45yo Male...Unconscious

[boingo]

Playing Monday morning quarterback, I would probably have intubated the patient as you presented him, unresponsive, coarse breath sounds w/copious emesis, hypoxic and hypercarbic. The fact that you were able to oxygenate him to the mid 90's w/assisted ventilation is great, it will provide me with a bit more time to intubate. I see opiate OD's on a daily basis and very rarely intubate them, however this patient seems like a good candidate. Waking up someone with lungs full of crap is very likely going to turn to shyte quick. Fighting a hypoxic patient all the way to the hospital is no fun, and is not helping the patient. Secure the airway, deliver some PEEP and improve his oxygenation is what my probable course of action would be on this patient. My $0.02.

 

[MrBrown]

If your medical director has a problem with you not giving this patient naloxone then he needs to be taken out back and shot.

I think we are confusing the concepts of oxygenation and ventilation; this guy is obviously well ventilated but poorly oxygenated. It's not about adequacy of the airway and how well we are providing ventilatory assistance but that his puke has made its way down in to the bronchioles and alveoli which is imparing gas exchange.

That is something we cannot fix alone in the back of a moving ambulance with very limited tools. Having said that obviously we do have a role in providing a patent airway as best we can.

If we wake this guy up to a near normal GCS and he starts to crash again we're gonna have to do something; he is now going to be a hell of a lot more resistant to us placing an LMA or trying to bag him than if we didn't wake him up. The only way for us to overcome that is to knock him out again which is really not something I want to have to contend with doing as it puts us deeper in a pile of shyte.

Agreed that if we don't wake him up his autonomic drive to protect his airway from any aspirated secretions is going to be slim to non existant but is that worth the problems we're going to encounter if we wake him up and then have to deal with an awake guy who is crashing and going to try and resist whatever we do to help him?

Ever tried to bag a conscious status asthmaticus patient who is crashing? They already feel like they can't get enough air in (as I bet this guy would too) so us placing a bag mask over thier face doesn't help .... I know, lets try and get this guy to comply with us shoving a laryngeal mask down his throat and inflating it; I can see that going over well.

This guy needs treatment we can't provide, so let's put away our flash toys and use good clinical judgement by taking him to the hospital.

 

[denverfiremedic]

Maybe I'm missing something, but why are you using a BVM on this Pt. ? His RR is not really requiring that and as far as his spo2 level 88% is not great but it is not low enough to be a major concern at this point ? I'm I wrong?

 

[denverfiremedic]

Maybe I'm missing something, but why are you using a BVM on this Pt. ? His RR is not really requiring that and as far as his spo2 level 88% is not great but it is not low enough to be a major concern at this point ? I'm I wrong?

Also if you are using a BVM his RR should be 12

 

[taporsnap44]

Maybe I'm missing something, but why are you using a BVM on this Pt. ? His RR is not really requiring that and as far as his spo2 level 88% is not great but it is not low enough to be a major concern at this point ? I'm I wrong?

Respirations shoot up into the 40-50 range with oxygen sats dropping when moved to the stretcher.

Also looking at this as already knowing what happened, it seems there were two choices. Narcan and wake him up, have him vomit again and have respriations shoot way up and O2 sats drop. Now you have, im sure a very scared and paniced patient fighting to get more oxygen. Which this stress on top of what has already occured cannot be good on the patient.

Or you can intubate the patient and have his sats remain in the 80's which is much better than the 60's. Also with the tube in his airway is protected from anymore aspiration.

 

[MrBrown]

Maybe I'm missing something, but why are you using a BVM on this Pt. ? His RR is not really requiring that and as far as his spo2 level 88% is not great but it is not low enough to be a major concern at this point ? I'm I wrong?

Dude ... did you get your license out the crackerjacks?

Of course like anything we should not consider diagnostic indicators in silos and the larger clinical picture should be evaluated however in this case 88% SPO2 is rather hypoxic and would fit the clinical indicators that this patient is very poorly oxygenated.

 

[denverfiremedic]

No I didn’t crazy enough! .. but I have worked in areas that were 10,000 ft. + and 88% sop2 is actually quiet normal for someone not having the best day! and they were just fine. You clearly have not had a wide variety of experience if you call that severely hypoxic.. Further more I was asking a question " hints the ? marks.. take er easy big guy

 

[Akulahawk]

Maybe I'm missing something, but why are you using a BVM on this Pt. ? His RR is not really requiring that and as far as his spo2 level 88% is not great but it is not low enough to be a major concern at this point ? I'm I wrong?

Unless this patient normally has a lower SpO2, I get VERY concerned with a SpO2 of 88%... especially if the patient is on O2!

Also if you are using a BVM his RR should be 12

When you're tracking a patient's breathing, you want to bring them down to a normal rate. That's between 12-20/min. Go any slower and the patient will likely start breathing on his own because you're going too slow...

I'm just guessing here, but once that patient was awake and able to protect their own airway, he probably would have done as well coaching him without the BVM... Oh, and he probably would have been RSI'd in the ED or in ICU... while they try to keep aspiration pneumonia from killing him.

