Unresponsive man from nursing home

[Lifeguards For Life]

Probably was going down the overdose plan and thinking that reversing narcotics would fix the patient's breathing. Always start with A and B, as you suggested! You don't even really need to reverse the narcotics (if there were any) if you do good at A and B.

In the setting of an accidental or intentional overdose, if the patient has AMS; with or without a gag reflex, or shows signs of respiratory depression, airway management takes precedence over reversing the overdose with Narcan.

Narcan reverses opioid intoxication and is a life-saving measure for patients with profound respiratory depression. However, sudden withdrawal from narcotics, or unopposed effects of other substances accompanying an opiate overdose can pose an extremely dangerous scenario. Experienced clinicians learn to titrate Narcan fittingly, and to withhold it entirely in the absence of hypoventilation and hemodynamic instability.

I wouldn't push Narcan unless the patient exhibited 1) diminished respiratory drive and 2) pinpoint pupils.

 

[Melclin]

This was a very, very sick patient. Assuming full code status immediate needs were airway control, mechanical ventilation and fluids (4-5 liters if I can get it on board). Watch B/P carefully and consider levophed if he starts crapping out. Consider running an inline neb to help loosen secretions.

4-5 litres is way too much as an initial bolus. Round these parts, 20ml/kg NS is the go first up followed by various combinations of ringers and nutrient infusions after that depending on blood. Being an older bloke, that's probably going to mean not much more than 1600mls.

4-5 litres and I think you can guarantee one of those important type organs taking their bat and their ball and buggering off home.

 

[Aidey]

We also don't know what his past history is or what his "normal" vitals are, and that much fluid could end up creating way more problems than it would fix. For all we know the pts normal BP is in that range, and the reason he is tachycardic is because of the hypoxia and not the BP.

There are also some patients whose blood pressure drops when they are fluid overloaded. The heart is so overloaded that it can't pump efficiently, causing the BP to be low. When some of the fluid is removed the BP improves.

 

[triemal04]

Actually, usalsfyre wasn't completely wrong in what he said. Giving him the benefit of the doubt it was just worded wrong. I think a bit of reading on sepsis is in order.
http://emedicine.medscape.com/article/786058-treatment Read them whole thing, not just the treatment section.
http://emedicine.medscape.com/article/168402-treatment Again, read it all.
http://emedicine.medscape.com/article/234587-overview

As presented this pt should have gotten about 20ml/kg of saline (which I'm sure everyone knows is roughly 2L for many people) to start with, or more, assuming nothing changed during the administration to require it to stop. After that it would depend on how the body reacted to it, but a couple more liters would not in anyway be out of the ordinary for someone this sick.

And come on...this pt absolutely meets 2 of the criteria for being septic, and has a high probability of meeting the other 2. This is not a stable, healthy pt. Treat him!

 

[Lifeguards For Life]

Actually, usalsfyre wasn't completely wrong in what he said. Giving him the benefit of the doubt it was just worded wrong. I think a bit of reading on sepsis is in order.
http://emedicine.medscape.com/article/786058-treatment Read them whole thing, not just the treatment section.
http://emedicine.medscape.com/article/168402-treatment Again, read it all.
http://emedicine.medscape.com/article/234587-overview

As presented this pt should have gotten about 20ml/kg of saline (which I'm sure everyone knows is roughly 2L for many people) to start with, or more, assuming nothing changed during the administration to require it to stop. After that it would depend on how the body reacted to it, but a couple more liters would not in anyway be out of the ordinary for someone this sick.

And come on...this pt absolutely meets 2 of the criteria for being septic, and has a high probability of meeting the other 2. This is not a stable, healthy pt. Treat him!

Okay, assuming it was poorly worded, I still disagree with such a large fluid challenge.

# The first step involves titrating crystalloid fluid administration to CVP by administering 500-mL boluses of fluid until the CVP measures between 8 and 12 mm Hg. CVP is a surrogate for intravascular volume, as excess circulating blood volume is contained within the venous system. Patients with septic shock will frequently require 4-6 L or more of crystalloid to achieve this goal. Clinical signs of volume overload should be monitored as well, including developing periorbital or extremity edema, crackles on pulmonary examination, increasing oxygen requirement, or increased difficulty breathing. In patients who are mechanically ventilated, the target CVP goal is 12-15 mm Hg due to increased intrathoracic pressure.
# The second step, if the patient has not improved with fluid alone, is to administer vasopressors to attain a mean arterial pressure (MAP) greater than 65 mm Hg. It is important to first administer an adequate crystalloid fluid challenge (at least 2 L normal saline) before administering vasopressors, unless the patient is in extremis and requires immediate vasopressor support.

Below is a short breakdown of the progression from SIRS to MODS.

1. Systemic inflammatory response syndrome (SIRS) replaced the previous term 'sepsis syndrome'. This is the body's response to a variety of severe clinical insults. It is characterised by the presence of two or more of the following features:
* Temperature >38°C or <36°C
* Heart rate > 90/min
* Respiratory rate > 20/min or PaCO2 <4.3kPa
* White cell count > 12 x 109/l
2. Sepsis is defined as SIRS in response to infection.
3. Severe sepsis is sepsis associated with:
* organ dysfunction (altered organ function such that normal physiology cannot be maintained without support)
* hypotension (systolic blood pressure < 90mmHg or a reduction of > 40 mmHg from the patient's normal in the absence of other causes of hypotension)
* organ hypoperfusion (revealed by signs such as lactic acidosis, oliguria, acute alteration of mental status).
4. Septic shock describes sepsis with hypotension despite adequate fluid resuscitation.
5. Multiple organ dysfunction syndrome (MODS) describes a state where dysfunction is seen in several organs.
In this article the term SIRS is used. The clinical appearance of a patient with SIRS resulting from infection (sepsis) or other causes (such as burns or pancreatitis) is similar. However there will be differences in the management of the different underlying problem. The initial approach to looking after these patients is similar. [Top]

http://www.google.com/url?sa=t&sour...Gmp4bTGFlAwGnA1Ww&sig2=T-9mt1QIZ4v4jAjydfYD0Q


Five liters of fluid and levophed is not yet warranted in this patient.

