The Good, Bad and Ugly

RocketMedic

RocketMedic

Californian, Lost in Texas
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It's been a long week here. Ended today with a 55 y/o M c/c respiratory distress. Found pt. cool/pale/diaphoretic, very agitated and anxious, screaming that he couldn't breathe. GCS 14 (e4 v4 m6) CAOx0. Diminished, wet lung sounds, capnography high-30s, RR40/min, pulse 130, BP 160/100, SpO2 61%. Reported chest pain, abdominal pain, weakness. Sugar was 361, ECG was sinus-tach with massive Q-waves in V1,2,3 and decent ST-elevation in V1, V2, V3, V4. Prior history of cardiac failure, MI, cardiac stents, CHF, COPD, insulin-dependent diabetes, HTN, and multiple psych issues. BGL 361.

I got a line in, put him on BiPap (after restraining him) and transported emergently to a larger hospital here. 2 nitros given, no effect. I did manage to improve his SpO2 to 85%, but he was pretty sick. I was thinking PE or MI, possibly pneumonia or CHF, but his complaints were very, very vague. Gangrenous right toes as well.

On the bad side, the IV catheter sheared. I didn't know it- it was a typical, standard insertion, with no fishing, binding, or any other problems. The catheter remained seated on the needle, and the angle was pretty shallow. It advanced in a nice smooth motion, and it flushed, flowed and worked splendidly. I didn't know it was sheared until I came into the hospital with another patient and they showed it to me (they pull most EMS lines after a few hours). I feel really bad about it, but I had no way to know it had sheared at the end. Who pulls patent, flowing, easy lines in the field?

The guy was in DKA, septic shock, pneumonia, and potentially throwing an MI. RSIed a few minutes after arrival. Sick, sick dude.

Your thoughts?

On the bright side, my total time with him was only 21 minutes, I diverted him from a level-four community hospital to a real hospital, and I correctly and rapidly identified that he was sick and treated him appropriately to the best of my ability. I didn't know exactly what was wrong, but I knew it was related to fluid in the lungs, DKA, and potentially a PE. Me and my student learned a lot from it.

...and then my partner left IV trash (no sharps) in the jump bag. Very, very, very frustrating. I need a new partner, or to get this one trained. He's a great guy, but frustrating.
 
You ever get tempted to call in your report as just "trainwreck, two minutes"?

How much nitro can you give by protocol?
 
Interesting case! You've given us a lot of data, which is helpful, but it leaves me wanting more!

Great call not dumping him on the level-4! What ever was going, hypoxic and combative needs to get some stuff done, and quick.

I'll give my opinion that it's pretty unlikely he had DKA, pulmonary edema, and a PE at the same time, though. The cluster of DKA/sepsis/pneumonia will usually cause a big drop in the preload, due to fluid losses, hypovolemia. Even with profound chronic heart failure, these patients often need a couple liters of NS right up front.

On the other hand, it could have been acute CHF. With the hypertensive presentation, I wouldn't expect the PetCO2 to be decreased, but it has uncertain utility in that area regardless. Anyways, the ED doc probably threw in some antibiotics, even if they were fairly sure of CHF, just in case some PNA was hanging out.

Can't go wrong with NIPPV.

Any fever found in the ED? Any labs? (BNP, lactate, especially!)
 
I heard 6.7 being bandied about as a lactate, with a white count "retarded high" as well. I reckoned that all of them werent going on, but my short list of bad things.

Sepsis and DKA crossed by mind, but screaming "I cant breathe!" dropping to Gcs10 imediately afterward with persistently low sats and wet lungs pushed me towards CHF and pneumonia...or a PE.

No idea how the catheter sheared. It went in just like any other IV.
 
Strong work, though it sounds like that heart doesn't have many beats left.

No evidence of trauma at the iv site? Bleeding, swelling?
 
I don't doubt the DKA, or that there are likely multiple things going here at once. Keep in mind whenever you have someone in DKA you should be wondering WHY they went into DKA to begin with..... noncompliance, infection, new onset diabetes, medical/surgical "stress", myocardial infarction, etc....
 
Follow-up: Hes in ICU, apparently hasnt taken his insulin or other meds consistently in "weeks", no idea on what else yet. Hospital apologized though, turned out that the catheter was just compressed a little at the end and was not actually shorn, just crimped a little with no pieces missing. Glad it didnt shear, but it did show me that iv access does have complications. The site was totally normal, no swelling or infiltration.

I feel better now. "Trainwreck" indeed.
 
If they say "sheared" ask for X-ray. They're supposed to be radio opaque.

Sounds like you were riding the rim between diagnoses-osis and treatment with good results. You ned to go further in your classical education and licensing. Good on you.
 
More info: white count 30, necrotic right foot (inside, not outside), "some bizarre metabolic mismatch", lactate up to 7.0, tryponin "skyrocketed" after ICU admit, throwing dysrhythmias. Im thinking multiple organ failure.

The charge RN apologized personally, she said the catheter was fine. Apparently, a new RN tried to draw blood from it, pulled it back a bit, repositioned it and pulled it, then mistook a kink for a shear. Lesson learned- document the security and patency of IVs at transfer of care and any complications of insertion.