This is just one of those times that you can or should "buck" the normal OD protocol and intubate without giving naloxone. The guy was a GCS 3, no gag-reflex with indications of having aspirated some unknown quantity (but likely significant) of vomitus. I'd rather intubate, scoop & run with this guy. Can't get an IV? If you have IO available...

An 88% SpO2 at say 10,000+ feet would be good... at lower altitudes... not so much. Given the OP is in Texas, and residential area, I'm guessing, MUCH closer to sea level... I'd expect the SpO2 to max out somewhere in the mid 90's, if not >97/98% or better on >90% O2 concentration...

 

[denverfiremedic]

I agree , 88% is not a good thing but I see 80's sop2 all day out here at 5,280ft and its not a huge thing, thats all I intended. Its normal for Colorado natives haha.. his RR was 10 - 14 right? that seems normal enough.

 

[MrBrown]

I agree , 88% is not a good thing but I see 80's sop2 all day out here at 5,280ft and its not a huge thing, thats all I intended. Its normal for Colorado natives haha.. his RR was 10 - 14 right? that seems normal enough.

Well you should be considering the larger clinical picture of this specific patient then and not relying on one-size-fits-all cookbook approach.

Interestingly enough I thought Denver Fire was a first response agency and that Denver Health provided ALS? I know Aurora (where I was) and some of the suburban Fire Departments around Denver have Paramedics.

 

[denverfiremedic]

yea thats right , I actually work for both. I did consider the whole picture, I was just looking at the ABC's first and didnt really see why it was alarming. %88 is hangin in there in my book.. thats all.. The rest is pretty strait forword, LMA , Narcan and maintain VS and airway exc..

 

[Dwindlin]

I actually disagree with those saying skip the Narcan. Based on the inital assesment and management I think it was appropriate. The trend is for the least invasive management posible. 99% of the time an ER is going to try everything else before intubation because all the data says mortality sky rockets (relatively) once they go on a vent. My school uses a community model so on EM months I rotate through 6 different hospitals, and all of them likely would have tried CPAP/BiPAP with this guy first before RSI'ing him. You jump the gun and tube him in the field that option is skipped and maybe thats all he would have needed.

My only question, is did you try just a NRM after you woke him up? Or did you simply keep bagging? I find it odd he was oxygenating well with a GCS of 3 and BVM assistance, then suddenly drops once hes awake, and still being assisted. Perhaps he wasn't as cooperative with the BVM as you thought?

 

[Fox800]

I actually disagree with those saying skip the Narcan. Based on the inital assesment and management I think it was appropriate. The trend is for the least invasive management posible. 99% of the time an ER is going to try everything else before intubation because all the data says mortality sky rockets (relatively) once they go on a vent. My school uses a community model so on EM months I rotate through 6 different hospitals, and all of them likely would have tried CPAP/BiPAP with this guy first before RSI'ing him. You jump the gun and tube him in the field that option is skipped and maybe thats all he would have needed.

My only question, is did you try just a NRM after you woke him up? Or did you simply keep bagging? I find it odd he was oxygenating well with a GCS of 3 and BVM assistance, then suddenly drops once hes awake, and still being assisted. Perhaps he wasn't as cooperative with the BVM as you thought?

CPAP was in our thoughts, unable to get ahold of medical control at the receiving hospital to get authorization (it's not authorized for overdoses). The physicians were busy with a critical patient are were in the middle of some procedure.

After the patient awakened to GCS 14, they were placed on a NRB at 15lpm as were moved to the stretcher and transported. The patient desaturated approximately half-way to the hospital and their ventilations were assisted once more with a BVM. Up until that point their SP02 was between 90-95% with a nonrebreather. The increase in RR and CO2 and decrease in SPO2 began while en route to the hospital. Vital signs at a low point were HR 40-50, SPO2 65%, ETCO2 55-60 mmHg.

 

[Aidey]

Hmmm. So he was doing fine on the NRB. So what changed? A decline like that doesn't happen for no reason, there had to be something. Did the narcan wear off? O2 run out?

 

[Crepitus]

CPAP was in our thoughts, unable to get ahold of medical control at the receiving hospital to get authorization (it's not authorized for overdoses).

For everyone - Why would CPAP not be allowed in overdoses? I thought it was indicated for any non-asthmatic case of inadequate ventilation?

After the pt was given Narcan then maybe they aren't an overdose anymore

Crepitus

 

[Akulahawk]

For everyone - Why would CPAP not be allowed in overdoses? I thought it was indicated for any non-asthmatic case of inadequate ventilation?

After the pt was given Narcan then maybe they aren't an overdose anymore

Crepitus

CPAP is good and all... but it is of no help when the patient has an inadequate drive to breathe... like say... NO drive to breathe.

Now if the patient just got woken up via naloxone... discovered there's crud in his lungs, and feels like he can't breathe, you think he's going to want to have the CPAP on?

 

[Crepitus]

CPAP is good and all... but it is of no help when the patient has an inadequate drive to breathe... like say... NO drive to breathe.

Now if the patient just got woken up via naloxone... discovered there's crud in his lungs, and feels like he can't breathe, you think he's going to want to have the CPAP on?