 

[triemal04]

Okay, assuming it was poorly worded, I still disagree with such a large fluid challenge.


Below is a short breakdown of the progression from SIRS to MODS.

http://www.google.com/url?sa=t&sour...Gmp4bTGFlAwGnA1Ww&sig2=T-9mt1QIZ4v4jAjydfYD0Q


Five liters of fluid and levophed is not yet warranted in this patient.

Not as an initial bolus no; that's what I meant by being poorly worded. But an initial bolus of 20ml/kg is warranted, and the potential to need to continue fluids (albeit under different conditions than we'll have and while monitoring different things than we will) is also definitely there. Basically, this pt might end up needing that much; though not definite, it's a strong possibility. The best you can hope for is that this pt is septic right now.

Think I'd stay away from norepi at this point as well; it's not as bad as people used to think it was, but without appropriate fluid levels in the body it's not good to use. And this pt isn't there yet.

 

[usalsfyre]

Poorly worded reply, my fault. However 1500-2000mls is probably just gonna get this gentleman started. Not only is he vasodilated, he's rapidly third spacing due to the increased capilary permeability of SIRS. Fill the tank, or put the guy at even greater risk of the coagulapathies that are the hallmark of MODS. 2 liters, reevaluate and give more as needed.

Norepinephrine is indicated if this patient fails to respond to fluid.l This guy needs vasoactive is constriction. His heart is probably already working overdrive trying to create a b/p in the presence of massive vasodilation, throwing the chrono and inotrpic effects of dopamine on it are probably not gonna help things(I'll grant you levophed also has chonotropic effects)

 

[Aidey]

We still have no idea what this patients baseline is. Or his past history. What if the mental status and blood pressure are normal for the patient?

Tachycardia, tachypnea and AMS are also symptoms of hypoxia. If his normal baseline is decreased already, he could appear very altered by just being slightly hypoxic.

We also have a patient who is already needing increased O2 to maintain his SpO2 and he has poor lung sounds. That right there is a reason to not be as aggressive with the fluids without additional information.

I know what aggressive fluid management of sepsis is becoming the standard of care, but in this patient (with the information we have), being that aggressive prehospital could end up killing him.

 

[Melclin]

Poorly worded reply, my fault. However 1500-2000mls is probably just gonna get this gentleman started. Not only is he vasodilated, he's rapidly third spacing due to the increased capilary permeability of SIRS. Fill the tank, or put the guy at even greater risk of the coagulapathies that are the hallmark of MODS. 2 liters, reevaluate and give more as needed.

Norepinephrine is indicated if this patient fails to respond to fluid.l This guy needs vasoactive is constriction. His heart is probably already working overdrive trying to create a b/p in the presence of massive vasodilation, throwing the chrono and inotrpic effects of dopamine on it are probably not gonna help things(I'll grant you levophed also has chonotropic effects)

I'm not comfortable going down the sepsis pathway with the information we have. Sepsis is ganna mean 20+mls/kg of NS, adrenaline, ceftriaxone and dexamethasone (assuming I'm a MICA paramedic). I'm not giving that to a person on the basis that their BP is low, they're tachy and have a crap GCS.
Need more information. Although I understand that the OP might not have it since they were at the mercy of their medic's assessment.

I wanna know more about their history, namely, their normal BP, medical problems, surgical history (lung sounds and a possible iatrogenic cause of the miosis), medications, and usual conscious state. Has he been unwell or suffered any trauma lately?

 

[triemal04]

We still have no idea what this patients baseline is. Or his past history. What if the mental status and blood pressure are normal for the patient?

Tachycardia, tachypnea and AMS are also symptoms of hypoxia. If his normal baseline is decreased already, he could appear very altered by just being slightly hypoxic.

We also have a patient who is already needing increased O2 to maintain his SpO2 and he has poor lung sounds. That right there is a reason to not be as aggressive with the fluids without additional information.

I know what aggressive fluid management of sepsis is becoming the standard of care, but in this patient (with the information we have), being that aggressive prehospital could end up killing him.

I can't really disagree with any of that. But...what would you do for this pt based on what's been presented? And I also agree that more info is definitely warranted...though according to the OP that's not possible, so a decision is needed. Not nitpicking, just curious what you'd do.

The BP may be normal for him...but the tachycardia isn't, though it definitely could be due to the hypoxia. It's safe to assume that the lungs sounds are also not normal, and most likely the body temp isn't either. So, you have an unresponsive, tachycardic, borderline hypotensive pt cool/cold to the touch with lung sounds indicative of pneumonia (as I read the scenario anyway). Now what?

 

[Jeffrey_169]

First things first...ABC"s. Fix the snoring respirations and give O2 via BVM. Now, start an IV NS/ LR and find out what is going on with those lungs; when you said they sounded "junky", in what way? How is compliance with the BVM? How are our sats doing? I would consider a cardiac monitor at this point just in case (if I had time). Beyond that I would need to know more info.