Slumpy

[MrBrown]

After a day of dragging people strapped to a gurney into your van with tinted windows and giving them drugs (what? ... you make it sound like something bad) you are sent to a guy passed out in his car on the side of the road.

When you arrive there are two cops and seven firefighters standing round doing nothing and the Engineer who is leaning on the truck looking at the chalkboard menu of the diner he has parked the outside of.

Single male patient in his fifties on the drivers side, slumped down over the seat and passenger seat.

- Unresponsive, GCS 3
- RR 24 PR 90 HR 130 BP 230/120 SpO2 96 BGL 90 (~4 mmol/l)
- Sinus rhythm on 3 leads
- Clear and equal lung sounds
- Constricted pupils
- Medic alert bracelet says diabetic

There are two bottles of medication in the centre console; one of Effexor and the other is Captopril.

So while the fireys sit round eyeing up the daily specials what are you gonna do?

 

[exodus]

He's depressed, and he has HTN.... Awesome! Diabetic, nah, BGL is fine. Unless of course our glucometer is bonked, which I doubt.

What are my skins?

 

[MonkeySquasher]

I take it vehicle isn't locked, and patient cannot be roused by verbal/pain.

Is the vehicle running? Any oders? No possible CO problem or toxic suicide attempt? (Effexor use can cause suicide attempts.) Smell of alcohol?

Check the pills in the bottles. It's not an overdose of either of them, as both would cause hypotension and he's hypertensive. See if he's taking both medications regularly. (Date filled compared to pills left) Have PD check the car (they have the right gloves) for needles/drugs.

Any other medications? Any ID? Note? Emergency Contact? Cell phone to get ahold of someone? Maybe run the license plate for home address?

Physically... Any trauma? Skin? Color? What's his temp like, any hyper/hypothermia? Any posturing? Lung sounds? Any signs of emesis/urination?

What's the weather like, vs his temp?

Once I have some more info I'll work on a plan. For now, we'll do O2 NC 2LPM and attempt getting him out of the car onto a backboard or topdeck -> cot -> ambulance.

 

[MrBrown]

Appears compliant with meds

No odours, knives, bombs, weapons, drugs, grenades or Osama Bin Laden in the car

The police are checking for reg owner details (and drinking thier latte)

Patient is transferred to the ambulance

 

[MonkeySquasher]

Appears compliant with meds

No odours, knives, bombs, weapons, drugs, grenades or Osama Bin Laden in the car

The police are checking for reg owner details (and drinking thier latte)

Patient is transferred to the ambulance

Okay, but that gives me none of the physical assessment questions I was looking for. lol

Once we're in the rig, make him naked, check his whole person again. Get an IV, large bore. Grab bloods. Check pupils, RR, HR and BP again, on top of all the physical stuff I requested before. Recheck the monitor on a 4-lead.

What's his breathing pattern?

 

[MrBrown]

No trauma
Normal skin and color
Temp 37 °C / 98.6°F
No posturing
Patient pee'd himself

Right pupil is constricted and the left has blown
PR 140 RR 26 BP 220/120

We only use 3 lead or 12 lead - what additional lead does a 4 lead show?

 

[Veneficus]

We only use 3 lead or 12 lead - what additional lead does a 4 lead show?

I'd just give lead 2.

Looks like he is suffering from effexor side effects which may have caused a hemorrhagic stroke.

 

[MrBrown]

When you strap him to a gurney and move him into your van with tinted windows to give him drugs (what, man you make it sound like a bad thing, the cops are here aren't they?) he starts to have a seizure and becomes incontinent.

5mg midaz IV settles that down

You now hear rales

 

[Smash]

Venlafexine (spelling?) is known in some cases to cause prolonged hypertension, and may also cause SIADH and resultant hyponatremia and encephalopathy. Atypical antipsychotics may also cause seizures. I'd also like to have a look at his QTc to know how ready I need to be for some torsades. I'm not aware of any significant interactions between ACE inhibitors and Efexor; I would presume he is on the ACE inhibitor for hypertension, which perhaps isn't working as well as it should be, all things considered.

Anyway, this chap appears to have, if you'll excuse my technical terminology, blown his FooFoo Valve. Depending on transport time and so forth, I would consider RSI, supportive care, driving of the big white truck to the big white building where the clever people with drills can fossick around in his head for a bit.

 

[MrBrown]

I would presume he is on the ACE inhibitor for hypertension, which perhaps isn't working as well as it should be, all things considered.

HX HTN RX ACEI

Anyway, this chap appears to have, if you'll excuse my technical terminology, blown his FooFoo Valve. Depending on transport time and so forth, I would consider RSI, supportive care, driving of the big white truck to the big white building where the clever people with drills can fossick around in his head for a bit.

What, Black and Decker aint in your scope of practice?

If you want to RSI that'd be my consideration I mean he's gonna get it at the hospital anyway (presumably) for a CAT scan and whatnot.

 

[MonkeySquasher]

No trauma
Normal skin and color
Temp 37 °C / 98.6°F
No posturing
Patient pee'd himself

Right pupil is constricted and the left has blown
PR 140 RR 26 BP 220/120

he starts to have a seizure and becomes incontinent.

You now hear rales

Brain hemorrhage, probably Pons bleed. Rales are probably secondary pulmonary HTN. RSI, drive fast but safe, check for organ donor card.

 

[Smash]

HX HTN RX ACEI



What, Black and Decker aint in your scope of practice?

If you want to RSI that'd be my consideration I mean he's gonna get it at the hospital anyway (presumably) for a CAT scan and whatnot.

Well, there's an EZ-IO floating around the rig somewhere, I could have a red hot go with that I reckon. He's already coning, so what harm can I do?!

So what was wrong with the chap? Did we do good?

 

[MrBrown]

Apparently his HTN caused a neuro bleed which resulted in seizures, pulmonary edema 2° to an infarct which was caused by some massive sympathetic response.

 

[reaper]

So what was on that menu board?

 

[MrBrown]

So what was on that menu board?

What would you like?

 

[reaper]

T-bone and mashed potatos!

 

[firetender]

Let me take a stab; at the risk of getting skewered!

So while the fireys sit round eyeing up the daily specials what are you gonna do?

A Dinosaur's approach:

With all the local inattention, get him away from prying eyes to save my butt because I'd start yelling and they'd do nothing but get in my way.

On site, I'd do no more than assure airway, assess, but in that include check for head/neck trauma before placing on a transferring device and get him in the rig.

Inside, start IV, draw bloods, start ambulance after BP found to be approximate same as first one taken.

THEN I'D FIGURE OUT HOW MUCH TIME BETWEEN THERE AND THE HOSPITAL (Oh, you know, one of those nagging little details that determine EVERYTHING that follows)

Once the pupil blows and he starts seizing, sure try whatever it was you did to stop the seizure, but that's en route and only to keep him from doing the tuna on you,

but at this point, hey, let's face it, why waste one second entering into a juggling contest of seeking deeper diagnosis/understanding (for what and for who's satisfaction?) or application of further meds, the longer I jerk around with the guy the worse his prognosis becomes.

A stroke is a stroke. How many have you reversed in the back of the rig and how much time do you want to spend on handling symptoms of a much deeper and more critical etiology?

 

[MrBrown]

Good point, I know we all advocate for deeper knowledge/assessment/treatment regimes by Paramedics but this guy is one of the people who needs a hospital pretty quick

 

[firetender]

For a while there, it looked like no one thought there was a hospital!

...and not once did anyone call in for orders; isn't that done anymore?

 

[MrBrown]

...and not once did anyone call in for orders; isn't that done anymore?

Hmm, orders for what?