Endometrial Hyperplasia

[vquintessence]

You are a dual Paramedic unit.
Approximately at 13:00 you're dispatched to intercept with a FD BLS Rescue already en route to local level 3 facility. Call comes in as syncope. En route the Rescue provides no updates, but asks you to continue.

U/A you find a 37 y/o female AOx3 speaking full sentences and semi-fowler. Woman presents very pale and notably lethargic; pt has to be continually prompted to answer questions and remain alert. Pt only offers a complaint of abd pain.

BLS relays pt was about to under go a biopsy in a physicians medical office for endometrial hyperplasia. They state the physician had ordered/given: diazepam 10 mg PO (this morning self administered by pt) and demerol 50 mg IM.

About twenty minutes after demerol, pt found by staff to be profoundly lethargic, at which point EMS was activated.

BLS relays pts only PMHx is "thickened uterus", takes no medicates, denies allergies. Their vitals prior your arrival: 120/62, 72 HR, 15 RR. The EMT teching denies any changes in status while in their care, and the driver offers a nearly inaudible apology for "wasting your time".

How would you proceed based on your initial findings, and the story relayed to you? Transport time is completely irrelevant...
[After a few treatments and options are followed, I'll go with the crews actual findings and field treatment.]

 

[Onceamedic]

IV, O2, monitor and narcan. The endometrial hyperplasia is a bit of a red herring, as the pts vitals do not support hypovolemic shock.

 

[Griff]

I would need detailed assessment findings and an ECG to make a more definitive treatment decision. Regardless, I agree with the above poster; IVO2Monitor (one word ) and transport. I wouldn't give narcan in route unless noted respiratory depression was observed (which it doesn't seem to be), and that is the protocol here (it might be different somewhere else).

 

[RyanMidd]

I would also give the "driver" a smack, because no altered LOC is a "waste of time".

But second the previous Tx - Narcan, O2, position of comfort, and keep an eye on BP change.

 

[JPINFV]

If V/S are good and the patient is A/Ox3 (Guess here, this is a location that favors A/Ox3 over A/Ox4), why Narcan?

I would also give the "driver" a smack, because no altered LOC is a "waste of time".

Sorry... can't find a Gibbs head slap LOLcat picture.

/I can haz Caterday?

 

[RyanMidd]

If V/S are good and the patient is A/Ox3 (Guess here, this is a location that favors A/Ox3 over A/Ox4), why Narcan?

Because you asked her if she had taken any of her own medications, and she said no. Obviously she's a liar and a thief!


But really, though? In a case of altered LOC with recent physician interaction, perhaps the Dr. made a "whoopsie", and the Narcan will cancel out that mistake.

 

[mycrofft]

Pallor, lowered LOC but not hallucinating, belly pain and normal VS.

It's dark in there, get her to a hospital.

No pupillary info, no capillary refill, no belly exam or ausc, no chest ausc. No characterization of pulses (bounding, regular, thready, irregular,) nor resps. Not to fault you, probably fine and discounted mentally, but I'm not there. Back or shoulder pain? Pedal pulses compared and characterized? Gums or mucosae pale or red? Temperature?

C/O plus signs suggests something is interfering with brain perfusion, maybe all over.

If the pt has endometriosis then her menstrual hx would be of interest to the ER staff.

OK...GIVEN transport time no matter, O2 can't hurt,monitor is good idea along with frequent BP's, Naloxone not indicated strictly by this hx and could cause repercussions with demerol, IV not indicated since VS ok and no parenteral route tx indicated so far. If transport time is a factor, get a line started with large bore needle. Fingerstick glucometry not a bad idea if obtunded but VS are good. Ask if pt has been sleeping ok.

 

[Griff]

Because you asked her if she had taken any of her own medications, and she said no. Obviously she's a liar and a thief!


But really, though? In a case of altered LOC with recent physician interaction, perhaps the Dr. made a "whoopsie", and the Narcan will cancel out that mistake.

