daedalus
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Endometrial Hyperplasia
- Thread starter vquintessence
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vquintessence
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The diazepam was ordered by the physician to be taken starting this morning and to continue after biopsy. Temperature unavailable, only have skin condition to go by. Socially, this pt is ostensibly an upstanding citizen. Appears well nourished, well kept and is very articulate. No physical indicators of drug abuse are observed.
As Mycrofft mentioned, the menstrual cycle is pertinent to the procedure that was going to be performed. For simplicity the pt has had troubles with her cycle for years and years.
So far yall have given three possible working dx's and treatments: OD, bradycardia secondary to ?, and internal hemorrhaging being masked by circumstances. I apologize for offering the information in pieces; I just didn't want to inadvertently point the discussion towards to final diagnosis or crews actual treatment.
Just picking your brain Griff, how much Narcan would you administer until you get the pt to your comfort level? Flumazenil for diazepam 10 mg PO?
Linuss, how aggressively will you treat the hypotension/bradycardia? I got confused by the sarcastic pacing then fluid loading. ^_^
As Mycrofft mentioned, the menstrual cycle is pertinent to the procedure that was going to be performed. For simplicity the pt has had troubles with her cycle for years and years.
So far yall have given three possible working dx's and treatments: OD, bradycardia secondary to ?, and internal hemorrhaging being masked by circumstances. I apologize for offering the information in pieces; I just didn't want to inadvertently point the discussion towards to final diagnosis or crews actual treatment.
Just picking your brain Griff, how much Narcan would you administer until you get the pt to your comfort level? Flumazenil for diazepam 10 mg PO?
Linuss, how aggressively will you treat the hypotension/bradycardia? I got confused by the sarcastic pacing then fluid loading. ^_^
Onceamedic
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I didn't give details for my reasoning because I wanted everybody to have a chance to rant... I mean educate ^_^
Endometrial hyperplasia is most often caused by unopposed estrogen. Typical patients are usually obese (fat cells produce estrogen) and/or perimenopausal - patient stated age of 37. While distressing, the condition is no more painful than a very heavy period. The bleeding is caused by constant shedding of an endometrial lining that does not have a chance to breakdown. It is very rarely a sign of serious metastasis, thus hypovolemia due to uncontrolled bleeding is not likely.
That left me with one option - which was an OD.
Endometrial hyperplasia is most often caused by unopposed estrogen. Typical patients are usually obese (fat cells produce estrogen) and/or perimenopausal - patient stated age of 37. While distressing, the condition is no more painful than a very heavy period. The bleeding is caused by constant shedding of an endometrial lining that does not have a chance to breakdown. It is very rarely a sign of serious metastasis, thus hypovolemia due to uncontrolled bleeding is not likely.
That left me with one option - which was an OD.
Griff
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To be on the safe side (and the pt isn't going to enjoy this, but it's better than being dead I suppose)-
-Two LB IVs and start fluid replacement.
-Atropine .5mg IV titrated to HR of >60/min.
-Naloxone 2mg and monitor for effect, then another 2mg and monitor for effect. I'm looking for a change in mental status (is it caused by the demerol or not) and possibly a change in HR. I'm iffy on this one but going on the safe side because it's relatively safe and quick to do.
-Start pacing if HR doesn't improve with above Tx.
-Call for flumazenil orders if BP doesn't improve with fluids/atropine/opiate reversal/pacing; I'm thinking possible drug mix-up and the wrong benzo was given (unlikely but possible). Unlike the narcan, I'm worried about acute withdrawal effects with this drug and it is a last-resort option as far as I'm concerned.
-Diesel fuel
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mycrofft
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Did she die yet?
I know.....
"Paraneoplastric syndrome", House MD"s answer to "subspace anomalies".
I know.....
"Paraneoplastric syndrome", House MD"s answer to "subspace anomalies".
Aidey
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2mg Narcan at once? Wouldn't it be more prudent to maybe give .4mg at a time and titrate it to affect? If this is opiate induced giving 2mg of narcan at once has a good chance of making the pt sick. If it isn't opiate reduced you've just completely knocked out the pain management. Titrating it to affect will allow you to improve her vitals without making her miserable.
I should mention my MD sponsor is vehemently opposed to giving multiple mgs of narcan at once unless the pt is unconscious or not breathing. If you bring in a patient and you didn't try .4 or .8 before giving 2mg or more you better have a damn good explanation for him.
