Straightforward...or is it?

[Fox800]

You are dispatched to a sick patient. Dispatch information is that your patient is a 22 year old patient who "seems sick". You are working on an ALS ambulance, you and your partner are both paramedics of equal clinical authority.

On scene, the patient's mother and father guide you in to a well-kept house. They called you because the pt. seems very lethargic and is slow to respond. They tell you that the patient has chronic back pain and was having trouble sleeping last night so she took some pain medications to try to go to sleep. You find the patient sitting in a kitchen chair, she looks like she is asleep. Her head is down with her chin to her chest and you notice there is a reddish syrupy liquid spilled on her face and down the front of her shirt. The bottle on the table next to you is Tussionex, and by your powers of deduction you establish that that's what is also spilled on the patient. Here's your initial information:

28 year old female
PMH: Chronic back pain, depression. No diabetes, no seizure history, no cardiac or respiratory history.
Meds: Parents aren't sure what she takes, but they bring you what they can find...Norco, Tussionex, Prozac...and some OTC supplements and stuff, not important
NKDA per family

BP: 74/40 manual
HR: 140
RR: 40-50, pt. does not slow her breathing in response to coaching
SPO2: 85% on 15lpm NRB
ETCO2: Varying between 55-65
Lung Sounds: "Junky"
BGL: Normal, lets say 100
Temp: Normal, let's say 98.5.
Pupils: Constricted, 1-2mm and reactive
Pain scale: Unable to obtain due to mental status
ECG: Sinus tachycardia, 12-lead unremarkable
Mental status: Responsive to loud verbal stimuli, GCS=11 for incomprehensible verbal. Pt. barely opens her eyes when you yell and will obey commands somewhat.
Skin: Pink, cool, dry
Physical examination: Unremarkable except what's noted above. No incontinence. No signs of trauma observed. No MedicAlert tags.

Parents deny any history of drug/alcohol abuse and aren't aware of any life changes that may have made the patient more depressed/unstable than normal.

An IV has been established. What's your next move/questions?

 

[firecoins]

put her on the monitor. whats her rhythm?

Is she pregnant?

 

[Fox800]

Sinus tachycardia on the monitor. 12-lead doesn't show anything interesting. Not pregnant. And oops, I put two different ages. The pt. is 28 years old, not 22.

 

[Sassafras]

For the stupid people here, Tussionex is what? Some for of Robitussin or guiafenessen (sp?)?
It's kind of crappy she's only statting at 85% on a NR. I'm thinking first things first is establish a decent airway. But with junky lungs there's something pathological going on unless she aspirated something. Hmmm...thinking here with just my BLS cap on.

 

[firecoins]

Sinus tachycardia on the monitor. 12-lead doesn't show anything interesting. Not pregnant. And oops, I put two different ages. The pt. is 28 years old, not 22.

I figured it as a dispatching mistake.

 

[Fox800]

I figured it as a dispatching mistake.

Nicely done.

"Tussionex contains a combination of chlorpheniramine and hydrocodone. Chlorpheniramine is an antihistamine that reduces the natural chemical histamine in the body. Histamine can produce symptoms of sneezing, itching, watery eyes, and runny nose. Hydrocodone is a narcotic cough suppressant.

Tussionex is used to treat runny or stuffy nose, sneezing, and cough caused by the common cold or flu."

I'll also throw in that the Tussionex is an old prescription, from >6 months ago.

Her airway is patent.

 

[Melclin]

Seems like she's overdosed and aspirated. Maybe not realizing the tussionex and norco both contain opiates (per my googling. Why do you Americans insist on using brand names in case studies?). But that seems too obvious given the title of the thread.

The RR of 40-50..are they deep or shallow? How hard is she working?

If they're shallow, lets ventilate her with a closed circuit. I don't really know if you would do the same with a BVM. Like so, but without the straps.

If they're deep or she's working hard, we need MICA quick smart. A prehospital RSI might be in her future. That's not my decision, but I think its appropriate to call someone for whom it is.

Grey Turner's of Cullen sign?
Any abdominal distension or rigidity?
I know her back pain is chronic but there's no harm in checking.
How's here peripheral circulation and temp?

