76 y/o M - Hypotension

[mycrofft]

It's supper time in my time zone....

If considerable fluid goes in and neither goes out nor increases BP nor other signs, it's time to go to Page 2 of the Protocol.

Remember somewheres between 20k and 400k die annually from medical mistakes.

 

[Veneficus]

It's supper time in my time zone....

If considerable fluid goes in and neither goes out nor increases BP nor other signs, it's time to go to Page 2 of the Protocol.

Remember somewheres between 20k and 400k die annually from medical mistakes.

I guess it is the medical version of "how many people can we fit in the clown car?"

 

[systemet]

Believe me, I would have loved to do one. I was not on a mainline bus that day, and they have all the 12 leads. Transfer squads only get LifePak 10s. Ugh.

Just a thought here. If you have the 10D, you can hit the "DIAG" button, and get diagnostic quality for leads I, II, III. You can also fire it into lead one, use the foot lead, and get MCL1-6, or MCL4R, etc.

I'm not saying that you're going to get to ER bypass to cathlab based on a handful of MCL strips, or that you'll get orders for 'lytics -- but you may identify an acute MI and save your patient some valuable myocardium.

And yes, I know it's a pain in the *** trying to glue all those strips to a PCR.

 

[Veneficus]

Just a thought here. If you have the 10D, you can hit the "DIAG" button, and get diagnostic quality for leads I, II, III. You can also fire it into lead one, use the foot lead, and get MCL1-6, or MCL4R, etc.

I'm not saying that you're going to get to ER bypass to cathlab based on a handful of MCL strips, or that you'll get orders for 'lytics -- but you may identify an acute MI and save your patient some valuable myocardium.

And yes, I know it's a pain in the *** trying to glue all those strips to a PCR.

I appreciate the ingenuity, but you must really have some long transports times to go through all of that.

 

[systemet]

I appreciate the ingenuity, but you must really have some long transports times to go through all of that.

Haven't had to work without 12-lead since.... maybe 2003? And even that was an exception, most places I was working had them from 2000 on. I even remember using the LP11.

I agree, it takes a lot of time, and unless other people in your system are doing it on a regular basis, a lot of ER docs / RNs are going to ignore a big mess of paper and tape. But it does work.

Screening II / III for IWMI is pretty quick and easy, at least. If you identified an MI, and got the patient reperfused quicker, I reckon the time savings would justify it.

 

[Veneficus]

Haven't had to work without 12-lead since.... maybe 2003? And even that was an exception, most places I was working had them from 2000 on. I even remember using the LP11.

I agree, it takes a lot of time, and unless other people in your system are doing it on a regular basis, a lot of ER docs / RNs are going to ignore a big mess of paper and tape. But it does work.

Screening II / III for IWMI is pretty quick and easy, at least. If you identified an MI, and got the patient reperfused quicker, I reckon the time savings would justify it.

No doubt it works. It is brilliant.

If ever pressed I am going to use it and pretend like I thought of it.

 

[systemet]

No doubt it works. It is brilliant.

If ever pressed I am going to use it and pretend like I thought of it.

That's what I did.

Can't remember who taught me to do it though. And sadly, I don't think I ever found anything using this method. It would have been pretty MacGyver.

 

[Veneficus]

That's what I did.

Can't remember who taught me to do it though. And sadly, I don't think I ever found anything using this method. It would have been pretty MacGyver.

NO it would be MacGyver if you found something and then purposefully induced an allergic reaction in the patient to cause degranulation of histamine and heparin thereby resolving the acute pathology.

(Never did that, but damn straight I would take credit for it if it worked.)

If not, I'll just blame it on austere environment.

Better still use morphine or PCN to cause an anaphylactoid reaction...

 

[d_miracle36]

What meds is he taking? Are you SURE he didn't take his beta blockers? Hypotension with a slower HR and HX of HTN always makes my nose perk up and start sniffing around for the BetaBlocker bottle.


My first thought was this guy may need some glucagon.

 

[Veneficus]

What meds is he taking? Are you SURE he didn't take his beta blockers? Hypotension with a slower HR and HX of HTN always makes my nose perk up and start sniffing around for the BetaBlocker bottle.


My first thought was this guy may need some glucagon.

What are the risks of acutely reversing a B-Blocker?

Do you think a mentating patient with no complaints qualifies for acute reversal based soley on quantatative diagnostics of only pulse and BP?

Would it benefit the pt to use the glucagon as a diagnostic tool?

What other pathologies may cause this?

 

[systemet]

A few questions:

* What was his blood pressure prior to transfusion?

* Why is he receiving PRBCs?
* What prompted this?
* How anemic was he?
* Do they know why?
* Do we have H&H for post- or pre- transfusion?

* Do we have any idea of his baseline labs?
* Does he have urine output?
* How's his renal panel?
* How are the 'lytes? In particular the K+?

* Why does the doctor want him to go to the hospital? What pathology is he/she concerned in ruling in/out? What are they worried about?

 

[Dwindlin]

What are the risks of acutely reversing a B-Blocker?

Do you think a mentating patient with no complaints qualifies for acute reversal based soley on quantatative diagnostics of only pulse and BP?

Would it benefit the pt to use the glucagon as a diagnostic tool?

What other pathologies may cause this?

Do any services really carry enough glucagon to have any real effect? None that I've ever worked for do. The loading dose is a 150mcg/kg, followed up by a 1 - 4mg/hr drip. That's 10.5mg loading on a 70 kilo person (and I don't know about you all but I don't have many 70 kilo patients). I'm sorry but 1 - 2mg is a waste, other than making us feel as if we've done something. Frankly I've never even seen reversal attempted unless they are so unstable they are near/post arrest. Typically I see rate/BP support and up to ICU to wait out the BB.

