19y.o AMS

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EMT B

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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?
 
TechYourself

TechYourself

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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.

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?
Click to expand...

last oral intake, to include drugs and alcohol.
 
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EMT B

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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.
 
chaz90

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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

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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.
Click to expand...

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

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just realized i forgot to give the vitals.

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

Here is the 12 lead
124838.fig.001.jpg
 
chaz90

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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

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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

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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.
Click to expand...

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

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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.
 
chaz90

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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
Click to expand...

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

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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

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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).
 
chaz90

chaz90

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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.
Click to expand...

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

chaz90

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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.


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).
Click to expand...

Haha, the echo has struck yet again...
 
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EMT B

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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

chaz90

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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

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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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