Possibility of pregnancy would be high on my list (but you answered that).

Regarding that iatrogenic hole in her arm, I don't much care for the idea of putting naloxone in it, but I do think it would look pretty nice with 20mls/kg of NS trotting through. If the doctors wanna narc her, that's their decisions, they've got more options for sedation, induction and pain relief. But I sure wouldn't wanna do that until MICA were quite they weren't going to intubate her.

 

[Fox800]

Respirations are very rapid (40-60) and shallow.

Negative Grey Turner's or Cullen's signs.
No abdominal distention/rigidity.
Weak radial pulses, normal temp, skin is cool but dry and has good color.
Negative pregnancy.

IV is ran wide open. We got 1000mL NS in and her BP is up to...let's say 88/56. Nothing else changed from the fluids, though.

Transported emergent to a comprehensive receiving facility.

More questions/ideas? This one threw us and the ED physician for a loop (at least initially).

 

[DrParasite]

I'm thinking drug overdose as well, probably opiate based.

chronic back pain, constricted pupils, decreased LOC, and the reddish liquid (possible the result of an aspiration) makes me think monitor/maintain the airway, and since apparently people on this board don't like to give narcan in the field, so M+T to an ER for further tests and evaluation.

 

[Melclin]

Respirations are very rapid (40-60) and shallow.

Negative Grey Turner's or Cullen's signs.
No abdominal distention/rigidity.
Weak radial pulses, normal temp, skin is cool but dry and has good color.
Negative pregnancy.

IV is ran wide open. We got 1000mL NS in and her BP is up to...let's say 88/56. Nothing else changed from the fluids, though.

Transported emergent to a comprehensive receiving facility.

More questions/ideas? This one threw us and the ED physician for a loop (at least initially).

Did you ventilate her? If so what was her response?

OD/Aspiration doesn't quite fit (unless it was intentional and she did something else as well), but I can't imagine what else this would be.

I'm thinking drug overdose as well, probably opiate based.

chronic back pain, constricted pupils, decreased LOC, and the reddish liquid (possible the result of an aspiration) makes me think monitor/maintain the airway, and since apparently people on this board don't like to give narcan in the field, so M+T to an ER for further tests and evaluation.

I'm not totally against naloxone, but its not a great idea to narc a person who is hypoxic and who will wake up into a world of probably severe respiratory distress. This doesn't totally fit the bill for a straight opiate OD either, so what I'm doing in not giving naloxone is saying, I don't know whats going on, and I'm not going to simultaneously remove the possibility of an important prehospital treatment (RSI), and cause my pt possibly significant distress (withdrawal, hypoxia, resp distress) by giving a drug that only fixes problems that can be fixed in other ways that don't involve the above.

 

[Veneficus]

Meds: Parents aren't sure what she takes, but they bring you what they can find...Norco, Tussionex, Prozac...and some OTC supplements and stuff, not important

OTC supplements and stuff are always important.

But it looks like she is quite the mad scientist. She has a double dose of opioids, a SSRI, which thogh less than a TCA still antagonizes muscarinic, histaminergic, and a1 adrenergic.

So she is probably breathing really rapidly to offset her rather profound metabolic acidosis.

Better still, she has probably also lost control of her peripheral vascular control.

If she took some OTC pain meds to help (like acetominophen) before during or after the competition for activation/inactivation in the liver there is probably a reduced metabolism prolonging and or potentiating the effects of any or all.

Better still if she took some ibuprofin or its derivitives like naproxin, her kidneys are probably paying the price for that too with some acute renal insufficency or failure.

Perhaps she really hit the jackpot and mixed it up with some aspirin and has not only metabolic acidosis but respiratory alkalosis as well.

We can also probably rule in some self medication with the ETOH for pain.

Kidneys are probably going down anyway from insufficent BP, and since the receptors are antagonized already by the prozac, it will probably take a lot of vasoactive support along with fluids to help the BP.

Cardiac output compromised by decreased venous return.

I think she qualifies for some narcan in order to help redce some vasodialation a bit. we hope.

