Down After a Night Out

OrthoHypo

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Ambulance ALS 69 is dispatched code 3 to a train station in a major urban area for the unconscious person. On arrival, the patient is found prone on the platform. Crew repositions him for assessment. He winces in response to pain but is otherwise unresponsive. ABCs are as follows: Vomitus in his airway, respirations are slow and shallow, pulse is weak and rapid. No external trauma is noted.

Community ER is 5min away, the level 1 trauma center is 10min away.

I will continue to add to the scenario as people chime in. What are your immediate concerns? What will you assess? What treatments are you considering?
 

M3dicalR3dn3ck

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I'd suction the airway, IF indicated I'd drop a king airway (assuming my paramedic doesn't intubate). Other things to assess, not necessarily in this order, are:
Does he have an odor of alcohol?
What is his skin condition?
What about his pupil size, shape, and reactivity?
What does the body sweep tell me besides no external trauma?
What does palpation reveal (e.g. is there internal trauma)?
What is his skin temperature (hot, cold, or normal)?
What is his skin color (e.g. jaundiced, cyanotic, normal, etc)
When we assess vital signs, what's his blood sugar?
Will my paramedic or AEMT partner want to gain venous access? If so, will they want to administer anything? If so on that as well, what will they want to administer? (In other words, what ALS interventions do I need to prepare equipment for so my partner can perform said intervention)
Is there any evidence of possible drug usage?
There's more but don't have time to list them
 

DrParasite

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ABCs are where I would start @M3dicalR3dn3ck pretty much covered what I would want to know.

Some other things I would want to know is what happened before he collapsed? what do the bystanders say was occurring before 911 was called? how old is this guy?
 
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OrthoHypo

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I'd suction the airway, IF indicated I'd drop a king airway (assuming my paramedic doesn't intubate). Other things to assess, not necessarily in this order, are:
Does he have an odor of alcohol?
What is his skin condition?
What about his pupil size, shape, and reactivity?
What does the body sweep tell me besides no external trauma?
What does palpation reveal (e.g. is there internal trauma)?
What is his skin temperature (hot, cold, or normal)?
What is his skin color (e.g. jaundiced, cyanotic, normal, etc)
When we assess vital signs, what's his blood sugar?
Will my paramedic or AEMT partner want to gain venous access? If so, will they want to administer anything? If so on that as well, what will they want to administer? (In other words, what ALS interventions do I need to prepare equipment for so my partner can perform said intervention)
Is there any evidence of possible drug usage?
There's more but don't have time to list them
Forgot to mention but the patient is a male in his mid-20s-early-30s. During assessment, a strong odor of alcohol is noted and multiple empty syringes are found in the patient's pocket. The pupils are equal, round, fixed, and dilated. The blood sweep is clean and a quick head-toe reveals no DCAP-BTLS. Patient's skin is flush, hot, and moist. Airway is suctioned with a rigid catheter. Vitals are as follows: BP 100/60, PR 120, RR 8, Dexi 92 mg/dL. 4-Lead is unremarkable. A medic starts a 20G IV in the patient's hand and naloxone is administered with no response. The patient is transferred to the stretcher and secured for transport. In the ambulance, the medic attempts to intubate but stops when the patient begins to gag. BLS airway measures are resumed. Transport is initiated code 3.
 
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OrthoHypo

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ABCs are where I would start @M3dicalR3dn3ck pretty much covered what I would want to know.

Some other things I would want to know is what happened before he collapsed? what do the bystanders say was occurring before 911 was called? how old is this guy?
Patient is a 25-30ish male. The station attendant states that the patient looked confused and was unsteady on his feet, then slumped over while sitting on a bench waiting for the train. She did not see him use any substance or interact with anyone. She does not know the patient. Any other bystanders had already left the scene.
 

