Foaming At The Mouth

Tigger

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I've temporarily removed a thread that I recently created that would totally give this away, so if you already read that maybe don't spoil this immediately.

Your ALS ambulance and two person BLS fire unit are dispatched on a 31D2 Subject Unconscious--Severe Respiratory Distress, patient is a 16 year old female. You are responding to a residence that is about 15 minutes away, and while enroute dispatch advises that the patient is "foaming at the mouth." You and fire arrive on scene at the same time, where you are met by the father who beckons you into a holiday rental home that is well kept and rather pricey looking. He brings you into the ground level bedroom where you find your patient supine in bed where other, borderline hysterical family members are trying to wake her up.

Your initial assessment reveals the following: Pt is breathing at approximately 30 times per minute with normal depth and occasional snoring respirations. Heart rate of 130.

Mental Status: Pt responsive to painful stimuli only, which causes her to open her eyes, no verbal response. Skin: Well-perfused, hot, and dry. HEENT: Significant amount of saliva is present in the oropharynx, pt appears "almost trismused" (2 cm gap between teeth, jaw is fixed). Pupils open during painful stimuli to reveal that they are somewhat dilated, equal, and reactive. Pt has an obvious leftward gaze with occasional nystagmic movements through all fields. Chest: Equal rise and fall bilaterally with clear lung sounds throughout. Abdomen: Soft, palpation does not elicit pain responsive. CTLS: Unremarkable. Pelvis: No incontinence or other abnormalities noted. Extremities: Decorticate posturing noted with both feet and wrists. No signs of trauma noted anywhere on patient.

Vitals: BP: 110/70, HR: 130 Sinus Tach, RR: 30, SpO2: 94% RA, EtCO2: 25, BGL: 81.

Family states patient does not take any medications aside from Emergen-C. Patient has no diagnosed history, though family stated that patient has had frequent nosebleeds over the last few weeks. No drug or food allergies. They stated that patient flew in from Arkansas yesterday, which is a 6000 foot change in elevation and twoish hour flight. Once she arrived pt went sledding but did not appear to suffer any trauma during that. No one in the house takes prescription medications. Patient went to bed at nine last night, and mom came in at 730 this morning to wake her up, pt smiled then went back to sleep. At nine they were unable to wake her and called 911.

So what are you going to do? What are your differentials? There is a six bed critical access ED 15 minutes away and a Level II, pediatric accepting facility 1 hour by ground. Flight is not available due to low cloud cover and occasional snow showers.
 

Gurby

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Slap on a NRB, extricate, suction, 12 lead, call med control.

See what med con says, but probably running in saline (possibly chilled), ice packs under arm pits and groin. We don't have RSI but this seems like a good candidate.
 
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MS Medic

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I assume where this is going would be HACE. (I live in an area that is slightly below sea level, so I had to look this up to confirm my memory wasn't faulty.)

Treatment without specialization is to remove the pt from altitude. Since the local hospital is a level II, I'll assume the specialization isn't available there. That means load her up and roll. Since it isn't mentioned, can I assume that peds facility has said decrease in elevation?
 
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Tigger

Tigger

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I assume where this is going would be HACE. (I live in an area that is slightly below sea level, so I had to look this up to confirm my memory wasn't faulty.)
Treatment without specialization is to remove the pt from altitude. Since the local hospital is a level II, I'll assume the specialization isn't available there. That means load her up and roll. Since it isn't mentioned, can I assume that peds facility has said decrease in elevation?
You are at 7500 feet and the peds facility is at 6000. That hospital also has a hyperbaric chamber incidentally.
 

Summit

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Sxn, 4l nc, npa, 2 ivs
Left lateral recumbent (but first lift knees to see of head lifts)
Focused assessment head for evidence of trauma
Focused assessment nose arms for evidence of drug use.

How long has this been going on?
Temperature? Ekg?

Consider rsi but not sure we need this right now.

Ddx: sx, drugs, closed head injury, meningitis

I do not suspect altitude related illness.