Had a vaguely similar case to start tonight, same basic presentation and treatment, dialysis + diabetes + HTN + MI, I suspect metabolic something.
 
...and to kick the Crazy into overdrive, I had my first-ever encounter with a malfunctioning internal defibrillator, mixed with legitimate PVCs. 2 shocks prior to arrival, then four more soon after we arrived and started assessing, then peace and quiet for our a-fib + ST-elevation + PVC patient to perfuse fairly well in. It turned out to be a broken sensor wire.

Lesson learned: trust my instincts on the ICD-disable magnet. I was planning to use it when the four quick shocks hit, but they stopped and I held off on it. Probably should have taped it down on his chest instead.

It's been a seriously long week.
 
Brandon Oto said:
You ever get tempted to call in your report as just "trainwreck, two minutes"?

How much nitro can you give by protocol?
Click to expand...

I've called in, "Metro Hospital, this is Medic 123. Trauma Alert for a Trauma Arrest, CPR in progress with BVM, trying to establish a line, see you in the trauma bay in 10!"

My partner's reply was, "Well, that certainly was efficient!"
 
Brandon Oto said:
You ever get tempted to call in your report as just "trainwreck, two minutes"?

How much nitro can you give by protocol?
Click to expand...

Unlimited, 0.4mg SL q5min as long as systolic BP remains over 100 and/or pain is present.
 
After talking it over with my dad, I think I should have intubated him. Im fairly uncomfortable with RSI, and all we carry is versed and etomidate to induce, along with fent for pain management. No paralytics.

Am I too timid on airways? Im not great at them yet, and BiPap worked, but intubating would have been better (maybe?)?
 
Better? Sounds like you did fine. He was conscious ("screaming"), and the BiPAP helped, so there you go.

Just because the ED decided to RSI doesn't mean that you should have. They've got better drugs, more staff, back-up anesthesia and surgery. What makes sense doing in a fully-equipped ED doesn't necessarily make sense doing 10 minutes earlier at 50 mph on a bumpy street with (maybe) 1 basic partner.
 
Yeah, but we're(ROAR!)medics! We do the same :censored::censored::censored::censored: as doctors at 60mph!
 
Are you only able to give 0.4mg at a time? Are you allowed to give multiple sprays in the same dose?
 
epipusher said:
Are you only able to give 0.4mg at a time? Are you allowed to give multiple sprays in the same dose?
Click to expand...

Termination offense if you do, or so Im told. "Nitro can cause massive and fatal hypotension and must never be delivered rapidly in large boluses."
 
Wow. Really glad I didn't pursue working there. :/

Rocket, sounds like it's job search time.
 
Sorry I keep busting in, but you keep bringing up good questions!

From the journal Prehospital Emergency Care, a recently published abstract directly addressed this issue.

PREHOSPITAL ADMINISTRATION OF MULTIPLE SIMULTANEOUS NITROGLYCERINE SUBLINGUAL TABS RARELY CAUSES HYPOTENSION
Brian Clemency, Gina Tundo, Jeffrey Thompson, Heather Lindstrom, University at Buffalo, State University of New York
Background. High-dose intravenous nitroglycerin is a common in-hospital treatment for respiratory distress due to congestive heart failure (CHF) with hypertension. Intravenous nitroglycerin administration is impractical in the prehospital setting. In 2011, a new regional emergency medical services (EMS) protocol was introduced allowing advanced providers to treat CHF with oral nitroglycerin. Patients were treated with two sublingual tabs (0.8 mg) when systolic blood pressure (SBP) was >160 mmHg or three sublingual tabs (1.2 mg) when SBP was >200 mmHg every 5 minutes as needed. To assess the protocol’s safety, we studied the incidence of hypotension following prehospital administration of multiple simultaneous nitroglycerin (MSN) tabs by EMS providers.
Methods. A retrospective case review of records from a single commercial EMS agency over a six-month period (January–June 2012). Cases with at least one administration of MSN were reviewed. For each administration, the first documented vital signs before and after administration were compared. Administrations were excluded if they were missing pre- or post-administration vital signs. Blood pressure was measured in mmHg.
Results. One hundred cases had at least one MSN administration by an advanced provider during the study period. Twenty-five cases were excluded because of incomplete vital signs. Seventy-five cases with 95 individual MSN administrations were included for analysis. There were 65 administrations of two tabs, 29 administrations of three tabs, and one administration of four tabs. The mean change in SBP following MSN was –14.7 (standard deviation 30.7; range +59 to –132). Three administrations had documented systolic hypotension in the post-administration vital signs (97/71, 78/50, and 66/47 mmHg). All three patients were over 65 years old, were administered two tabs, had documented improved respiratory status, and had repeat SBP of at least 100 mmHg. The incidence of hypotension following MSN administration was 3.2%.
Conclusion. Hypotension was rare and self-limited in this sample of prehospital patients receiving MSN.
Click to expand...

I talked about this study at length in a recent review - check it out if you want background, other references, etc.

Our local protocols allow for 2-4 tabs q 5 minutes * however long it takes you to get to the resus bay!
 
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