DrParasite

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Forgot to mention but the patient is a male in his mid-20s-early-30s. During assessment, a strong odor of alcohol is noted and multiple empty syringes are found in the patient's pocket. The pupils are equal, round, fixed, and dilated. The blood sweep is clean and a quick head-toe reveals no DCAP-BTLS. Patient's skin is flush, hot, and moist. Airway is suctioned with a rigid catheter. Vitals are as follows: BP 100/60, PR 120, RR 8, Dexi 92 mg/dL. 4-Lead is unremarkable. A medic starts a 20G IV in the patient's hand and naloxone is administered with no response. The patient is transferred to the stretcher and secured for transport. In the ambulance, the medic attempts to intubate but stops when the patient begins to gag. BLS airway measures are resumed. Transport is initiated code 3.
based on what you are state here, I'm not thinking opioid overdose, but a definite mixing of drugs and alcohol.

take em to the hospital, let the toxicologist and the ER docs keep him alive until the drugs pass through his system.
 
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OrthoHypo

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based on what you are state here, I'm not thinking opioid overdose, but a definite mixing of drugs and alcohol.

take em to the hospital, let the toxicologist and the ER docs keep him alive until the drugs pass through his system.
Pretty much what happened. On arrival at hospital (when I saw the patient) the ER MD performed RSI and the patient was placed on a ventilator. Labs were drawn and CT scan (head-neck-chest) was ordered. CT revealed no intracranial or spinal abnormalities but showed evidence of aspiration. Labs showed an alcohol level of 0.780 and were positive for PCP. Patient became increasingly hypotensive and norepi was started, as well the "banana bag" and antibiotics for aspiration pneumonia. Patient was admitted to ICU.
 

M3dicalR3dn3ck

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Even though we've already learned the outcome, I'll say that another thing my paramedic and I would consider is what capabilities each hospital has besides the one that's a level 1 trauma center for transport decision. For example, does the trauma center have any other significant capabilities besides being a Level 1 trauma center? Does the community hospital have some unexpected capability that the trauma hospital doesn't have that would be more beneficial to the patient?
 

CCCSD

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Forgot to mention but the patient is a male in his mid-20s-early-30s. During assessment, a strong odor of alcohol is noted and multiple empty syringes are found in the patient's pocket. The pupils are equal, round, fixed, and dilated. The blood sweep is clean and a quick head-toe reveals no DCAP-BTLS. Patient's skin is flush, hot, and moist. Airway is suctioned with a rigid catheter. Vitals are as follows: BP 100/60, PR 120, RR 8, Dexi 92 mg/dL. 4-Lead is unremarkable. A medic starts a 20G IV in the patient's hand and naloxone is administered with no response. The patient is transferred to the stretcher and secured for transport. In the ambulance, the medic attempts to intubate but stops when the patient begins to gag. BLS airway measures are resumed. Transport is initiated code 3.
Typically…when doing scenarios, one doesn’t “forget to mention” as it directly impacts decisions. Might want to remember that.
Might I suggest attending a NAEMSE Instructor class?
 

DrParasite

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On arrival at hospital (when I saw the patient) the ER MD performed RSI and the patient was placed on a ventilator.
I have a question, one that I will punt to all you smarter people... Should we (EMS) have RSIed the patient in the field? That thought crossed my mind, esp with the low RR and aspiration issues, but I know there are also some people who are hesitant to RSI in the field... but if the ER is going to RSI in the ER, should we do it prehospitally?
 

VentMonkey

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I have a question, one that I will punt to all you smarter people... Should we (EMS) have RSIed the patient in the field? That thought crossed my mind, esp with the low RR and aspiration issues, but I know there are also some people who are hesitant to RSI in the field... but if the ER is going to RSI in the ER, should we do it prehospitally?
I would have a hard time explaining my way out of not RSI’ing this patient with the information provided.

However, I am no longer a ground provider and there are a few nuances to consider in the aeromedical vs ground environment. Anyhow, I digress.
 

Tigger

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This patient is not protecting their airway very well. In my experience attempts at intubating people like this without medication never go well and often results in more airway comprise. If you think this airway needs managing, I would be doing it through RSI and not other means.

Also, provided this patient is easily intubated and placed on the ventilator, the extra five minutes to the level 1 makes no difference to me so we’d go there. It’s not clear what the pathology is here, might as well try to avoid a transfer if it’s not a tox issue.
 
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OrthoHypo

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This patient is not protecting their airway very well. In my experience attempts at intubating people like this without medication never go well and often results in more airway comprise. If you think this airway needs managing, I would be doing it through RSI and not other means.

