Treatment Question

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fyrfyter

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I have a 77y/o Female. We were called for weakness, difficulty breathing, abd pain. She has been feeling weak and has had the abd pain for approx. 1 week. She does not remember when her last bowel movement was and has been vomiting for the past couple of days. She also has COPD. Her lung sounds there was some wheezes present. Pt has not ate anything in the past couple of day either. Pt is 130 Sinus Tach. Pt had labored breathing at 22x min. Pulse OX 83% via a NC at 4lpm. 12 lead was negative and a blood glucose was 90 mg/dL. PT was AO X3 for the whole transport. Also pt rated her pain a 10/10 very tender upon palpation. Her first pressure was 97/79. I have an approx. 7 Min transport time. I started a breathing treatment, IV (18GA). Upon my arrival to the ED her pressure had fallen to 74/42. I did not place her in a trendlenbug position due to her COPD. Her next pressure while in the ED was 62/44. The ER nurse decided to yell at me that her breathing was not an issue and I should of for went the treatment and placed in in trendlenburg position. My belief was that there is no clinical proof that the trendlenburg position was effective and I wanted to correct her breathing problem before she went in to respiratory arrest. Also her pressures didn't start dropping until we were already in the ED. I am just wondering what should or could I of done different.
 
IV fluids for dehydration.


Giving a "breathing treatment" usually entails albuterol... a beta agonist. That will increase the HR on someone who's already dehydrated. Did you also do Atrovent?
 
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Fluid bolus.
 
We only have albuterol as an option. I did have the fluids going. I do understand the risk of the increased HR but I felt that I should try to fix her breathing problem. One thing I forgot to mention was that she had not had her breathing treatment for a day and she usually has a treatment 4x a day.
When I left the ER she the DR. suspected a AAA.
 
Did breath sounds merit spending the itme on a treatment?

With seven minutes and a crashing BP, you had to decide which was the most pressing, no pun intended. She live?

Receiving people who get excited tend to ventilate. Some nurses look upon med techs as mindless scut workers. Talk to your boss about your decision. Keep track of people who consistently dump on you when the boss's second guess was you did OK, turn the name over to the boss with dates times sand notes. The fugedaboutit.
 
Pain relief?
 
fyrfyter said:
We only have albuterol as an option. I did have the fluids going. I do understand the risk of the increased HR but I felt that I should try to fix her breathing problem. One thing I forgot to mention was that she had not had her breathing treatment for a day and she usually has a treatment 4x a day.
When I left the ER she the DR. suspected a AAA.
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It sounds like you were at least attempting to treat both problems. You were giving her a breathing treatment and you had fluids running, nothing else you really could have done for the BP unless you wanted to try a dopamine drip, but with a 7 minute transport time that would be kind of unproductive. Did you tell the nurse that there has been no clinical proof that Trendelenburg works?
 
ill second the fluid bouls her breathing might always be like that due to her COPD 84% is probably normal for her.
 
Trendellenburg is BS. That nurse suffered from Cerebrorectal Inversion Syndrome. Don't sweat it.

SpO2% with a low BP will more than likely be inaccurate unless you still have 2+ radial pulses giving a perfect sawtooth waveform on the pleth. Otherwise the SAT is lying to you period. So don't trust it.

About the abd pain, where was it? Tender to palpation? Rebound? Pulsating mass? Radiating to her back? Bowel sounds? Vomiting? Vomiting bile? Fever?

Low BP. Did she have radial pulses? Did you take a manual? If pulsating mass, BP's in both arms (for signs of dissecting AAA)?

You started a line. How fast?

Pedal pulses?

Fever?

BGL?

Don't think You have enough information to discern whether or not you could have done more or less.

Not brow beating you by no means. Just armchair quarterbacking to give you a different perspective.
 
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Could be any one of four billion things wrong with her.

Unless she had markedly increased work of breathing or was showing signs of being hypoxic Brown might not give her salbutamol.

Brown would put in a drip and give her a litre of fluid.

Brown would probably also have given her some methoxyflurane
 
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ill second the fluid bouls her breathing might always be like that due to her COPD 84% is probably normal for her.
Click to expand...

You know that hypoxic drive and all the related beliefs are a myth right?
 
I would withheld the albuterol also, god knows how her muscle will react with the bump in activity, do you have CPAP?

And with the drop in systolic after fluid administration and the severe abdominal pain leads me to believe shes bleeding somewhere, did you witness any dip in her mentation.

Yup she is sick, and her best shot, is to maintain the pressure if you can maybe lay off the fluids see if her pressure bounces and address the respiratory problem if its feasible and bring her to the hospital.

Sometimes are best efforts end up at the bottom of the toilet, not every complaint is within reach, sometimes you just have to hold the mess together until you reach the ER, you did that

The nurse is a nitwit., don't sweat it.
 
fyrfyter said:
I have a 77y/o Female. We were called for weakness, difficulty breathing, abd pain. She has been feeling weak and has had the abd pain for approx. 1 week. She does not remember when her last bowel movement was and has been vomiting for the past couple of days. She also has COPD. Her lung sounds there was some wheezes present. Pt has not ate anything in the past couple of day either. Pt is 130 Sinus Tach. Pt had labored breathing at 22x min. Pulse OX 83% via a NC at 4lpm. 12 lead was negative and a blood glucose was 90 mg/dL. PT was AO X3 for the whole transport. Also pt rated her pain a 10/10 very tender upon palpation. Her first pressure was 97/79. I have an approx. 7 Min transport time. I started a breathing treatment, IV (18GA). Upon my arrival to the ED her pressure had fallen to 74/42. I did not place her in a trendlenbug position due to her COPD. Her next pressure while in the ED was 62/44. The ER nurse decided to yell at me that her breathing was not an issue and I should of for went the treatment and placed in in trendlenburg position. My belief was that there is no clinical proof that the trendlenburg position was effective and I wanted to correct her breathing problem before she went in to respiratory arrest. Also her pressures didn't start dropping until we were already in the ED. I am just wondering what should or could I of done different.
Click to expand...

Screw the ER nurse. A zillion things are in the differential - bowel obstruction high on my list, not treatable in the field. IV and transport.
 
MSDeltaFlt said:
SpO2% with a low BP will more than likely be inaccurate unless you still have 2+ radial pulses giving a perfect sawtooth waveform on the pleth. Otherwise the SAT is lying to you period. So don't trust it.
Click to expand...

Really? Come to my OR and I'll totally dispel that myth for you.

If you don't have a pulse ox waveform, your readings are questionable at best (I try and tell this to my recovery room nurses all the time when they scream that the SaO2 is 70 and the patient's lips are pink and they're conversing with me and smiling.)

If you DO have a pulse ox waveform, ignore the number at your own risk. It doesn't have to be a "perfect sawtooth" pattern to get a reading. As the pressure gets lower, the waveform may decrease in amplitude or look like more of a "damped out" tracing, just like an arterial pressure waveform.
 
jwk said:
Screw the ER nurse. A zillion things are in the differential - bowel obstruction high on my list, not treatable in the field. IV and transport.
Click to expand...

Pain relief? Anyone? (well done Brown though ;) )
 
Smash said:
Pain relief? Anyone? (well done Brown though ;) )
Click to expand...

Thanks mate, Brown remembers something from the Clinical Procedures about "pain" being an indication for "pain relief" hmm ....

Brown LOL'd at "12 lead was negative" oh no .... you mean he put on the dots and nothing printed? That's not good! Good on this bloke for even doing a 12 lead, but they are useful for things other than STEMI mate :D
 
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