Yep I get why CPAP won't work with a pt who's respiratory drive is absent. I can see where CPAP could be a challenge with this particular pt. (Of course I could see where bagging this particular pt could have been a treat as well).

I'm just trying to get more up to speed on CPAP as it was added to our scope while I was on hiatus. I've seen/heard of protocols where CPAP is contraindicated in asthma's and COPD's. (Seen some where it isn't as well for that matter).

What I'm curious about was the original comment that for drug overdoses across the board CPAP wasn't authorized. Maybe it's not that CPAP wouldn't work, but rather than their medical director only specifically authorizes CPAP for a few conditions and those conditions alone.

Thanks for the response.

For the OP, I can agree with the comments that waking the pt up isn't always the only option, but I also feel for how challenging the call can be. I remember a pt almost 20 years ago that was similar, younger male (20-25 yo), OD'ed with aspiration, compromised airway, our guy was jaw clenched. The charge medic 'forced' a supraglottic airway, (a PTL probably, I don't remember now), got bit in the process, then an attempt was made to wake the pt, who's LOC improved briefly and partially as his OD turned to be out both narcotic and non narcotic. He thrashed like crazy, jerked out the airway, vomitted profusely, struck the charge paramedic and crumped all over again. I believe he expired (the pt, not the charge medic) some months later after being discharged to a rehab unit.

In retrospect none of the choices on our scenario were well organized, but sometimes you are right on the wire and you make the choices that you make.

 

[Akulahawk]

For sake of clarity, I'll respond in Red, inline.

Yep I get why CPAP won't work with a pt who's respiratory drive is absent. I can see where CPAP could be a challenge with this particular pt. (Of course I could see where bagging this particular pt could have been a treat as well).
The problem with bagging this particular patient is that BVM use without any cricothyroid pressure is likely to cause gastric insufflation and he's going to vomit again... So, use the BVM while preparing to intubate, and leave him under. Most OD patients would probably do just fine with some BVM while you wait for the naloxone to work... This guy... probably better to just intubate, scoop and run.
I'm just trying to get more up to speed on CPAP as it was added to our scope while I was on hiatus. I've seen/heard of protocols where CPAP is contraindicated in asthma's and COPD's. (Seen some where it isn't as well for that matter).
The with the CPAP on those patients is that you just have to be aware of the patient's ventilatory status. COPD patients do a little "autoPEEP" on their own.
What I'm curious about was the original comment that for drug overdoses across the board CPAP wasn't authorized. Maybe it's not that CPAP wouldn't work, but rather than their medical director only specifically authorizes CPAP for a few conditions and those conditions alone.
For a Drug OD, CPAP normally isn't indicated. Normally, reverse the OD and you restore the patient's own respiratory drive. Remember, CPAP provides airway pressure, not rate or depth of breathing. With this patient, use of CPAP MIGHT have been useful if just enough narcan was used to increase his breathing rate without waking him up. However, CPAP use might also lead to the guy expelling more gastric contents into a mask that's attached to his head with straps.
Thanks for the response.

For the OP, I can agree with the comments that waking the pt up isn't always the only option, but I also feel for how challenging the call can be. I remember a pt almost 20 years ago that was similar, younger male (20-25 yo), OD'ed with aspiration, compromised airway, our guy was jaw clenched. The charge medic 'forced' a supraglottic airway, (a PTL probably, I don't remember now), got bit in the process, then an attempt was made to wake the pt, who's LOC improved briefly and partially as his OD turned to be out both narcotic and non narcotic. He thrashed like crazy, jerked out the airway, vomitted profusely, struck the charge paramedic and crumped all over again. I believe he expired (the pt, not the charge medic) some months later after being discharged to a rehab unit.
You've experienced one VERY good reason to leave this patient down or at least a very good indication for carefully titrated use of narcan.
In retrospect none of the choices on our scenario were well organized, but sometimes you are right on the wire and you make the choices that you make.

This is why Paramedics DO need the education to be able to think outside the box. My system has in the protocol that says that I have to give naloxone to OD patients... Now if I can articulate why I held the naloxone or provided careful titration of it, no trouble comes my way.

I'm not exactly a garden variety cookbook medic...

 

[emtfarva]

question? When his Sat's were in the 60's, he was warm and pink?

did you ever think that the SPO2 sensor was messed up? he had poor circulation, you said you tried 4 times to get an IV, and you still couldn't. I mean, you are bagging them, they are pink and warm, then maybe that the SPO2 was wrong.

 

[MrBrown]

question? When his Sat's were in the 60's, he was warm and pink?

did you ever think that the SPO2 sensor was messed up? he had poor circulation, you said you tried 4 times to get an IV, and you still couldn't. I mean, you are bagging them, they are pink and warm, then maybe that the SPO2 was wrong.

You consider SPO2 as part of the larger clinical picture, not in isolation however this clinical scenario fits with the SPO2 reading be as low as it was.

Some dude who is warm and pink with good ventilation and mentation who the SPO2 says 60% I'm going to go "yeah, right" but this guy I'd be inclinded to believe his SPO2 was in the 60s or 70s because it fists with his presentation.