Alt mental status

[Veneficus]

I think he is trying to point out that with the bath there is an increase in transdermal absorbtion.

But we'll have none of that talk about downregulation of pain receptors, fecal elimination of fentynal, lesions in the CNS that could cause the same presentation, or even a grossly apparent finding on a physical exam.

Or you could be like me and get sucked into looking at complex pathological interactions and mixed medications.

and i don't agree with giving narcan to this lady either.

 

[JPINFV]

and i don't agree with giving narcan to this lady either.

Just curious (and, for the record, I'm not advocating slamming her with it, just taking the edge off of the OD), but why?

 

[MrBrown]

Just curious (and, for the record, I'm not advocating slamming her with it, just taking the edge off of the OD), but why?

I agree with you JP I think its maybe a little better to as you say "take the edge off" most ODs than to totally wake them up as then they're often restless/disorentaited/agitated and harder to manage.

 

[Veneficus]

Just curious (and, for the record, I'm not advocating slamming her with it, just taking the edge off of the OD), but why?

Once you remove the medication patches you will be reducing her pain relief as well as the rate of absorbtion now that she is not in the tub. Even without slamming it, which I don't think anyone here would do. You might have a patient in pain which you cannot control nd the effects of that. Since an opioid will last longer than narcan will, in order to keep the edge off you will need to keep readministering it or set up a drip.

All of the harmful effects of narcan studies I have seen (including pulmonary edema) were demonstrated in the elderly, not 20 year old heroin addicts.

If you can simply remove the source and ventilate the patient for the time (probably about 1/2 hour or so, which is a majority of your transport here it seems) it takes for her to come around without adding a chemical to the mix, why not just manage her airway? Her HR is a little low, but her BP is still in a reasonable range for somebody of her age.

Speaking of HR and BP, when her hert does start suddenly increasing contractility and rate you are going to stress the myocardium by acutely making it work harder. She has a hstory and management of hyperthyroid, which is going to add yet more stress to that. Similar in thinking to: you would not want to acutely reverse hyperglycemia, why would you acutely reverse this in a frail person?

Let's say you do start to get an onset or exaxerbation of pulmonary edema? Are you going to start adding furosimide to fix that?

I am not saying narcan is wrong, but in this case it could take you down a path you don't want to go. If you just support her breathing you can eliminate all of that potential. Pathology doesn't happen in a bubble, patients develop compensatory mechanisms over a long time, and if you start rapidly changing their stasis, you can not only make things worse for them, but can cause a really big headache for yourself.

 

[Aidey]

The reason I got this is because I've had this patient, complete with hysterical family member. It was quite the facepalm case...not to tease you Veneficus but the fire medic did exactly what you did and went off into left field and was ready to activate the stroke team (ignoring the slow onset of decreased LOC...but that is another issue). The look on his face when I pulled off the patches was priceless.

It was a 20 something Granddaughter was taking care of grandmother with dementia. She was basically winging it as she went along (she had taken over for another family member who just up and left...lots of family drama). She called because grandmother had been deteriorating for a couple weeks and now was too out of it to eat.

She ended up having 4-5 fent patches on. We didn't give her narcan, we just removed the parches and transported her. If I remember right she had no acute medical issues aside from the OD. It ended up being a social services issue mostly. I believe the hospital arranged for a few days of emergency in home care until something permanent could be found.

 

[Veneficus]

The reason I got this is because I've had this patient, complete with hysterical family member. It was quite the facepalm case...not to tease you Veneficus but the fire medic did exactly what you did and went off into left field and was ready to activate the stroke team (ignoring the slow onset of decreased LOC...but that is another issue). The look on his face when I pulled off the patches was priceless.

It was a 20 something Granddaughter was taking care of grandmother with dementia. She was basically winging it as she went along (she had taken over for another family member who just up and left...lots of family drama). She called because grandmother had been deteriorating for a couple weeks and now was too out of it to eat.