Narcan is used in my region solely to correct respiratory depression secondary to opiate overdose. Perhaps your protocols are different, but I agree with JPINFV that naloxone isn't indicated in this case based on the available information. I would guess that benzodiazapine/opiate administration has caused potentiation of limbic system inhibition, resulting in the AMS without the pronounced respiratory depression noted with opiate overdose. I would certainly monitor vitals and keep the narcan handy, but I would only give it if protocols indicated (which mine do not). Just my $0.02. ^_^

 

[mycrofft]

Second Griff. Better said than mine.

Unilateral signs? Speech slurred, or slow but distinct?

 

[JPINFV]

Because you asked her if she had taken any of her own medications, and she said no. Obviously she's a liar and a thief!


But really, though? In a case of altered LOC with recent physician interaction, perhaps the Dr. made a "whoopsie", and the Narcan will cancel out that mistake.

That's my question, though. Given that some systems use A/Ox3 as being fully alert and oriented, it doesn't sound like she's altered any more based on the scenario as given. Additionally, her respiratory system isn't being depressed. Altogether, this makes me question whether administering Narcan would produce any positive benefits short of being one step closer to being able to bill ALS2.

Similarly, let's assume for a second that she's A/Ox1 (hence clearly altered) with the same vital signs. Still, what benefit would be had by giving Narcan? Sure, she's more alert and oriented, but you haven't changed her ability to load oxygen and unload carbon dioxide. The only thing you've done would be to bring her more into the world of the living while increasing her pain level by decreasing the effectiveness of her pain control.

 

[Shishkabob]

Need more info. BGL? O2 sat? Etco2?



It's not only the rr we're looking for, but also how effectual they are.

 

[vquintessence]

Sorry for delay

AOx3 is the same as systems using AOx4 (sorry for not clarifying).

Neurological: Speaking full and coherent sentences; -dysphasia, -dysarthria. There are no auditory or visual hallucinations. Pupils PERRL bilat; tracking appropriately on command and conjugate. As far as sensory and motor there are no deficits, there's nothing atypical to note. Pt is notably lethargic.

Rapid Assessment: No trauma whatsoever in present or recent past. All extremities stable however cap refill is delayed; nailbeds blanched. Skin condition is pale/cool/dry. Abd is not distended and palpation reveals guarding all quadrants; pain gets no worse nor better during palpation for all quadrants. (Sorry Mycrofft no gastric sounds checked).

Pulmonary: No respiratory distress, lungs CTA bilat. RR is appropriate and has adequate tidal volume. spO2 99% on O2 at 2 l/min via NC. There is no Etco2 available for this system.

Vitals: RBG is 104 mg/dL. As yall suggested, and based on the young pt presenting like crap, you obtain your own vitals and it's drastically different from what was reported.

BP is 76/P which is obtained c difficulty due to weak radial pulse; it is very difficult to auscultate in the moving ambulance. Pulse is staying in high 40's, confirmed by palpation and EKG. a 12 lead reveals Sinus Bradycardia. There is no aberrancy or ectopy to the rhythm. No AV blocks. No axis deviation, -BBB.

Course of action?

P.S. Transport time being irrelevant was only meant to prevent any cop outs for assessing/treating.

 

[Griff]

That's my question, though. Given that some systems use A/Ox3 as being fully alert and oriented, it doesn't sound like she's altered any more based on the scenario as given. Additionally, her respiratory system isn't being depressed. Altogether, this makes me question whether administering Narcan would produce any positive benefits short of being one step closer to being able to bill ALS2.

Similarly, let's assume for a second that she's A/Ox1 (hence clearly altered) with the same vital signs. Still, what benefit would be had by giving Narcan? Sure, she's more alert and oriented, but you haven't changed her ability to load oxygen and unload carbon dioxide. The only thing you've done would be to bring her more into the world of the living while increasing her pain level by decreasing the effectiveness of her pain control.

This is exactly my point; the (possible) reversal of opiate-induced AMS (assuming the Demerol alone is causing it) seems like a fairly weak benefit compared to the potential cost of reducing analgesia. Her vitals are WNL with opiates on board and reduced analgesia could compromise that stability (i.e. elevated BP, RR, HR secondary to poor pain control). Clinically, we don't stand to gain a whole lot from naloxone administration (maybe a better history from the pt); the cost versus benefit analysis (let alone protocol) simply does not indicate Narcan, in my opinion.