She is going to get a couple litres of saline and might as well toss in some pressor too, dopamine couldn't hurt, though with the antagonism it is probably going to take a fair amount.

Then she gets an NG and a charcoal.

Not going to tube her or add o2, until the hospital tells me she does not have ASA in the system as well.

While somebody make get the bright idea to push some bicarb because this is going to be a rather interesting (aka complex) tox management in the ICU, I think that can wait too.

Next she gets to go to the hospital, where hopefully the ED will be turfing her post haste to the unit for more precise workup and correction. Maybe even some dialysis.

What's your next move/questions?

Does she have insurance?

 

[Fox800]

Did you ventilate her? If so what was her response?

OD/Aspiration doesn't quite fit (unless it was intentional and she did something else as well), but I can't imagine what else this would be.



I'm not totally against naloxone, but its not a great idea to narc a person who is hypoxic and who will wake up into a world of probably severe respiratory distress. This doesn't totally fit the bill for a straight opiate OD either, so what I'm doing in not giving naloxone is saying, I don't know whats going on, and I'm not going to simultaneously remove the possibility of an important prehospital treatment (RSI), and cause my pt possibly significant distress (withdrawal, hypoxia, resp distress) by giving a drug that only fixes problems that can be fixed in other ways that don't involve the above.

She was alert enough to not tolerate a BVM.

 

[Fox800]

Let's assume that her only OTC item was a daily Wal-Mart brand multivitamin. For the purposes of this scenario it wasn't important.

I like the details about Prozac. Honestly I'm not sure what antidepressant she was on, this happened about six months back, I just remember she was on one. The Norco and Tussionex were the important parts that I remembered.

Aaaand...she has Medicaid B)

This is a case of two underlying problems happening at once. You guys are right with the OD but there's another element to this picture...

 

[usalsfyre]

Seems awful septic, except for the temp. Any history of olguria that might indicate ARF? Coughing, flu like symptoms that made you think pneumonia?

The plan:
Lots and lots of fluid, preferably LR to prevent contributing to any preexisting acidosis.

RSI. Based on what's presented she needs it. We don't have any other indication she took an ASA overdose, so I'm ok with pulling the trigger on this one.

NG with copious amounts of suction. Consider an inline neb with the mechnical ventilation. Maybe a pressor if she doesn't respond to fluid, based on the fact she doesn't look tight (pink skin) I'd probably go with norepi or phenylephrine.

 

[Melclin]

I've just read the bit where it said slumped with chin on chest. How long after that was corrected did you get those vitals? I don't quite get the logistics of this. What time is it? What time last night did she take the pain meds? What time is it now? Has she just been sitting there all night drooling cough syrup? I wasn't ganna bother clearing this up because I figured the outcome would be above my head anyway, but now I'm interested.

OTC supplements and stuff are always important.

But it looks like she is quite the mad scientist. She has a double dose of opioids, a SSRI, which thogh less than a TCA still antagonizes muscarinic, histaminergic, and a1 adrenergic.

So she is probably breathing really rapidly to offset her rather profound metabolic acidosis.

Better still, she has probably also lost control of her peripheral vascular control.

If she took some OTC pain meds to help (like acetominophen) before during or after the competition for activation/inactivation in the liver there is probably a reduced metabolism prolonging and or potentiating the effects of any or all.

Better still if she took some ibuprofin or its derivitives like naproxin, her kidneys are probably paying the price for that too with some acute renal insufficency or failure.

Perhaps she really hit the jackpot and mixed it up with some aspirin and has not only metabolic acidosis but respiratory alkalosis as well.

We can also probably rule in some self medication with the ETOH for pain.

Kidneys are probably going down anyway from insufficent BP, and since the receptors are antagonized already by the prozac, it will probably take a lot of vasoactive support along with fluids to help the BP.

Cardiac output compromised by decreased venous return.

I think she qualifies for some narcan in order to help redce some vasodialation a bit. we hope.


She is going to get a couple litres of saline and might as well toss in some pressor too, dopamine couldn't hurt, though with the antagonism it is probably going to take a fair amount.

Then she gets an NG and a charcoal.

Not going to tube her or add o2, until the hospital tells me she does not have ASA in the system as well.



