"Unconcious Unresponsive"

[Dominion]

You are toned out at 0830 for a 38yo unconscious unresponsive male. You arrive at the residence/apartment complex and proceed upstairs to the apartment where he is found. The patients girlfriend greets you at the door and says she found him like this when she woke up this morning. He’s recently divorced, lost his children, and lost his home. He was living in his car until last night when his girlfriend let him crash at her apartment. She says he said he wasn’t feeling good and went to bed however he looked fine to her. She doesn’t know much about his medical history, but she does know that he was recently released from rehab for alcoholism and possible drug abuse but she doesn’t know for sure.

You find your patient lying in bed on his left side curled into a ball. Your initial impression of the patient is pale, cool, and extremely diaphoretic. His eyes are barely open and he is moaning softly. He has what appears to be a white powder around his mouth and doesn’t respond when you call his name. Giving painful stimuli produces a slight withdraw from pain.

Initial Vitals are:
HR: 68 & weak @ radial
BP: 94/56
RR: 12 shallow, LS are clear
GCS: E2 / V2 / M3

You have the standard EMS ground transport drug box and supplies. Your crew consists of two EMT's in the truck and 1 Paramedic in a fly car. You have also dispatched an engine company for lift assist. What do you want to know and what do you want to do?

 

[TransportJockey]

CBG please. and a pulseox.

 

[Dominion]

You get a BGL of 180 and 94% on room air

 

[8jimi8]

1. Pupils (consider narcan if suspicion of opiate overdose), Corneal reflex?

2. Estimated weight and height?

3. 2L n/c
4. Try to get a sample of whatever powder he has on his face, or find the baggie that it came from. Check wallet.

5. Apply monitor, rapid head to toe (also looking for track marks in between fingers, toes, etc.)

6. Stretcher.

7. 2 bilateral acs consider 250-500cc bolus if the bp trends down.

8. Do we have an Istat?

 

[Dominion]

1. Pupils (consider narcan if suspicion of opiate overdose), Corneal reflex?

2. Estimated weight and height?

3. 2L n/c
4. Try to get a sample of whatever powder he has on his face, or find the baggie that it came from. Check wallet.

5. Apply monitor, rapid head to toe (also looking for track marks in between fingers, toes, etc.)

6. Stretcher.

7. 2 bilateral acs consider 250-500cc bolus if the bp trends down.

8. Do we have an Istat?

1. Constricted & sluggish
2. Approx 230lbs and 5' 8"
3. O2 applied
4. You have a sample, you do not see any baggy where it could be from. No wallet found but girlfriend can give you name, dob, and says to use her address as his mailing address.
5. Monitor shows Sinus Rhythm with occasional PVC's. Head to toe exam reveals no track marks. When you attempt to pull the patient straighter to go to the stretcher his muscles are extremely tense and he crys out when you attempt to straighten any limb.
6. He is now on the stretcher without incident, I assume you also want to start transport at this step of your reply
7. IV's successful c 250 bolus. Bp remains around 90's systolic.

We'll go ahead and say you're in route now you've given 2mg narcan, the patient now opens eyes and responds to voice however reactions are significantly delayed.

 

[Fox800]

Capnography?
12-lead EKG?
Temperature?

Any odors noted on breath? Any alcohol bottles/drug bottles noted near the pt.? Any suicidal ideation/gesturing that the girlfriend witnessed? Anything noted in the oropharynx?

 

[Fox800]

Based on the info given I'm leaning towards polypharmacy overdose or an inferior MI, possibly precipitated by drug use (although with a cocaine-induced MI you might think there would be hypertension and tachycardia).

Waiting to here about the 12-lead...

 

[Dominion]

As you're in route one of your EMT partners say "Oh yea, I found this on the dresser". The bottle itself says hydromorphone and inside is a variety of pills. You have your partner contact poison control in an attempt to ID the pills, they ID two of the four in the bottle. One is confirmed to be hydromorphone, the other is Zoloft. They are unable to ID the other two types of pills.

No odors were noted to the breath and you did not see any other bottles that would contain alcohol.

The girlfriend on scene said that she noticed he had been depressed since the affair went public and the divorce but he hasn't mentioned suicide, in fact he's been better since he got on medication. She also remarked that they had not drank the night prior, he came over for awhile, ate dinner, said he felt bad (despite looking ok) and went to bed.

You perform a 12-lead prior to leaving the parking lot which reveals the same, sinus with a PVC.


I'll reveal the answer of this on Monday, this was a real patient and the answers are coming from that run. The answer might suprise you....or not if you're reeeaaaaly thourough

 

[Trayos]

The girlfriend on scene said that she noticed he had been depressed since the affair went public and the divorce but he hasn't mentioned suicide, in fact he's been better since he got on medication. She also remarked that they had not drank the night prior, he came over for awhile, ate dinner, said he felt bad (despite looking ok) and went to bed.

Ceasing to discuss suicide is generally a major warning sign, did we get a more intensive history (what forced him into rehab, drug abuse specifics, etc.)

 

[Dominion]

Ceasing to discuss suicide is generally a major warning sign, did we get a more intensive history (what forced him into rehab, drug abuse specifics, etc.)

A more specific history was attempted but the girlfriend doesn't know much about that stuff.

 

[Dominion]

I'm not going to be able to post results tomorrow so here is the outcome of this run.

Everything up to this point has been exactly how the run went. We arrived on scene to find him in an AMS. He was curled into a ball and whenever you tried to straighten him for anything (BP, IV, etc) he would cry out. So we loaded him onto our stretcher, O2 NRB, and transported L&S. Enroute he maintained a 90's systolic, it never deviated. IV was difficult due to his positioning and due to the same positioning he has a bit of a snoring respiration (until roused). NPA was inserted without any fight, finally able to hold his arm down to get an IV. 2mg Narcan given and he came to a very slight bit. He would respond to verbal command but it was EXTREMELY delayed and sluggish. We were never able to get more from the girlfriend (all of our history was gathered on scene as she stated she didn't want to go with him in the ambulance and would drive up later). We had no medical history other than the two meds we were given, the hydromorphone pills were prescribed in his name recently.

Shortly before our arrival to the ER he lost all bowel and bladder muscle tone and became as obtunded as he was prior to the narcan if not more. Due to our proximity to the ER (a few blocks by this point) Nasal intubation was ruled out by the medic.

In the trauma room he was started for work up for OD. The ER docs recognized the other two meds and said that this was a common reaction when these meds were mixed. Sorry I didn't catch the names of the two pills poison control couldn't identify.

This run happened that morning, at approx 1800ish we recieved a call from the infectious disease liason person stating our patient had confirmed bacterial meningitis and that we were recommended to get prophylactic cipro. At no time did the patient feel like he had a fever, we do not carry any sort of thermometer to test and they did his temp later after we had left. Was a run that drove home the point of differentials. In hindsight the evidence to OD was so overwhelming that none of us even contemplated meningitis or similar.

 

[Trayos]

If he felt bad before coming to dinner, and had been sleeping out in the car, could he have contracted a virus/inhaled CO2 from a blocked exhaust tube? Just speculation, but the OD seems like its a contributing factor.

Holy :censored:, I did not expect to get anywhere on the mark with that!