What was going on with this patient??

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chickj0434

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So got called for unresponsive male about 48 years old. Get on scene pt is laying on couch unresponsive but breathing. Sternum rub the hell out of him...nothing. pick up his hand and let it drop on his face, guy is out. Family states no drug history. Pts pupils slighlty pinpoint. Breathing is normal all his vitals good blood sugar 90. So we package him and head out. He's foaming/spitting from the mouth a bit so we suction. We meet will medics. The guy is out vitals all good but this medic decides to push narcan iv. Guy pops his head up for a sec then back down. We get to hospital and this guys vomits all over the stretcher and everywhere. Nurses are pissed the medic gave narcan.

Any ideas what it was? Also I'm an emetaphobic so do you guys this his vomit was contagious or just a result of the narcan.
 
Well, in the absence of definitive vitals, I’d be very suspicious of a neurological or toxicological cause of symptoms. Vomit May or may not have been associated with Narcan, but it is possible to see transient effects from competitive antagonism of the mu-receptors followed by a return to baseline AMS if the agonist isn’t an opiate. Benzos, for example, can produce similar results and result in persistent sedation.
Was he able to maintain his own airway?
 
RocketMedic said:
Well, in the absence of definitive vitals, I’d be very suspicious of a neurological or toxicological cause of symptoms. Vomit May or may not have been associated with Narcan, but it is possible to see transient effects from competitive antagonism of the mu-receptors followed by a return to baseline AMS if the agonist isn’t an opiate. Benzos, for example, can produce similar results and result in persistent sedation.
Was he able to maintain his own airway?
Click to expand...

No was 180/90
Hr 80's
Sat 96

And yes he was able to maintain his own airway
 
FWIW I wouldn’t be terribly suspicious of cardiac or infectious causes; those would typically present with some sort of pre-acute symptoms or unstable v/s. Trauma’s a possibility but a relatively unlikely one if the history doesn’t support it. This COULD be a head bleed with fairly normal v/s though, IIRC some pontine bleeds and the like are very similar. Pupillary response can be an OK gauge but isn’t constant or reliable and you wont’ typically see big problems until enough pressure to damage the nerves and dislocate issue is applied.

ABC,package, quick run to hospital ED with CT (Ideally, a primary stroke center at the minimum) and ALS stuff as needed. Narcan isn’t necessarily a terrible idea but if spontaneous respirations are adequate in rate,rhythm, depth and effort it’s not an opiate and likely isn’t a benzo. Ketamine and some of the exotic drugs out there can certainly cause persistent AMS, but subjective factors tend to rule those in or out. I wouldn’t be dropping Romazicon on this dude in a prehospital setting, if that makes any sense.

UPDATE: With that B/P, I would be very, very suspicious of a head bleed. Emergent/rapid transport to a neuro-surgical capable facility; do stuff. Might have to intubate, so get ready for that, but this to me screams head bleed.

Edit Edit: Intubation will likely become necessary, but this is a hugely individual and system factor and decision. In my current system, this guy might get intubated, but I’m decently confident and have VL + RSI, and even then I’d read the patient and situation first. If you’re close to the hospital or don’t have the drugs, tools, ability or confidence to perform a reasonably rapid tube, I’d go BLS on that airway and sprint to a neuro center.
 
Thank you for your response. When checking his pupils on scene his eyes were rolled back in his head. Also his jaw was clenched a bit.
 
I'm with RocketMedic on this. Some of what you saw may have been seizures secondary to the brain bleed.
 
While the others gave you decent clinical information, here are some practice guidelines:

NEVER do sternum rub. NEVER do arm drop over face.

What exactly are you trying to prove, diagnose, or rule in/out with this? Neither are solid indicators of anything clinical other than being an ....

Both are hideous, unprofessional "exams".

FYI, even the new guidelines for the Glasgow Coma Score have strongly asserted, NO sternum rubs.
 
Stupid question but likely I could get sick from this pt or not something viral? Like I said I'm emataphobic which makes this job tough some time haha
 
Not
chickj0434 said:
Stupid question but likely I could get sick from this pt or not something viral? Like I said I'm emataphobic which makes this job tough some time haha
Click to expand...
Not unless you drank the puke
 
Epidural bleed,
Can cause transient consciousness.
His BP is severely elevated,
His life is in danger,
I hope he does ok.
 
The narcan didn't hurt, and in my opinion wasn’t a bad move. You have an unresponsive patient with constricted pupils(cut this “slightly” **** out. It’s a yes or no question). They have an adequate respiratory drive, which is the only questionable part of giving them narcan. As far as the debate between “evidence based” treatment and the old days of the coma cocktail, like Meatloaf said, two out of three ain’t bad. I would have been thinking more seizure or stroke, but I probably would have given the narcan also.

I’m going to assume emataphobia is a fear of vomit or vomiting. Either way, unless you’re trying a cure by repeated exposure kind of thing, you’re in the wrong business. Good luck to you, but know that we deal with vomit. A lot. You’re not quite a NYC window washer that’s afraid of heights, but you’re damn close to a cab driver that’s afraid of the highway...
 
With the story as gleaned over a couple posts, I would also be suspicious for a head bleed. If the patient isn't breathing adequately and has pinpoint pupils, I'd consider naloxone, but if the patient has a reasonably decent pulse and is breathing adequately, I'm not likely to push naloxone right away. Since the patient is hypertensive, an opiate overdose isn't high on my list of possible problems, so naloxone admin will be even further down my list of things to do...

Package, load, transport. Start an IV line or saline lock or two, and head toward a facility that does stroke care, preferably comprehensive stroke care (has a neurosurgeon at the ready). Such a facility will be able to deal with the garden variety OD but will greatly eliminate transfer time (can be >1 hour) between facilities if you go to a basic ED and find out there's a bleed... Sometimes going another 10 or 15 minutes will save the patient 1-3 HOURS before seeing a neurosurgeon and getting to an OR.
 
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