I would probably do .8mg of narcan first, then a fluid bolus, then atropine....maybe. Hypotension is only one symptom of symptomatic bradycardia. Chest pain, SOB and decreased LOC are all symptoms also and if she doesn't have any of them I would be reluctant to treat with atropine. Yes the pt is lethargic, but that is very likely from the medications and not from the low BP, especially since she is lacking any of the other symptoms of symptomatic bradycardia.
Also, has anyone found out if the Abd pain is chronic or new?
I should mention my MD sponsor is vehemently opposed to giving multiple mgs of narcan at once unless the pt is unconscious or not breathing. If you bring in a patient and you didn't try .4 or .8 before giving 2mg or more you better have a damn good explanation for him.
I would probably do .8mg of narcan first, then a fluid bolus, then atropine....maybe. Hypotension is only one symptom of symptomatic bradycardia. Chest pain, SOB and decreased LOC are all symptoms also and if she doesn't have any of them I would be reluctant to treat with atropine. Yes the pt is lethargic, but that is very likely from the medications and not from the low BP, especially since she is lacking any of the other symptoms of symptomatic bradycardia.
Also, has anyone found out if the Abd pain is chronic or new?
Griff
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Meh.
That dosage is verbatim from my protocols (your protocols may be different). I am a student, which means I only have protocols to rest on (not experienced enough to be deviating without fully understanding the clinical implications of that deviation); I'm sure that opinions abound as to the pros and cons of narcan administration, but this is what my protocols advise me to do. In the same token, my protocols indicate atropine for hemodynamically significant bradycardia. Specifically, "hemodynamically significant" is not an "all or none" phenomenon.
TL;DR - Your service/med director/state may do things differently from mine.
http://www.adph.org/ems/assets/5thEdParamedicProtocols110209.pdf
JPINFV
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First sentence of the protocol book. It's a guide, not a cookbook. I know your a student, but the sooner you start looking at it as a guide and not as a cookbook, the better. To be honest, if your best reasoning for an intervention is "because of protocol," then you should feel just a tad dirty afterward. Judgment? Sure, even if it's a little off. Doing something because of a protocol? This should evoke an icky feeling.
Now, to be clear, I'm not advocating a complete disregard for the protocol book. In the vast majority of patients, the treatment plan you develop for your patient should essentially mirror what the protocol book says. This is because the protocol book is the ideal treatment for the ideal patient. Most patients are ideal and there are plenty of patients that don't read the textbook. It's a psychological difference between you administering a treatment because you know it's the right treatment on it's own and administering the treatment because of a few characters in a printout, even if the treatments are the exact same.
Griff
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I'm not disagreeing with you; I use protocols as a starting point because that is what they are there for.
Aidey
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No, it's not an all or none, but when you only have one symptom of hemodynamicaly unstable bradycardia, and it may be caused by other things going on (as in this case, both the valium and demerol) you don't want to be too aggressive and over treat the pt.
"Indicated" doesn't necessarily mean "mandatory to give".
For example, say this was your patient and you only have a 5 minute transport. You don't want to push both narcan and atropine at once because then you will never know which drug it was that helped. So you decide to push narcan first.
So you draw up the narcan, give it, call the hospital while waiting for it to have an affect, assess the affect, and then take vitals and by that time you are likely at the hospital. Giving atropine somewhere in there wouldn't give the narcan time to work and for you to properly assess its effects before the atropine took affect and you wouldn't have time to properly assess the atropine's effects either. So yeah, atropine is "indicated" but that doesn't mean that you have to give it no matter what.
"Indicated" doesn't necessarily mean "mandatory to give".
For example, say this was your patient and you only have a 5 minute transport. You don't want to push both narcan and atropine at once because then you will never know which drug it was that helped. So you decide to push narcan first.
So you draw up the narcan, give it, call the hospital while waiting for it to have an affect, assess the affect, and then take vitals and by that time you are likely at the hospital. Giving atropine somewhere in there wouldn't give the narcan time to work and for you to properly assess its effects before the atropine took affect and you wouldn't have time to properly assess the atropine's effects either. So yeah, atropine is "indicated" but that doesn't mean that you have to give it no matter what.
