Unresponsive 32 year old female

Simplistic enough that it either has to be traumatic or cerebral bleed. Decorticate posturing is a lower response on the pons but not as dramatic as decerebrate posturing. As well, since the pupils are at 3mm and fixed ? Administering Narcan should not be considered as the "coma cocktail" has been outdated for several years. Lortab and other opioid derivatives would produce pinpoint type pupillary response not dilated and fixed. In regards to the posturing type response after Narcan, I truly doubt it was decorticate posturing. Rather I believe it was due to improper administration and dosage of Narcan in a patient with history of analgesics. Again, a foolish treatment regime.

>You are right that administering narcan was hasty and probably foolish. However, we did not have much to go on at that point in time. As I stated before, this was a new paramedic and a new EMT...neither of us has enough experience to know everything right off the bat. I don't have a lot of experience with posturing, but this girl was definitely decorticate when we left the scene and when we arrived at the hospital. The ER dr also made a comment regarding the posturing, so it wasn't imagined.

In one of the responses I read where the GCS was 8 and the patient had "snoring respirations". Perform a quick detailed neuro assessment (brachial cephalic response, Babinski reflexes, cornea reflex, uvula mid-line?, cold water tympanic response? ) and prepare the patient for RSI. Sorry, this patient exhibits the inability to maintain airway and intubation should be performed. Maintaining ICP (exhibition of decorticate posturing?) can also assist by sedating the patient and maintaining oxygenation. As well, ICP patients have a bad habit of projectile vomiting. Etiology at this time is really irrelevant at this time, (it would be nice) but realistically it will be assumed a closed head injury (CHI) no matter what (trauma or medically) induced. A CT will verify the true injury and assist in deduction of the cause.

>We cannot do RSI, although I agree that it was definitely indicated in this patient. She had an intact gag reflex and was just conscious enough to be outside of our parameters for intubation. She was intubated in the ER not long after arrival. CT showed a temporo-occipital bleed of unknown etiology.

Not having a "large cuff" is not good enough answer not to get a blood pressure. It only comes from those that do not know how to assess patients. Take a forearm, calf, etc blood pressure. Use your brain.

>The BP we had was obtained on her forearm.

If trauma was suspected, one should see a scalp laceration or hematoma within a few minutes. Scalp injuries are one of the fastest areas to swell and bleed due to the vast circulation.

>No visible injuries to the head.

At this time all the focus should be on airway control and monitoring changes. Neuro changes would not be noted since RSI has occurred, but along with the usual continuation of ECG, EtCo2 (which would change in ICP as well) and changes in variation of pressure and heart rate (Beck's Triad).

If one cannot RSI, then intubation should still be attempted by facilitation of medications (Versed, Valium) etc. Alike above a very detailed neuro examination prior to administration. Continuation of neuro changes and again vital sign changes.

>Good ideas, but we have no protocols for that.

As many like to point out, maintain the ABC's. Due to the obvious signs of obesity, this patient has multiple causes of < LOC. Anything from HTN/head bleed to P.E. ... who knows?

>Will post the results when I get home from work. I need to see what (if anything) happened to her while I was out of town.
 
The Paramedic may consider "nasal intubation" next time; no RSI required.

R/r 911
 
Ridryder911 said:
The Paramedic may consider "nasal intubation" next time; no RSI required.

R/r 911
Click to expand...

i thought nasal intubation was not indicated in a pt with a brain bleed? or is that just a traumatic head injury? sorry, been a very long week with little to no sleep and the brain is a little fried....

and as far as the scenario goes...i'm bls but first things first, after quick assessment when you roll the pt over, use c-spine and roll her onto a lbb and immobilize her. can't hurt anything if there's no trauma and if there is you won't get yelled at for not immobilizing, plus it makes it easier to move her, as well as if she becomes combative you don't have to worry about getting orders for restraints (per local protocols). RX: o2 vitals monitor load and go re-assess iv check sugar enroute then call MC with report - treat anything you find in your assessment and confer with MC for orders. Transport emergent rate (L&S) and get her to the hospital.
 
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I'm a 2nd year paramedic specialist student so I thought I would give this a try for practice. When u first arrived as the paramedic I would had my basic held C-spine due to the fact the family said she family out of bed and she weighs so much. (350 lbs) Cuts to the hand and hit head. While Family and I or if the Fire department is there now would roll her on her back checking the back as she is on her side. While I fix the snoring problem with a jaw thrust maneuver also check in the mouth for any blood or glass due to the cuts on the hand. Respirations were 12 and snoring, so not adequate to me so she needs to be bagged with a bagged valvle mask with 100 percent 02 Hopefully the fire department was there cause i would make them work, there usaully trained as EMT Basic or higher, so have one of the FF bagged her once every 5 to 6 seconds. No need to cut off clothes she's nakes, disclose the body and see if your missing anything (DCAP-BTLS) Airway is the most import thing, u said she was at a 8 with the GCS, so she needs to intubated, so partner holding inline, i drop a ET tube. She can't even talk, she only moans and responds to pain. Secure the ET and make sure it in the proper place and have to FF switch to once every 6 to 8 seconds. Get the back board secured with help from fire deparment and place head blocks in place and secure and place to cot and secured and lift to ambulance. Family usaully tells you what history whether its has to medical, allergies, or whatever. Or while your working on patient, have a firefighter get some information, usually firefighters come in big groups. Hook up to the heart monitor, try to start a IV, good luck, heart rate was sinus tach, lungs were clear resper were 12, BP/140, so just keep Normal saline open. Sugar level was 144. Try to fine out if family knows what her sugar level is usally. Diabetic diet, Pupils fine. Narcan i think u said didn't work. Can't get a IV, start start a IO of Normal saline. What was wrong with her, doctor will figure that out.
 
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