 

[Veneficus]

[ Typically I see rate/BP support and up to ICU to wait out the BB.

Because it is a really bad idea to acutely reverse a beta blocker.

I was trying to be nice and educational like.

 

[jjesusfreak01]

A few questions:

* What was his blood pressure prior to transfusion?

* Why is he receiving PRBCs?
* What prompted this?
* How anemic was he?
* Do they know why?
* Do we have H&H for post- or pre- transfusion?

* Do we have any idea of his baseline labs?
* Does he have urine output?
* How's his renal panel?
* How are the 'lytes? In particular the K+?

* Why does the doctor want him to go to the hospital? What pathology is he/she concerned in ruling in/out? What are they worried about?

Same questions, but I think the primary reason for referral is the hypotension post infusion. They probably expected better than 82/38 after two units. Seeing as he's being transferred from an infusion center, they may have transferred due to protocol rather than on a doctors specific orders.

 

[d_miracle36]

Ok maybe glucagon isn't the appropriate treatment for this pt. What circumstances would it be good for? And why do we not want to give glucagon? I'm still learning but everything I have read has it as the mainstay treatment/antidote. For pts who are symptomatic of course. Our protocols allow 2-5 mg.

 

[d_miracle36]

I just spoke with our er doc and he was curious as to why you wouldn't want to give it.

 

[Veneficus]

I just spoke with our er doc and he was curious as to why you wouldn't want to give it.

A couple of reasons actually,

In this scenario, the patient is neither bradycardic nor mentally altered, and there are likely other pathologies in play.

Outside of this, the Beta blocker (BB) reversal with glucagon is not always a first-line agent, though it usually is.

It is administered IV, and often with Chloride. (While fine in the hospital, that is an aweful lot of chemistry for prehospital EMS) The dosage is listed starting at 5mg IV with follow up bolus as needed and then an infusion of 9mg/hour, until the effects of the BB wear off.

Potential side effects: arrythmia (with side effects common to those), rebound HTN, induced attack of angina, N/V, worsening of baseline cardiac function.

From the practical point, most EMS agencies don't carry that kind of dose, use it IM and not IV, and even if you were to give an IV bolus, what is the likelyhood this patient would be brought into the ED and they would automatically set up a drip on your word?

Furthermore, when you are talking about an infusion over hours, the ED is not going to sit on that patient and perform serial labs.

It makes more sense for EMS to provide supportive therapy, with definitive reversal started in the ED, continued in a unit or floor, or simply admitted there to begin with and allow those people to do their job.

An arrest or peri-arrest situation would of course be a bit different, but I am thinking so rare that therapy like transcutaneous pacing or IV fluid therapy might be a but more prudent out of the hospital as well.

 

[systemet]

Same questions, but I think the primary reason for referral is the hypotension post infusion. They probably expected better than 82/38 after two units. Seeing as he's being transferred from an infusion center, they may have transferred due to protocol rather than on a doctors specific orders.

The OP states he was coming from a "cancer center". Maybe that means something specific in their region, but it seems pretty vague. I've been to places I'd consider a "cancer center" that were associated with a large universty hospital / trauma center, were centers for basic research, had their own CT, MRI, etc. and ran mini-ICUs. So, to me, "cancer center" means something a little more than a basic infusion clinic. But perhaps that's all it is.

I understand completely if the information isn't available --- sometimes that's just how it is. But this seems more like a transfer than a scene call. I would assume some of this stuff would have been available.

In all likelihood the patient's a train wreck of acute and chronic multisystem pathology. I was just wondering if there was anything specific to the blood product use like hyperkalemia or citrate toxicity. These are probably just zebras though.

 

[d_miracle36]

A couple of reasons actually,

In this scenario, the patient is neither bradycardic nor mentally altered, and there are likely other pathologies in play.

Outside of this, the Beta blocker (BB) reversal with glucagon is not always a first-line agent, though it usually is.

It is administered IV, and often with Chloride. (While fine in the hospital, that is an aweful lot of chemistry for prehospital EMS) The dosage is listed starting at 5mg IV with follow up bolus as needed and then an infusion of 9mg/hour, until the effects of the BB wear off.

Potential side effects: arrythmia (with side effects common to those), rebound HTN, induced attack of angina, N/V, worsening of baseline cardiac function.

From the practical point, most EMS agencies don't carry that kind of dose, use it IM and not IV, and even if you were to give an IV bolus, what is the likelyhood this patient would be brought into the ED and they would automatically set up a drip on your word?

Furthermore, when you are talking about an infusion over hours, the ED is not going to sit on that patient and perform serial labs.

It makes more sense for EMS to provide supportive therapy, with definitive reversal started in the ED, continued in a unit or floor, or simply admitted there to begin with and allow those people to do their job.

An arrest or peri-arrest situation would of course be a bit different, but I am thinking so rare that therapy like transcutaneous pacing or IV fluid therapy might be a but more prudent out of the hospital as well.

That all makes sense. I am new and have yet to come upon a situation requiring glucagon(for bbod). I did have a suspected pt. that was brady yet very stable so no treatment was renderd except for supportive. Im not one to give drugs just to give them but I believe if presented with a unstable brady/hypo pt. I wouldnt hesitate to give my initial 2 mg of glucagon along with fluids and prepare for more agressive treatment if needed. I also learned that along with a bb od esophageal spams are likely and the glucagon can also reverse thouse. The ED doc said he has given it about twice in the past 10 years for esophageal obstruction which i was like mmhmmm....thinking thats awesome ive never heard of it!

 

[NomadicMedic]

Esophageal spasm is a a rare complication of a Betablocker overdose, however Glucagon is often used to relax the smooth muscle of the esophagus following a foreign body obstruction, helping to free a stuck food bolus. I'd gather that's what the doc may have used it for.