, Versed, Etomidate, Anectine, Rocuronium or Vecuronium. Where I work we are very aggressive with airway management. We sedate and paralyze most all tubed patients unless it isn't needed. "If you are thinking about securing the airway with a tube, DO IT"

So if I ever say "I'd tube this guy ASAP" it means I'd use every RX at my disposal, didn't mean it to sound barbaric or nothing.


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## Ramathorn90 (Sep 7, 2011)

O's via NRB and intervene with PPV if no improvement in sat or breathing condition during assessment.

IV- 16G because I love em' 

Fluids for possible sepsis 2nd to his HR 130 ST, 103.2 temp, and ALOC. (Monitoring for fluid overload)

Transport with the pretty lights if no improvement in breathing condition.

En route, try a bite of narcan and call it a day after turning the Pt over.


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## Smash (Sep 8, 2011)

KingCountyMedic said:


> Didn't really clarify myself I guess
> 
> RSI to me is using a lot of drugs, MS, Valium, Versed, Etomidate, Anectine, Rocuronium or Vecuronium. Where I work we are very aggressive with airway management. We sedate and paralyze most all tubed patients unless it isn't needed. "If you are thinking about securing the airway with a tube, DO IT"



I assume not all of those drugs at once, or together.  Specifically for this patient, I would be curious to know how you would actually go about securing his airway?


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## Handsome Robb (Sep 8, 2011)

Smash said:


> I assume not all of those drugs at once, or together.



I'm hoping the same thing.


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## KingCountyMedic (Sep 8, 2011)

Smash said:


> I assume not all of those drugs at once, or together.  Specifically for this patient, I would be curious to know how you would actually go about securing his airway?



Seriously?

Etomidate 20mg, Anectine 120mg,  Rocuronium 50mg. 

Monitor VS, HTN? Maybe some Valium.


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## Handsome Robb (Sep 8, 2011)

KingCountyMedic said:


> Seriously?



More of the way it was listed then you talked about 'aggressive' airway control. 

King County holds their medics to very high standards, we all know this.

10/10 for props 2/10 for delivery  No offense intended


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## KingCountyMedic (Sep 8, 2011)

have a good night, stay safe


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## Aidey (Sep 8, 2011)

KingCountyMedic said:


> Seriously?
> 
> Etomidate 20mg, Anectine 120mg,  Rocuronium 50mg.
> 
> Monitor VS, HTN? Maybe some Valium.



You would use etomidate in a potentially septic patient?


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## Smash (Sep 8, 2011)

KingCountyMedic said:


> Seriously?
> 
> Etomidate 20mg, Anectine 120mg,  Rocuronium 50mg.
> 
> Monitor VS, HTN? Maybe some Valium.



Why would I not be serious?  How will I learn things if I don't ask questions?

Aidey already bet me to the punch with the etomidate question.  I assume you would include some hydrocortisone or something similar if you were using etomidate rather than midazolam in this patient?

Would you routinely provide ongoing sedation and analgesia to this kind of patient?

Why not skip the succinylcholine altogether if you are going to use rocuronium for ongoing paralysis anyway?


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## systemet (Sep 8, 2011)

KingCountyMedic said:


> Wow this is a friendly place huh?



It's lovely!



> If I am within driving distance of a hospital and the flight time vs. drive time is absolutely not going to make a bit of difference and the patient is a suicidal then yea I'll drive thanks. Obviously some of you have never lost close friends in helicopter crashes. It may sound harsh but I will never risk a flight crew for someone that has attempted to take their own life unless it is absolutely the only option. If you are working someplace that has no local hospital then obviously things are different.



I've been lucky not to.  And I don't wish it on anyone.

If there no expected benefit from rotary wing transport, then it's silly to do it in any patient.  And part of the responsibility for the horrific amount of deaths in flight belongs to us for using the capability in inappropriate situations.

But that's any patient.  I just don't see why you'd be reluctant to fly an OD patient.  If they're sick enough to fly, they're sick enough to RSI.  At that point the risk is minimised.  Place some restraints, use a longer acting NMBA, and sedate appropriately.


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## Handsome Robb (Sep 8, 2011)

Smash said:


> Would you routinely provide ongoing sedation and analgesia to this kind of patient?
> 
> Why not skip the succinylcholine altogether if you are going to use rocuronium for ongoing paralysis anyway?



First question: Yes. It's cruel to paralyze someone and not sedate them. We 'do no harm' correct? Paralyzation without proper sedation/analgesia is harmful psychologically. People always criticize Medication Assisted Intubation with the 'if you aren't going to do it right, don't do it at all' argument. I'd say that applies here. If your gonna RSI this pt, keep them anesthetized.

Question two: Faster onset would be my thought. As long is it's not contraindicated why wait for a pharmacological paralytic agent like roc to kick in while oxygenation is compromised when sux allows for intubation conditions within 45 seconds, then continue the paralysis with a longer duration medication such as rocuronium or vecuronium? Also a med such as rocuronium or pancuronium can be used as a defasciculating agent if given prior to administration of the paralyzing dose of succinylcholine as I'm sure you know.



			
				systemet said:
			
		

> I just don't see why you'd be reluctant to fly an OD patient. If they're sick enough to fly, they're sick enough to RSI. At that point the risk is minimised. Place some restraints, use a longer acting NMBA, and sedate appropriately.



Agreed. If they need a chopper the bad, paralyze, sedate and breathe for them. They can't do anything dangerous to the crew after the have been RSI'd.