<RANT>
To get off-topic for just a second (sorry, I realize that Narcan has been beaten to death around here ), I see a lot of medic students (I am a student myself) wanting to push Narcan whenever possible. The most important point my instructors (who, unlike me, are quite experienced paramedics) have instilled in me is this: just because we can doesn't mean we should. Great clinicians operate with the "big picture" in mind and weigh the pros and cons of each intervention.
</RANT>

 

[lightsandsirens5]

Narcan is used in my region solely to correct respiratory depression secondary to opiate overdose. Perhaps your protocols are different, but I agree with JPINFV that naloxone isn't indicated in this case based on the available information. I would guess that benzodiazapine/opiate administration has caused potentiation of limbic system inhibition, resulting in the AMS without the pronounced respiratory depression noted with opiate overdose. I would certainly monitor vitals and keep the narcan handy, but I would only give it if protocols indicated (which mine do not). Just my $0.02. ^_^

Same here. Although I have wanted to give it to some CAO pts just to ruin their impending high or whatever!

 

[Griff]

AOx3 is the same as systems using AOx4 (sorry for not clarifying).

Neurological: Speaking full and coherent sentences; -dysphasia, -dysarthria. There are no auditory or visual hallucinations. Pupils PERRL bilat; tracking appropriately on command and conjugate. As far as sensory and motor there are no deficits, there's nothing atypical to note. Pt is notably lethargic.

Rapid Assessment: No trauma whatsoever in present or recent past. All extremities stable however cap refill is delayed; nailbeds blanched. Skin condition is pale/cool/dry. Abd is not distended and palpation reveals guarding all quadrants; pain gets no worse nor better during palpation for all quadrants. (Sorry Mycrofft no gastric sounds checked).

Pulmonary: No respiratory distress, lungs CTA bilat. RR is appropriate and has adequate tidal volume. spO2 99% on O2 at 2 l/min via NC. There is no Etco2 available for this system.

Vitals: RBG is 104 mg/dL. As yall suggested, and based on the young pt presenting like crap, you obtain your own vitals and it's drastically different from what was reported.

BP is 76/P which is obtained c difficulty due to weak radial pulse; it is very difficult to auscultate in the moving ambulance. Pulse is staying in high 40's, confirmed by palpation and EKG. a 12 lead reveals Sinus Bradycardia. There is no aberrancy or ectopy to the rhythm. No AV blocks. No axis deviation, -BBB.

Course of action?

P.S. Transport time being irrelevant was only meant to prevent any cop outs for assessing/treating.

LOL now naloxone (and possibly flumazenil) is indicated. Did we get a med hx, especially in regards to how long pt has been prescribed diazepam? Any needle tracks? What is her temperature?
I would consider giving this pt atropine .5mg every five minutes up to .04mg/kg or until hemodynamically stable as per protocol.

 

[mycrofft]

Support vitals and boogey.

Blood's in the pelvis or the abd. Thinking a bleed disguised by uteral c/o.
Any women getting into this discussion?

PS: I'm thinking of the change in vitals as diagnostic, not a sign of medical incompetence.

 

[Shishkabob]

Screw atropine, she already has analgesics on board, go right to the pacing

 

[Shishkabob]

My edit button disapeared??


She's obviously near decompensated shock if not in it, so 2 large bore ivs with fluid running in to get bp around 90

 

[Griff]

My edit button disapeared??


She's obviously near decompensated shock if not in it, so 2 large bore ivs with fluid running in to get bp around 90

Good point. ^_^

 

[VentMedic]

Because you asked her if she had taken any of her own medications, and she said no. Obviously she's a liar and a thief!

Why is the patient a liar? These meds were orderd by a physician at a facility.

But really, though? In a case of altered LOC with recent physician interaction, perhaps the Dr. made a "whoopsie", and the Narcan will cancel out that mistake.

Why would you say it is a "whoopsie" or an error by the physician? The meds and dosages ordered are not abnormal. Some patients just react differently to other medications. As well, if you only focus on one area you could miss something else in the assessment.