Also, provided this patient is easily intubated and placed on the ventilator, the extra five minutes to the level 1 makes no difference to me so we’d go there. It’s not clear what the pathology is here, might as well try to avoid a transfer if it’s not a tox issue.
I agree with your judgment, but that was not an option at the time. If I post more scenarios in the future, I'll make sure to better clarify how the system functions, and what its capabilities are. I also don't know how I missed patient demographics in the original post since I always include them in radio calls and run reports.
A few final notes:
- I saw this case a few years ago, while I was rotating in the trauma center for my EMT class. I wasn't present in the field, so I extrapolated what happened from my memory of the medics' report and the patient's condition on arrival. Some details are fuzzy.
- Limited drugs and protocols in this system
- Early wave COVID may have impacted clinical decision making
- Actual transport times may have been shorter
 

CCCSD

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I agree with your judgment, but that was not an option at the time. If I post more scenarios in the future, I'll make sure to better clarify how the system functions, and what its capabilities are. I also don't know how I missed patient demographics in the original post since I always include them in radio calls and run reports.
A few final notes:
- I saw this case a few years ago, while I was rotating in the trauma center for my EMT class. I wasn't present in the field, so I extrapolated what happened from my memory of the medics' report and the patient's condition on arrival. Some details are fuzzy.
- Limited drugs and protocols in this system
- Early wave COVID may have impacted clinical decision making
- Actual transport times may have been shorter
Herein lies the problem: this is all suspect as it’s a memory, not a case with notes and information, and the field history is made up.
 

Sandiistaken123

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Ambulance ALS 69 is dispatched code 3 to a train station in a major urban area for the unconscious person. On arrival, the patient is found prone on the platform. Crew repositions him for assessment. He winces in response to pain but is otherwise unresponsive. ABCs are as follows: Vomitus in his airway, respirations are slow and shallow, pulse is weak and rapid. No external trauma is noted.

Community ER is 5min away, the level 1 trauma center is 10min away.

I will continue to add to the scenario as people chime in. What are your immediate concerns? What will you assess? What treatments are you considering?
My immediate concern is shock due to the pain and vital signs. I would put him on oxygen at a flow of 5 lpm and suction the vomitus for five seconds at a time. This could also be an overdose situation so narcan might be needed.
 

VentMonkey

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This could also be an overdose situation so narcan might be needed.
Unfortunately, I still see way too many field providers giving Narcan blindly without forethought in patient presentation and assessment. It’s recent layman’s accessibility does not help, but I digress.

I would be hard pressed to give this patient Narcan based off of the OP’s information provided. The patient has already vomited and has already put themselves into aspiration pneumonia rabbit hole.

To me, Narcan can be deferred to the receiving hospital if it’s found to be necessary, as airway protection seems to have superseded that particular therapy.
 

Sandiistaken123

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Unfortunately, I still see way too many field providers giving Narcan blindly without forethought in patient presentation and assessment. It’s recent layman’s accessibility does not help, but I digress.

I would be hard pressed to give this patient Narcan based off of the OP’s information provided. The patient has already vomited and has already put themselves into aspiration pneumonia rabbit hole.

To me, Narcan can be deferred to the receiving hospital if it’s found to be necessary, as airway protection seems to have superseded that particular therapy.
So what you’re saying is that airway management is the main priority here?
What happens if you take narcan without needing it?
 

VentMonkey

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So what you’re saying is that airway management is the main priority here?
What happens if you take narcan without needing it?
Correct, my priority would be proper airway management whether BLS or ALS.

Like most medications, Narcan carries a multitude of side effects, most applicable to this patient—who was either semi, or completely unresponsive—is vomiting.

Also, may I ask why you are thinking shock?

I’m guessing from your age, you are still a student looking to become an EMS provider. If I am right, good luck, you came to the right place to learn.
 

Sandiistaken123

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Thank you for replying! I am a student, I am 15 years old at the moment but am raising money to afford my EMT money. As of now, I’m studying through professional books

I’m thinking shock because of the thready pulse and weak breathing, additionally the nausea could be a sign of vasodilation caused by an overdose of medicine
 
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