While somebody make get the bright idea to push some bicarb because this is going to be a rather interesting (aka complex) tox management in the ICU, I think that can wait too.

Next she gets to go to the hospital, where hopefully the ED will be turfing her post haste to the unit for more precise workup and correction. Maybe even some dialysis.



Does she have insurance?

I suppose a severe aspirin OD as well as some opiates thrown in would fit but (this is probably one of those area dependent things because ASA is fairly rare as a household analgesic here) why would you withhold O2 from a hypoxaemic, hypo-ventilating pt on the off chance (there is no evidence of ASA) she may have taken a six month supply of dad's cardiprin as well? What about the temp? An ASA OD severe enough to cause resp alkalosis but with no elevate temp?

If there is some ASA involved and she is progressing to mixed resp/metabolic acidosis with pulmonary odema (?junky lungs), then isn't intubation indicated?

Aside from the ASA: I suppose "shallow vents" is subjective, but I picture a person with severely reduced tidal volume, with an elevated end tidal, and reduced SpO2. Surely ventilating them is a good idea. Hypoventilation is bad regardless of whether or not its the primary problem, or on top of metabolic acidosis.

Opiate induced hypoventilation Vs Metabolic acidosis induced hyperventilation. Is there going to be a winner? Or are you going to see an unpredictable merging of affects?

I'm still not sold on the naloxone. Her MAP is now 67 after only a litre of fluid. I wanted about 1400, and I'll say now she can have another 1400 (although we'd better keep an eye on these 'junky' lungs of hers). I don't see the benefits of waking up a hypoxic patient (and so probably non-compliant and mildly violent) in resp distress and pain in the hopes that her hypotension (which is now rising to more acceptable levels) is caused by the opiates, while taking away my MICA backup's ability to tube her if they feel she's indicated as it stands, or if she goes down hill. I think she can wait the 5-10 mins it will take for a rendezvous with MICA and then I'd be more open to narcing her if they decide not to tube. There have been a few jobs like this floating around where naloxone has been considered ill-advised on account of polypharmacy and aspiration.

 

[Melclin]

Seems awful septic, except for the temp. Any history of olguria that might indicate ARF? Coughing, flu like symptoms that made you think pneumonia?

The plan:
Lots and lots of fluid, preferably LR to prevent contributing to any preexisting acidosis.

RSI. Based on what's presented she needs it. We don't have any other indication she took an ASA overdose, so I'm ok with pulling the trigger on this one.

NG with copious amounts of suction. Consider an inline neb with the mechnical ventilation. Maybe a pressor if she doesn't respond to fluid, based on the fact she doesn't look tight (pink skin) I'd probably go with norepi or phenylephrine.

Sepsis that bad, that quick? We're only talking about 8 hours or so right?

 

[Veneficus]

the mystery component

I would think that if she was given some industrial strength caugh medicine that she would have some underlying infection. Pneumonia, meningitis, PID, take your pick, but it won't matter, get some cultures start some vanc.

An alergic reaction to the medication, possibly, but with the double suppression of the histamine I wouldn't think it was a major factor.

PCN if she took some could cause a type II hypersensitivity RXN, but I will look at the findings again when I get home.

 

[Veneficus]

RSI. Based on what's presented she needs it. We don't have any other indication she took an ASA overdose, so I'm ok with pulling the trigger on this one.

she doesn't need to take an ASA OD, all she has to do is tie up her metabolic pathways with all the other crap.

What are you planning to RSI her with that is going to add to her witches brew?

 

[usalsfyre]

she doesn't need to take an ASA OD, all she has to do is tie up her metabolic pathways with all the other crap.

What are you planning to RSI her with that is going to add to her witches brew?

Definitely NOT etomidate (our agent of choice per clinical guideline), I'm thinking the associated adrenal supression is the last thing she needs.

If I can get away with it (and where I'm currently at I could) I would probably nebulize some lido and do an awake intubation. Second choice would be a simple opiate induction with fentanyl to avoid hypotension and adding to the polypharm. Last choice would be propofol with a healthy slug of neo standing by to help with the inevitable hypotension. I'd like to stay away from benzos due to hypotension and length of action, etomidate for the above mentioned reasons, and ketamine to avoid adding to the "witches brew".