If your hand is forced into flying someone with suicidal thoughts/actions, RSI them. Document the heck out of why you did it, but flight crew's life comes first.


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## KingCountyMedic (Sep 8, 2011)

Where I'm at we only have a small number of choppers and our hospitals are all pretty close. We typically only fly trauma patients and that's fairly rare as well. We have no policy about who we choose to fly or not fly. It's entirely up to us.

The use of Etomidate is sepsis is still an ongoing debate on the west coast. For now we still use it in most patients that we RSI. Will that change? who knows?

As far as sedation for the intubated patient we carry Valium, Versed, Morphine. We initially use Anectine as a short acting paralytic and once the airway is secure we give a long acting paralytic. Sometime a small defasciculating dose of Vec or Roc is given prior to the Anectine. In treating a patient that has poly OD'd on benzos and opiates I would be very hesitant to start pushing more. I'm not saying I would absolutely never give them any but more than likely I'd hold off and continually re-evaluate.

The reason we use sux first is that it's quick and it doesn't last. This is good. If you encounter a difficult airway the patient isn't left paralyzed for 45 minutes to an hour. 

In my view this gentlemen in question had too many potential issues going on to leave breathing on his own. Aspiration risk and myocardial demand are a couple good reasons to protect that airway. I always put at least two large bore lines in every intubated patient because they may need it later whether it be fluid or multiple meds/antibiotics.

We have a huge area covered in our part of the state by only 3 helicopters so I'm really, really picky about what I give them. I'd hate to take a chopper out of service for an intentional OD that more than likely has a life ending disease, probably wants to be a DNR if they aren't already..........does that make sense? If we had tons of choppers maybe it's be a different story. Also my transport is free, the choppers here will run you 10-20 grand per flight easy.


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## KingCountyMedic (Sep 8, 2011)

NVRob said:


> More of the way it was listed then you talked about 'aggressive' airway control.
> 
> King County holds their medics to very high standards, we all know this.
> 
> 10/10 for props 2/10 for delivery  No offense intended



:beerchug:

I'm new at this forum stuff I'll work on delivery


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## KingCountyMedic (Sep 8, 2011)

Also please forgive the snappy attitude of earlier posts, bad mood and booze. Should stay away from posting while under the influence :wacko:


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## Melclin (Sep 8, 2011)

KingCountyMedic said:


> Also please forgive the snappy attitude of earlier posts, bad mood and booze. Should stay away from posting while under the influence :wacko:



Meh I say this about once a month. Never sticks. 

It can be a bit of a shock coming here some time. You expect the low and lazy conversation of a break room and you assume a certain amount of short hand.

In some of the groups its more like a formal conference. You have to be ready to justify what you say/do. I think thats a good thing. If you can't justify it to a bunch of faceless people on the internet, then you have to wonder about the wisdom of having done it in the first place. Keeps you on your toes.

There are so many idiots out there in addition to so many different scopes of practice and norms, that sometimes you have to expand on what is obvious to you, put our regional shorthand to the side. Its absurd to you that someone might try to intubate this pt without drugs or with a smattering of midaz, so its self evident when you say RSI that you mean a certain cocktail. Unfortunately I wouldn't put it past some people, and some systems to espouse intubating this guy without drugs, perhaps nasally, or with a couple of mgs of midaz. Hence the questions, and generally, a little extra detail in the original posts.


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## lightsandsirens5 (Sep 9, 2011)

I know it has been a few days, but would getting an ETCo2 help anything? Apparenly we trust the SPO2 in this case, as it seems to be correct, but with cold hands and a presentation that does not exactly say "This bugger has an SPO2 of 70." would the ETCo2 be of any use?

I am just trying to think outside the box. My ILS instructor seemed to be having a love affair with his ETCo2 machine, but seeing as how it isn't part of the ILS scope in my county, we were not taught much about it.


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## usalsfyre (Sep 9, 2011)

lightsandsirens5 said:


> I know it has been a few days, but would getting an ETCo2 help anything? Apparenly we trust the SPO2 in this case, as it seems to be correct, but with cold hands and a presentation that does not exactly say "This bugger has an SPO2 of 70." would the ETCo2 be of any use?
> 
> I am just trying to think outside the box. My ILS instructor seemed to be having a love affair with his ETCo2 machine, but seeing as how it isn't part of the ILS scope in my county, we were not taught much about it.



Useful, perhaps. Earth shattering? Probably not really. Many in EMS don't particularly understand the oxygenation vs ventilation relationship, or for that matter the fact that ETCO2 is not 100% reflective of PaCO2. It's entirely possible to have a "relatively normal" ETCO2 and still be profoundly hypoxemic and/or experiencing a severe respiratory acidosis. 

Your best bet with a variable patient presentation and mixed information is treat the apparent hypoxia. I'm not an "O2 for everyone" advocate but hypoxia kills quickly, hyperoxygenation does damage much more slowly in most cases.


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## Hunter (Sep 9, 2011)

lightsandsirens5 said:


> I know it has been a few days, but would getting an ETCo2 help anything? Apparenly we trust the SPO2 in this case, as it seems to be correct, but with cold hands and a presentation that does not exactly say "This bugger has an SPO2 of 70." would the ETCo2 be of any use?
> 
> I am just trying to think outside the box. My ILS instructor seemed to be having a love affair with his ETCo2 machine, but seeing as how it isn't part of the ILS scope in my county, we were not taught much about it.



I think this is a really good point, but in this case even without the SaO2 this guys respirations seemed pretty bad. I do think with the hypothermia SaO2 would probably be useless...


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