Guess what's wrong with this patient

[ffemt8978]

Just got back from an interesting call.

We were paged to a 35yo M C/C Unresponsive with difficulty breathing. Upon arrival, we find the pt. supine, unresponsive to painful stimulii, mumbling incoherently, with the following vitals:

HR 137 (on ECG), RR 32 & shallow, SPO2 92% on RA, Temp 98.0F, Lungs clear & equal bilat, bowel sounds present, pupils fixed & constricted at 2mm. No sig. HX other than syncopable episode 1 week prior, NKDA, NKM. Cap refill was less than 2 seconds.

We place him on 15lpm O2 via NRB, 3-lead ECG, and load him in the ambulance for an ALS intercept. In route, IV established of NS TKO. Just as we were preparing to do a BGM, his SPO2 drops to 74% and he begins to posture in both hands. We begin to bag him at a rate of 24 bpm, and insert an OPA, and are able to bring his sats back up to 92-100%.

I'm intentionally leaving out some of the information that we received about his HX, but I was curious as to how everyone would diagnose/treat this patient.

 

[rescuecpt]

Sounds like the narc OD I had a few weeks ago, except it took narcan and an ET tube to get his sats back up and there was no posturing. Lemme think on this...

 

[rescuejew]

Any new meds? That would be helpful...had a simliar patient with a methotrexate OD that causes pneumonitis. Wouldve done a CBG and checked a 12-lead to r/o as much as possible. With a RR of 32, I would not suspect that s/he was narcotized. Maybe a TIA or an atypical sz?

 

[usafmedic45]

Blood glucose level determination; IV or IM Narcan, 0.4 mg, repeat once if no effect to rule out a narcotics OD. I'd also probably intubate him if he did not respond to the Narcan, which I suspect he won't. This doesn't sound like a opiate toxicity to me. Something in this case is screaming brain bleed for some reason, but I'm not sure why it seems particularly. That or some form of toxidrome.....

 

[ffemt8978]

No know meds of any kind
































except the street variety.

Pt. has extensive HX of drug use, including cocaine, meth, marijuana, ETOH, and just about any thing else he could get his hands on. Exam showed no recent injection sites in the upper extremities or torso, and no powder residue in his nasal cavity.

.2mg of Narcan got him back enough to tell us he took 13-15 pain pills of unknown type. I didn't think I'd be able to fool anyone on this.

 

[rescuecpt]

My guy had no track marks anywhere and only weed was found in his apartment. When we got to the ER we found out he had been discharged from a hospital about 50 miles away earlier that week... with pain meds.

 

[TTLWHKR]

Originally posted by ffemt8978@May 22 2005, 07:51 PM
I didn't think I'd be able to fool anyone on this.

I had a patient last week w/ the same symptoms & vitals, only he was totally unresponsive, w/ some movement of the left arm. hx insulin dep/dia. Found in his barn, sitting at his desk, pen still in hand. Unkn how long he sat there, no trauma, hx of recreational drug use. Pupils were pinpoint. Sinus rythmn w/ frequent PAC. skin was pale, cool, very low SpO2 86 RA, snoring resps, teeth clenched, posturing; got a NPA in the right nare.. got out my box of 1953 war surplus tongue blades, wrapped up a big, fat bite stick and got in between his teeth, suctioned out a lot of white frothy phlegm. Snoring resps stopped, resps were good, and strong w/ some wheezing in the bases; bagged him a few times, got his sat up to 99, he was breathing fine on his own, put on a NRB.. checked glucose, 145. That wasn't the problem. Pushed the narc, that wasn't the problem...

He coded three hours later.

Massive Hemorrhagic CVA.

 

[Jon]

I was going to say - blood glucose, narcan. If no effect, then consider anurysm or CVA.

Jon