She ended up having 4-5 fent patches on. We didn't give her narcan, we just removed the parches and transported her. If I remember right she had no acute medical issues aside from the OD. It ended up being a social services issue mostly. I believe the hospital arranged for a few days of emergency in home care until something permanent could be found.

it is not teasing, no worries, but it frustrates the hell out of me when people post scenarios and leave out key bits of information to try and get you to "guess" what they are thinking. Obiously if you lift up somebody's shirt or are looking for abnormalities, if you see 4-5 medication patches on them, that is a readily apparent abnormality.

If you don't move/remove clothing and do an incomplete exam, that is another matter entirely.

 

[folpak]

it is not teasing, no worries, but it frustrates the hell out of me when people post scenarios and leave out key bits of information to try and get you to "guess" what they are thinking. Obiously if you lift up somebody's shirt or are looking for abnormalities, if you see 4-5 medication patches on them, that is a readily apparent abnormality.

If you don't move/remove clothing and do an incomplete exam, that is another matter entirely.

Veneficus, all you had to do was ask if there were patches, but i never seen anyone say they removed a shirt or anything to LOOK. Back to the basics with a proper Basic assessment. i wasnt really looking looking for the treatment of this pt so much as what was wrong.. it was my pt who was treated properly. i was just seeing if anyone would figure it out and no you would not see them right off the bat because she had clothes on. BTW a little Narcan worked great, 0.5mg I think it was...its been a while. she was awake and talking to us feeling great afterwards.

..... pt is hypotensive with no other symptoms or problems.... give a bolus.. how much fun is a scenario like that? i think im in the wrong forum.

 

[Veneficus]

all you had to do was ask if there were patches. i wasnt really looking looking for the treatment of this pt so much as what was wrong.. it was my pt who was treated properly. i was just seeing if anyone would figure it out and no you would not see them right off the bat because she had clothes on..

Please refer to my comments about not doing a proper or complete exam. If you are not visualizing patients, especially very sick ones, then you are simply providing poor medical care. it could probably take me the better part of a page to list every single thing I can notice on inspection, so with the exception of all but the rarest signs, I just request anything that is apparent would be provided.

..... pt is hypotensive with no other symptoms or problems.... give a bolus.. how much fun is a scenario like that? i think im in the wrong forum.

I usually don't respond to simple scenarios, but I figured that because you had a patient with a history of multiple pathologies that don't work and play well together, it would be something more engaging than:

"I'm going to withhold information like meds because the scenario is harder when you don't have all the information that would make a difference in your dx an treatment."

That is no different than hypotensive/give a bolus.

The more you know, the more informtion you need to exclude things. A basic can figure out an OD because they have nothing else to choose from relating to metabolism, toxicology, or interconnected pathology.

 

[folpak]

lets face it, 98% of pt's have a very simple problem. yes, a lot of times ALS in nature but yet simple. our job is to keep folks alive until they arrive .
I was bored one day and found a forum but not bored enough to argue EMS. so long B)B)

 

[alphatrauma]

... but it frustrates the hell out of me when people post scenarios and leave out key bits of information to try and get you to "guess" what they are thinking.

Reason # 101 why I rarely participate in this sort of thread.

 

[Veneficus]

Reason # 101 why I rarely participate in this sort of thread.

yea, i try not to either, but like I said, I had high hopes for this one, it has so much potential.

Sorry I scared him

 

[Aidey]

it is not teasing, no worries, but it frustrates the hell out of me when people post scenarios and leave out key bits of information to try and get you to "guess" what they are thinking. Obiously if you lift up somebody's shirt or are looking for abnormalities, if you see 4-5 medication patches on them, that is a readily apparent abnormality.

If you don't move/remove clothing and do an incomplete exam, that is another matter entirely.

It reminds me of EMT/Paramedic school where if you didn't ask for it specifically they didn't tell you.

 

[Veneficus]

It reminds me of EMT/Paramedic school where if you didn't ask for it specifically they didn't tell you.

I guess that works when there isn't a lot to ask for. But I have no intention of typing out qestions asking whether or not the skin is pulled tight and there are creases around the mouth and all the hundred or so pieces of information I can get just by looking at somebody.