I'd like to avoid NMBs if I can, but if I have to use one any of the non-depolarizers will work (roc being my favorite). Sux has to many side effects for my liking in this case.

 

[Veneficus]

You are dispatched to a sick patient. Dispatch information is that your patient is a 22 year old patient who "seems sick".

Good, I like patients who at least seem sick than ones that are not making any effort to be.

On scene, the patient's mother and father guide you in to a well-kept house.".

On medicade? A crack shack with a 60" plasma and the latest PS with 100 games I would expect, but certainly not a well kept house.

They called you because the pt. seems very lethargic and is slow to respond. They tell you that the patient has chronic back pain and was having trouble sleeping last night so she took some pain medications to try to go to sleep.

Back pain. From what?

Ovarian mets?

Mittlesmirtz?

Prior trauma?

Renal problems?

Stones?

Good excuse to get opioids? (don't hate, some people do that)

You find the patient sitting in a kitchen chair, she looks like she is asleep. Her head is down with her chin to her chest and you notice there is a reddish syrupy liquid spilled on her face and down the front of her shirt. The bottle on the table next to you is Tussionex, and by your powers of deduction you establish that that's what is also spilled on the patient.

Hopefully not caughing up blood from TB, malory weiss tears or bleeding peptic ulcer. Of course with the histamine block, probably not much acid.



Here's your initial information:

28 year old female
PMH: Chronic back pain, depression. No diabetes, no seizure history, no cardiac or respiratory history.

PGMA?

She is pregnant until proven otherwise by HCG.

Since she took some caugh syrup, there was probably some method to the madness. "say AHHHHH" or at least yell loud enough so we can evaluate the dental needs as a route of infection.

oooh, infective endocarditis... Not lupus yet. But if she is having renal manifestations of it...

But with her lungs and potential renal backpain lets add goodpastures and sarcoidosis to the list.

Meds: Parents aren't sure what she takes, but they bring you what they can find...Norco, Tussionex, Prozac...and some OTC supplements and stuff, not important

Track marks, lots of perfume or drug paraphanelia?

NKDA per family

Not that it matters with all the antihistamine.

BP: 74/40 manual

Cause she is in shock. Probably constipation from the opioids too now that I think about it.

HR: 140

"more shock, any abnormal heart tones?"

Pericardial effusion? (aka tamponade?) What is the amplitude of the QRS on the monitor? Normal or small?

RR: 40-50, pt. does not slow her breathing in response to coaching

Toxicity described above, perhaps a PE from her contraceptives and smoking?
Anxiety from antidepressant?

SPO2: 85% on 15lpm NRB

air not going in.

No o2 in or no gas exchange. Perhaps a pneumo from caughing? Not really thinking neoplasm, airway obstruction?

ETCO2: Varying between 55-65

not surprising with the hypervent.

Lung Sounds: "Junky"

very discriptive. TB, Pneumonia, aspiration, cardiogenic shock

BGL: Normal, lets say 100

At least she is eating well or gluconeogenisis works.

Temp: Normal, let's say 98.5.

too many factors for this to be reliable or really useful. At best it could be a sign of chronic infection.

Pupils: Constricted, 1-2mm and reactive

opioids.

ECG: Sinus tachycardia, 12-lead unremarkable

could show pericarditis or tamponade.

Mental status: Responsive to loud verbal stimuli, GCS=11 for incomprehensible verbal. Pt. barely opens her eyes when you yell and will obey commands somewhat.

toxic, not surprising. Could be menengitis as well.

Skin: Pink, cool, dry

Shock with vasodilation, but still pink at 85% spo2? Doesn't sound right. Sepsis. CO unlikely.

Physical examination: Unremarkable except what's noted above. No incontinence. No signs of trauma observed. No MedicAlert tags.

I am sure there is something abnormal. perhaps unnoticed.

Parents deny any history of drug/alcohol abuse and aren't aware of any life changes that may have made the patient more depressed/unstable than normal.

And she is a virgin too. I never believe parents, so all of this is still possible.

not describing toxic effects again