Aidey
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On the same note of what JPINFV is saying using the protocols as a starting point doesn't necessarily mean that you have to start at the specified dose every single time*
Aside from narcan, another medication that may be better to give under the protocol's starting dose is dextrose. Our hypothetical protocol states "For CBG lower than 60, or in a symptomatic patient administer 25mls of 50% dextrose IVP".
Now say you have someone who is a known diabetic. They are conscious, but altered with a CBG of 55 and you don't feel they can swallow safely. Giving them a whole amp may shoot their sugar up too much, so instead you give 1/2 an amp and see what affect that has first.
Sure it's not exactly what the protocol says, but it may be better for your patient and starting with a lower dose of dextrose is not going to harm the patient.
Disclaimer: Only with some specific medications is it safe to give a lower dose and depending on how your medical director feels.
Aside from narcan, another medication that may be better to give under the protocol's starting dose is dextrose. Our hypothetical protocol states "For CBG lower than 60, or in a symptomatic patient administer 25mls of 50% dextrose IVP".
Now say you have someone who is a known diabetic. They are conscious, but altered with a CBG of 55 and you don't feel they can swallow safely. Giving them a whole amp may shoot their sugar up too much, so instead you give 1/2 an amp and see what affect that has first.
Sure it's not exactly what the protocol says, but it may be better for your patient and starting with a lower dose of dextrose is not going to harm the patient.
Disclaimer: Only with some specific medications is it safe to give a lower dose and depending on how your medical director feels.
mycrofft
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And how is the pt this morning?
5=4...........
5=4...........
Griff
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vquintessence
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Whoops
Sorry to leave you guys hanging; I got distracted by a nasty shift and then just forgot. :sad:
I got the simplified version from the facility, but ultimately the labwork (specifically TSH) showed that the pt had quite the untreated hypothyroid disorder. This disorder, in conjunction with pts lifestyle, and recieving a hefty dose of narcs and a benzo that morning seem to be the culprit.
Sorry, nothing amazing or spectacular. No House episode to rise from this. I just found it intriguing because when this case was brought to rounds, there was nearly a 50:50 split in treatments and possiblities brought up by coworkers.
The crew treating the pt initially elected to start with a 500cc bolus of 0.9% NS and trendelenberg position. The perfusion showed little improvement and bradycardia persisted. Atropine 0.5mg IVP was administered once, which brought the pt to NSR in 70's and normotensive. Afterwards, the transport was largely uneventful.
In the hospital, the ED essentially monitored the pt in conjunction with labs and a cardiac work up. Levothyroxine was ultimately started and pt was released several days in.
Sorry to leave you guys hanging; I got distracted by a nasty shift and then just forgot. :sad:
I got the simplified version from the facility, but ultimately the labwork (specifically TSH) showed that the pt had quite the untreated hypothyroid disorder. This disorder, in conjunction with pts lifestyle, and recieving a hefty dose of narcs and a benzo that morning seem to be the culprit.
Sorry, nothing amazing or spectacular. No House episode to rise from this. I just found it intriguing because when this case was brought to rounds, there was nearly a 50:50 split in treatments and possiblities brought up by coworkers.
The crew treating the pt initially elected to start with a 500cc bolus of 0.9% NS and trendelenberg position. The perfusion showed little improvement and bradycardia persisted. Atropine 0.5mg IVP was administered once, which brought the pt to NSR in 70's and normotensive. Afterwards, the transport was largely uneventful.
In the hospital, the ED essentially monitored the pt in conjunction with labs and a cardiac work up. Levothyroxine was ultimately started and pt was released several days in.
mycrofft
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Good one!
Thyroid is often overlooked but it can cause many types of apparent syndromes and stray symptoms we rationalizing beings string together. In fact, many people have been put on Xanax who would have profited from a trial of propylthyrouracil (PTU)...which is 'way past tech stuff.
A thyroid thread would be good as pt hx and meds would be good info to bring in with him/her.
I would have had them pumping her with dye and preparing an OR in case.
Thyroid is often overlooked but it can cause many types of apparent syndromes and stray symptoms we rationalizing beings string together. In fact, many people have been put on Xanax who would have profited from a trial of propylthyrouracil (PTU)...which is 'way past tech stuff.
A thyroid thread would be good as pt hx and meds would be good info to bring in with him/her.
I would have had them pumping her with dye and preparing an OR in case.