Tp to peds facility
 

MS Medic

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Without any indications causing me to suspect trauma based on family history of events and a lack of evidence of toxidromes, coupled with the mentioned rapid rise in elevation, I'm going to suspect HACE until it is ruled out by the ED. Going to administer Narcan simply to rule out that possible cause of AMS but transport to the Peds center, providing supportive care.

But as I stated earlier, I live where I have absolutely no experience with altitude illnesses so I accept that I might be way off base.
 

DesertMedic66

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Without any indications causing me to suspect trauma based on family history of events and a lack of evidence of toxidromes, coupled with the mentioned rapid rise in elevation, I'm going to suspect HACE until it is ruled out by the ED. Going to administer Narcan simply to rule out that possible cause of AMS but transport to the Peds center, providing supportive care.

But as I stated earlier, I live where I have absolutely no experience with altitude illnesses so I accept that I might be way off base.
Are people still giving Narcan to patients just to rule something out? Pupils are not pinpoint, respiratory drive clearly has not been depressed, and really nothing about this patient is making me think a narcotic overdose unless I am missing something...
 

NomadicMedic

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I saw the original post, so I won't comment... But this is not what you think it is ... And there's a couple of important questions you'll be asking as soon as Tigger spills the beans on this.
 

MS Medic

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Are people still giving Narcan to patients just to rule something out?

Not as a matter of rote form, but there is an hour long Tx that will consist primarily of supportive care and since there isn't any harm in the administration or any way to completely confirm the pt isn't on an opioid, I would in this case.
 
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Tigger

Tigger

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long has this been going on?
Temperature? Ekg?
Sinus tach, no 12 lead. No thermometer, patient felt hot in bed. Enroute skin felt pretty normal.

Patient went to bed normally last night, awoke briefly at 7 (smiled at mom who left her to keep sleeping). At nine patient found unresponsive.
 

MS Medic

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I saw the original post, so I won't comment... But this is not what you think it is ... And there's a couple of important questions you'll be asking as soon as Tigger spills the beans on this.

Then I reserve the right to be wrong.
 

DesertMedic66

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Not as a matter of rote form, but there is an hour long Tx that will consist primarily of supportive care and since there isn't any harm in the administration or any way to completely confirm the pt isn't on an opioid, I would in this case.
But there is no indication for Narcan in this patient. How do we know the patient didn't overdose on narcotics? Because the patient is not presenting at all of an OD.
 

MS Medic

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If you wouldn't, that's fine. I agree that it probably won't make a difference and I don't want to derail this thread.
 

Summit

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What does the capno look like?

So does pt tolerate npa? Can we Opa? If extended then et and nasal intubation if needed.

I reserve the right to add sepsis to ddx to explain tachypnea and type 2dcs too but only because tigger mentioned hyperbaric chamber. Have extreme trouble believing that is the case since she was asymptotic on the flight.

Hace is extraordinarily unlikely less than 24 hours in and below 14000
 
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Tigger

Tigger

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What does the capno look like?

So does pt tolerate now? Can we Opa? If extended then et and nasal intubation if needed.

I reserve the right to add sepsis to ddx to explain tachypnea and type 2dcs too but only because tigger mentioned hyperbaric chamber. Have extreme trouble believing that is the case since she was asymptotic on the flight.

Hace is extraordinarily unlikely less than 24 hours in and below 14000
There is no way to open her mouth open enough to get an OPA in. There is obvious an pain response to NPA insertion but you are able to pass it which lessens but does eliminate snoring respirations. Capno waveform shape is unremarkable at 25.
 

MS Medic

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Since this pt has a RA SPO2 of 94%, I would consider her self maintaining an airway. I'd probably put her in fowlers with a canula.
 

redundantbassist

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Any family history of seizure disorders or diabetes? Last oral intake? Also, any possible way to suction and visualize the mouth?
 

Summit

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Tetnus shot? Kernigs and bridninskis signs?
 

MS Medic

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Do have a question. What is CLTS? That's a new anacronym to me.
 
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Tigger

Tigger

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Any family history of seizure disorders or diabetes? Last oral intake? Also, any possible way to suction and visualize the mouth?
No to all. Ate dinner last night with family.
 
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